Every finding on record at Delaware Bay Rehabilitation and Healthcare Center

Based on record review and interview, it was determined that for one (R1) out of one resident reviewed for hydration, the facility failed to ensure that R1 was offered sufficient fluids to maintain proper hydration. This failure resulted in harm when R1 was transferred to the hospital on 9/25/25 with a diagnosis of metabolic acidosis, hypokalemia and AKI (acute kidney injury) and elevated lab values indicative of dehydration. Findings include:Cross refer F686The BUN (blood urea nitrogen) lab measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023.Review of R1's clinical record revealed:9/2/25 - R1 was admitted to the facility.9/2/25 - A physician's order was written for lisinopril hydrochlorothiazide 20 mg - 12.5 mg one tablet by mouth twice a day for hypertension. The aforementioned medication is an antihypertensive as well as a diuretic.9/3/25 - A review of R1's labs (CMP) revealed a sodium level (NA) of 135 mmol/L (normal value is 137 - 145 mmol/L.) The blood urea nitrogen level (BUN) was 17.0 mg/dL (normal value is 9.0 - 20.0 mg/dL). As of 10/21/25 there was no evidence that these labs were reviewed by the provider. 9/3/25 - An admission nutritional assessment documented that R1's recommended fluid intake was 1724 - 2155 mL/day. 9/3/25 - A baseline care plan documented that R1 was as risk for alteration in hydration related to impaired mobility, medications and diagnosis of recent AKI (acute kidney injury), UTI, and course of antibiotic and the following interventions: encourage adequate fluid intake and monitor for signs and symptoms of dehydration such as poor skin turgor, dry mucous membranes, concentrated foul smelling urine, decreased urine output, change in mental status, notify nursing and MD as appropriate. The daily totals obtained from CNA flow sheets for R1's fluid intake were:-9/3/25 - Intake: 600 mLs. Output: 2050 mLs.-9/4/25 - Intake: 600 mLs. Output: 800 mLs.-9/5/25 - Intake: 480 mLs. Output: 1125 mLs.-9/6/25 - Intake: 600 mLs. Output: 1070 mLs. 9/6/25 - An admission MDS documented that R1 was dependent on staff for all ADL's including eating and hydration. The daily totals obtained from CNA flow sheets for R1's fluid intake were:-9/7/25 - Intake: 360 mLs. Output: 2650 mLs.-9/8/25 - Intake: 600 mLs. Output: 1400 mLs. -9/9/25 - Intake: 720 mLs. Output: 1050 mLs.-9/10/25 - Intake: 360 mLs. Output: 1550 mLs.-9/11/25 - Intake: 720 mLs. Output: 1250 mLs.-9/12/25 - Intake: 640 mLs. Output: 1500 mLs. -9/13/25 - Intake: 840 mLs. Output: 950 mLs. -9/14/25 - Intake: 720 mLs. Output: 850 mLs.-9/15/25 - Intake: 360 mLs. Output: 670 mLs.-9/16/25 - Intake: 600 mLs. Output: 300 mLs.-9/17/25 - Intake: 600 mLs. Output: 240 mLs. -9/18/25 - Intake: 360 mLs. Output: 0 mLs.-9/19/25 - Intake: 600 mLs. Output: 50 mLs. -9/20/25 - Intake: 480 mLs. Output: 110 mLs.-9/21/25 - Intake: 600 mLs. Output: 300 mLs. -9/22/25 - Intake: 600 mLs. Output: 460 mLs.-9/23/25 - Intake: 600 mLs. Output: 500 mLs.-9/24/25 - Intake: 360 mLs. Output: 750 mLs. -9/25/25 - Intake: 100 mLs. Output: 100 mLs (went to hospital) The facility failed to meet R1's recommended daily hydration goal on all the above dates. 9/25/25 - A hospital progress note documented that R1 presented to the emergency department with an acute kidney injury (AKI) with creatinine value of 9.1 mg/dL (high) and a BUN (blood urea nitrogen) level of 155 mg/dL (high). [R1] with severe metabolic acidosis. 10/20/25 2:50 PM - During an interview, E6 (CNA) and E7 (CNA) confirmed that R1 required total care with ADL's including feeding and drinking. E6 stated that R1 had a poor appetite and would pocket food and confirmed that staff would try to feed and encourage R1's intake. E6 confirmed that the staff nurses were aware of R1's decreased intake. 10/21/25 10:30 AM - During an interview, E4 (LPN) confirmed R1 had decreased intake and notified the UM (unit manager) and provider of these concerns. E4 stated that staff encouraged fluid intake for R1 and requested R1 be sent to the hospital related to decreased intake. 10/21/25 11:05 AM - Review of R1's EMR progress notes lacked evidence of efforts to address R1's decreased oral fluid intake including approaches to increase hydration and consultation with the doctor.10/21/25 1:45 PM - During an interview, E2 (DON) confirmed that the provider was not consulted regarding R1's decreased intake and no interventions were ordered to increase hydration. 10/22/25 12:34 PM - During an interview, E9 (LPN UM) stated that staff did not report decreased intake for R1 during the aforementioned dates. E9 stated that the dietician usually follows resident's closely regarding intake and hydration status. 10/22/25 2:57 PM - During an interview, E10 (Dietician) confirmed that she reviewed R1's nutritional status on 9/3/25 and again on 9/24/25. E10 confirmed that she reviewed R1's intake and addressed nutritional needs based on low oral intake (food) and the presence of the wound. E10 confirmed that a liquid protein supplement and nutritional supplement were added to R1's regimen. E10 confirmed that she did not address R1's hydration status or provide suggestions how to increase it. The lack of monitoring and interventions led to R1 being sent out for further evaluation. R1 was admitted to the hospital with a diagnosis of AKI and metabolic acidosis which is directly related to a decreased intake of fluids resulting in harm to R1. 10/22/25 3:15 PM - Findings were reviewed with E2 (DON) during the exit conference.

Based on interview and record review, it was determined that for one (R1) out of three (3) residents reviewed for pressure ulcer (PU), the facility failed to ensure that R1 received the necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU's) from developing. R1 had an avoidable unstageable PU develop on bilateral buttocks at the facility causing harm to the resident. Findings include: Cross refer F692 Review of R1's clinical record revealed: 8/25/25 - A progress note from the hospital documented that R1 had a stage II pressure ulcer to the sacrum measuring 4.5 cm L x 0.5 cm W. A wound photograph provided from hospital revealed R1's sacrum open, pink in color, matching the measurements. Additionally, a smaller open area noted approximately 2 cm L and 0.5 cm W, location distally, pink in color, and intact edges. 9/2/25 - R1 was admitted to the facility. 9/2/25 8:07 PM - A Braden scale assessment was completed for R1 with a score of 18 indicating moderate risk of skin breakdown. 9/2/25 8:13 PM - An admission skin check documented that R1 had a wound noted to the sacrum upon admission. The admission skin check lacked evidence of assessment, measurement, or staging related to the wound. 9/2/25 - A baseline care plan documented that R1 had a potential for pressure ulcers related to impaired mobility, decreased activity, potential for alteration in nutrition and potential for friction with the following interventions: barrier cream to buttocks, coccyx, sacrum and perineum every shift after each incontinent episode, monitor for adequate nutrition and hydration, offload heels while in bed, pressure reducing mattress to bed, pressure reducing cushion to wheelchair, turn and reposition every two hours, and weekly skin checks. 9/3/25 - A physician's order documented to wash sacral wound with Vashe, apply Medi-honey, and cover with boarder foam dressing daily on night shift. This treatment is consistent with a Stage II pressure ulcer treatment guidelines per standard practice. 9/3/25 - A review of R1's new wound alert assessment documented an open area noted to sacrum. The assessment lacked evidence of measurement, staging, and description of the wound. On the bottom of the form in the lower right-hand corner was an unsigned note dated 9/4/25 that documented, buttocks/coccyx 12 cm L x 15 cm W x UTD (unable to determine) D. 100% necrotic, continue same treatment and LLAM (low air loss mattress) to bed. The added note does not appear to be written in the same handwriting as the original form was documented and lacked signature. The facility lacked evidence that a consultation with the physician on 9/4/25 about the change in the wound and no new treatment was ordered for the wound. 9/6/25 - An admission MDS documented that R1 had a stage II pressure ulcer on admission with the following interventions: pressure relieving device to chair, pressure ulcer/injury care, and applications of medications or ointments. The MDS also documented that R1 was dependent for all ADL's including turning, repositioning, and incontinence care. 9/9/25 - The facility lacked evidence of a weekly pressure ulcer assessment including staging, measurement, and assessment of the wound. 9/11/25 - The admission MDS was signed off by E11 (MDS coordinator) as complete and the accuracy of the data that R1 had a stage II pressure ulcer noted. 9/11/25 - A review of R1's new wound alert assessment documented an area noted to coccyx measuring 15 cm L x 18 cm W x UTD D. Black in color and necrotic. Continues on LLAM. The note documented coccyx which is inconsistent to the previous note with handwritten assessment that documented buttocks/coccyx. The facility lacked evidence of an order for the use of the LLAM in the clinical record. 9/16/25 - A progress note from WCN documented that R1 had an 'unstageable bilateral sacrum: measuring 17 cm L x 20 cm W. The wound was 100% necrotic. A new order for Silvadene cover with ABD pad twice a day. The note is inconsistent with documentation from previous WCN progress notes as the documentation uses sacrum and coccyx. The note is unclear regarding location of wound. 9/17/25 - A physician's order documented unstageable to sacrum: apply Silvadene cream and cover with ABD pads twice a day. The physician's order mentions sacrum and lacks evidence of treatment to bilateral buttocks. 9/17/25 - A physician's order was added for a low air loss mattress (LLAM) for wound care healing. 9/23/25 - A progress note from WCN documented [R1] was seen by WC physician (WCMD) for unstageable wound bilateral sacrum measuring 23 cm L x 22 cm W and 100% necrotic, odiferous, with purulent drainage noted. [R1] to continue on Silvadene BID. Verbal consent from wife to debride next week. The note does not mention area noted to buttocks or evidence of treatment to buttocks. 9/25/25 11:13 AM - A progress note documented that R1 was sent to the emergency room due to altered mental status, abnormal labs, and strong foul odor to sacral wound. 9/25/25 - R1 was admitted to the hospital with a diagnosis of sepsis, AKI (kidney injury), and a large sacral ulcer with suspicion of gangrene. A photograph provided from the hospital revealing R1 with bilateral buttocks wounds that were black in color, yellow slough noted around border of bilateral wounds, measuring approximately 28 cm L and 22 cm W extending to bilateral buttocks, and pink tissue noted under lifting edges. 9/25/25 - A hospital progress note documented a gluteal excision debridement of skin, subcutaneous tissue, gluteal muscle, and sacrum measuring 28 cm L and 22 cm W was completed. A photograph provided from hospital revealing R1's bilateral buttocks post debridement exposing muscle, ligaments, connective tissue, adipose measuring approximately 28 cm L and 22 cm W extending to bilateral buttocks. 10/20/25 2:50 PM - During an interview, E6 (CNA) and E7 (CNA) confirmed that R1 was dependent for ADL's and verified the sacral wound was present on admission. E6 and E7 both confirmed R1 did not have a low air mattress when R1 was admitted and confirmed the wound did become larger in size over the time R1 was at the facility. 10/21/25 9:45 AM - During an interview, E4 (LPN) stated that the expectation of an admission with a new wound is to notify the WCN about presence of wound and an assessment of wound was to be completed by an RN. E4 confirmed there was a wound form to be completed and submitted to WCN. 10/21/25 10:00 AM - During an interview, E5 (LPN) confirmed that the expectation was all new admissions to have a full head to toe assessment completed by an RN, document any wounds with measurements in the medical record and notify the WCN. E5 also stated the admitting nurse was responsible to implement preventative measures and interventions for wounds upon admission. 10/21/25 10:30 AM - During an interview, E4 confirmed that R1's was present on admission and described the wound as a small open area on the coccyx/sacrum. E4 stated the treatment was completed on overnight shift and was seen when E4 completed a PRN (as needed) dressing change to wound, could not recall exact date but stated it was around 9/16/25. E4 stated the wound was necrotic noted on bilateral buttocks, very large in size compared to size on admission and not in the same area. E4 stated she notified E3 (WCN) immediately of these changes. E4 confirmed that the Silvadene treatment was initiated on 9/17/25 and the treatment would soften the necrotic areas of buttocks. E4 confirmed the wound had an odor and noted purulent drainage shortly before R1 went to the hospital. 10/21/25 2:45 PM - During an interview, E3 (WCN) stated R1's wounds were assessed on 9/4/25, the week of admission and confirmed that the wound started in the coccyx and then new areas was noted affecting the buttocks. On the second week (9/11/25), E3 stated the edges of the buttocks wounds were starting to lift but the center of the wound was hard and necrotic. E3 confirmed that R1 did not see E8 (WC MD) on 9/9/25 due to R1 being at an appointment. E8 (WC MD) assessed R1 and ordered the Silvadene on 9/16/25. E8 assessed R1 on 9/23/25 but did not change the treatment and did not order anything orally for the purulent drainage noted on the wound assessment. E3 stated she initiated the LLAM on 9/4/25 and confirmed the order was not put in until 9/17/25. There was lack of evidence that the low air loss was initiated on 9/4/25. R1 entered the facility with a stage II sacral wound and within 15 days was diagnosed with an unstageable pressure ulcer on the right and left buttocks. 10/22/25 - Findings reviewed with E2 (DON) during exit conference.

Based on record review and interview, it was determined that for two (R129 and R123) out of two residents reviewed for a change in condition, the facility failed to ensure residents were free from experiencing a significant medication error. For R129, staff administered another resident's medication resulting in the need for emergency medical intervention of Narcan for opioid overdose and transport to hospital for further medical intervention. The facility's failure placed R129 at risk for a serious adverse outcome including anaphylaxis, depressed respiratory status, and even death related to administration of a significant medication in error. Due to this failure an Immediate Jeopardy was called on 7/19/25 at 9:55 AM. Based on the facility's evidence at the time of the survey, the deficiency as determined to be past non-compliance as of 7/20/25 at 11:59 PM. For R123, staff administered insulin for a blood glucose outside of parameters, resulting in interventions related to critically low blood sugar. The facility's error caused hypoglycemia and placed R123 at risk for a serious adverse outcome including diabetic coma or even death from a critically low blood sugar. Due to this failure an Immediate Jeopardy was called on 12/13/24 at 12:08 PM. Based on the facility's evidence to correct at the time of the survey, the deficiency was determined to be past non-compliance as of 12/14/24 at 11:00 PM. Findings include: 1. Review of R129's clinical record revealed: 7/17/25 - R129 was admitted to the facility with diagnoses including diabetes, metabolic encephalopathy, and unspecified congestive heart failure. 7/18/25 - A physician's order documented that R129 was prescribed the following medication: sodium chloride (supplement), sodium bicarbonate (supplement), rosuvastatin calcium (reduces cholesterol), latanoprost eye drops (treat glaucoma), dorzolamide eye drops (treat glaucoma), and Lasix (diuretic). The EMR also documented R129 had an allergy to aspirin. 7/19/25 - An admission MDS documented that R129 was dependent for ADLs and documented a 99 in the BIMs section indicating R129 did not complete the interview. 7/19/25 9:55 AM - A facility incident report documented that R129 was administered another resident's medication. R129 received the following medications: ms contin 60 mg (narcotic for pain), xanax 0.5mg (narcotic for anti-anxiety), tizanidine 2mg (muscle relaxer) and aspirin 81 mg. Additionally, the report documented that R129 was administered a one-time dose of Narcan and supplemental oxygen. R129 was then sent to the hospital for further medical intervention and admitted . 7/19/25 12:59 PM - A nursing progress note documented that R129 received another resident's medication at 9:55 AM and vital signs were as follows: BP 139/84, P 73, T 97.0, R 20, and SPO2 80% (oxygen level) on room air. The progress note also documented that oxygen was applied at 4L/min and SPO2 (oxygen level) was 94% on 4L. Additionally, the note documented a new order for Narcan one dose and to send R129 to the emergency department via 911 for further treatment. 7/19/25 6:42 PM - A hospital progress note documented that [R129] presented to the emergency department with lethargy due to administration or wrong medications including sedative medications and medications that can cause respiratory depression including ms contin, Xanax, duloxetine (anti-depressant), tizanidine, and citalopram. [R129] will be closely monitored overnight with telemetry, continuous pulse oximetry, capnography until drug effects wear off. If [R129] continues to worsen, intubation will be needed. 7/25/25 1:45 PM - During an interview, E5 (RN) confirmed that R129 received the wrong medication and E17 reported the error immediately. E5 confirmed that R129 received a dose of Narcan, supplemental oxygen, and was sent to the emergency department for further treatment. E5 also confirmed the facility provided education regarding the medication error and the importance of utilizing the rights of medication administration. 725/25 2:02 PM - During an interview, E17 (LPN) confirmed that R129 received the wrong medication and the error was reported immediately. E17 stated that R129 was a new admission and the EMR did not have a picture uploaded E17 thought R129 was a different resident. E17 stated that the physician was notified immediately after realizing the wrong medication was administered and R129 was provided medical care per orders. 7/25/25 2:30 PM - An Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and E2 (DON). 7/25/25 – 4:30 PM – Based on a review of the facility's corrective actions, it was verified that past noncompliance was abated as of 7/20/25 at 11:59 PM. The incident was promptly identified, and Resident R129 was immediately sent to the hospital for evaluation and treatment. The root cause was determined to be the absence of a photo ID in R129's electronic medical record (EMR), which contributed to a medication error. The facility updated its admission process to ensure photo identification is captured, expanding staff access to the EMR system to facilitate timely uploading of resident photos. Additional staff were trained to take photographs at the time of admission, further supporting timely and accurate photo ID capture. A facility-wide audit was conducted to confirm that all current residents had a photo ID included in their EMRs. All nursing staff received re-education and training on the 7 Rights of medication administration. Staff interviews and medication administration observations conducted by surveyors verified the facility had returned to and maintained compliance. 2. 8/1/24 – R123 was admitted to facility with diagnoses including type 2 diabetes. 12/5/24 – The EMR documented a physician's order, Accu check before meals and HS [bedtime]. 12/11/24 – The EMR documented a physician's order, Aspart (fast acting insulin) flex pen subcutaneous solution pen-injector 100 unit/ml. Inject 5 units subcutaneously with meals for diabetes. Hold for FSG (finger stick glucose) <180 (less than 180) or if not eating. 12/13/24 12:06 PM – The EMR documented, R123 did not eat any breakfast and their lunch time finger stick glucose as 124 mg/dl. 12/13/24 12:08 PM – The EMR documented, Aspart insulin 5 units was administered to R123's left arm subcutaneously. 12/13/24 - The EMR documented, R123 did not eat any lunch. 12/13/24 – A nursing progress note in the EMR written by E12 (RN - Agency) documented, .approximately 1230 daughter reported that resident was not acting right.resident is laying supine (on back) in bed, leaned to the right, eyes closed, mouth open. Resident presents as disoriented, able to follow commands, A&Ox1, pallor skin color, diaphoretic. FSBS 46. Administered glucose gel 1 tube, called 911 at 1321, EMS arrived 1325 rechecked fingerstick [and it was] 65. 12/13/24 – The EMR documented that EMS transported R123 to the hospital, hypoglycemia resolved. 7/24/25 9:55 AM – During an interview, E2 (DON) confirmed that E12 administered Aspart insulin 5 units subcutaneously to R123 when the medication should have been held. Additionally, E2 stated that education was provided to all nursing staff regarding medication administration with medication parameters. 7/25/25 1:45 PM - 2:00 PM – During interviews with multiple nursing staff including LPN's and RN's it was verified that nursing staff received education and training on the facility's process when administering medications that have parameters. 7/25/25 - 2:50 PM - An Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and E2 (DON). 7/30/25 10:10 AM – During an interview E13 (Staff Educator) stated when there is an incident that occurs in the facility that requires education she is notified by the DON or ADON and E13 is then responsible for providing the education specific to the incident. Additionally, E13 stated that education began promptly at 4:00 PM on 12/13/24 and was completed at 11:00 PM on 12/14/24. 7/25/25 1:45 PM - 2:00 PM – During interviews with multiple nursing staff consisting of LPN's and RN's all nursing staff were able to correctly state the facility's process when administering medications that have parameters. Based on a review of the facility's investigation, documented response, completion of in-service training, and staff interviews, it was determined that past noncompliance occurred but was corrected prior to the survey. The plan of correction was initiated on 12/13/24 and completed on 12/14/24. The incident was promptly identified and R123 was immediately sent to the hospital for evaluation and treatment. The root cause was determined to be a failure to recognize or adhere to medication parameters outlined in the order. Nursing staff received targeted in-service training on following physician orders, with a focus on understanding and applying medication parameters. Staff interviews confirmed that nursing staff understood the expectations regarding physician order compliance. Medication administration observations (med pass) were conducted by surveyors to ensure staff were accurately following physician orders, including parameter-based instructions. Surveyor review of documentation and staff practices verified that the facility had returned to and maintained compliance. 7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON).

Based on observation and interview it was determined that the facility failed to ensure that essential kitchen equipment is maintained in safe operating condition. 1. 7/22/25 10:25 AM - During a tour of the kitchen, the sanitizing solution in 2 out of 2 red sanitizer buckets was tested for chemical concentration by E16 (Dietary Supervisor). The chemical concentration level was too low and did not register at the appropriate sanitizing level (400 ppm) on the test strip.The ineffective level of sanitizer in the bucket was confirmed by E16.7/22/25 - 10:32 AM - The sanitizing solution was tested by E16 at the source where it leaves the container, mixes with water, and flows into the three compartment sink. The chemical concentration level tested below 200ppm on the test strip, which is too low to provide appropriate sanitization for food safety.The ineffective level of sanitizer at the three compartment sink was confirmed by E16.7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on observation and interview it was determined that for two (R109 and R97) out of twenty eight residents reviewed the facility failed to ensure practices to prevent infection were followed. Findings include:Review of the CDC's Clinical Safety: Hand Hygiene for Healthcare Workers indicated, Protect yourself and your patients from deadly germs by cleaning your hands. https://www.cdc.gov/clean-hands/hcp/clinical-safety. Review of the Nursing Skills checklist for oral medication administration indicated, Multi-dose containers: When removing tablets or capsules from a multi-dose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Cut scored tablets, if necessary, to obtain the proper dosage. If it is necessary to touch the tablets, wear gloves. https://wtcs.pressbooks.pub/nursingskills/chapter/15-4-checklist-for-oral-medication-administration. 1. 7/22/25 9:06 AM - During an observation of medication administration E18 (LPN) was observed giving medications to R111, then exiting the room without performing hand hygiene. 7/22/25 9:10 AM - E18 (LPN) was observed preparing medications to administer to R109. E18 grabbed a bottle of Tylenol and poured a tablet into the palm of her bare hand, then tilted her hand until the tablet landed in a medicine cup. Next, E18 grabbed a bottle of supplements and poured two capsules into the palm of her bare hand, then tilted her hand until the tablet landed into the medicine cup containing the Tylenol. E18 then turned to the medications in the cup to R109. Upon surveyor intervention E18 immediately confirmed that medications should not be touched with bare hands to prevent infection and that hand hygiene should have been performed between medication administrations. 2. Review of R97's clinical record revealed: 6/11/25 - R97 was admitted to the facility. 6/11/25 7:00 PM - A physician's order for R97 documented to flush PICC line (IV line) with 10 mL normal saline before and after each use. 6/12/25 6:00 AM - A physician's order for R97 documented to administer cefazolin sodium (antibiotic) every eight hours for left groin seroma. 7/21/2025 2:12 PM - During an interview, R97 stated that staff does not wear a gown when administering antibiotics through the PICC line or when flushing the tubing. 7/21/2025 2:20 PM - During an observation, E19 (Agency LPN) disconnected R97's tubing from antibiotic administration. E19 did not have on a gown while accessing R97's PICC line. 7/21/2025 2:23 PM - During an observation, E19 administered a saline flush to R97's PICC line and did not have a gown on. 7/21/2025 2:25 PM - During an interview, E19 confirmed that she did not have a gown on and did not follow transmission based precautions while accessing R97's PICC line. 7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, it was determined that for one (R74) out of one resident reviewed for positioning, the facility failed to turn and reposition the resident and promote the healing of a pressure ulcer in accordance with professional standards of practice to prevent skin breakdown. Findings include: Review of R74's record revealed: 7/7/23 - R74 Was admitted to facility with diagnoses including cerebral Infarct, hemiplegia, muscle wasting, and contractures8/27/24 - R74's Braden Scale for pressure ulcer risk documented a score of 14 (moderate risk). 5/28/25 - An annual MDS documented R74 as dependent for turning and repositioning. 7/09/25 - R74's A care plan documented that R74 received turning and repositioning at least every two hours and as needed.7/23/25 - An observation of R74 position in the bed on right side at 9:09 AM, 10:00 AM, 11:00 AM, 12:30 PM, and 1:07 PM.7/23/25 1:19 PM - During an interview with E8 (CNA), she stated that when she does total care for a dependent resident, she will turn and reposition them 2-3 times a shift, depending on their needs, such as wound care.7/23/25 1:45 PM - An interview with E4 (LPN) confirmed that R74 had not been repositioned and would have E8 complete the task.7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for two (R31 and R10) out of two residents reviewed for PASRR the facility failed to ensure that a new referral for PASRR was completed upon a new mental health diagnosis and start of new psychotropic medications Findings include: The facility policy regarding PASRR undated, indicated The social services director shall be responsible for keeping track of each resident PASRR screening status, and referring to the appropriate authority . any resident who exhibits newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder. 1. Review of R31's clinical record revealed: 12/26/23 - A PASRR level I screening was completed for R31 that documented a diagnosis of dementia/neurocognitive disorder and use of anxiety medication. 1/18/24 - R31 was admitted to the facility with multiple diagnoses including dementia with psychotic disturbance and anxiety. 1/20/24 - An admission MDS assessment documented that R31 had diagnoses of dementia and anxiety. 5/23/24 - A diagnosis of psychotic disorder with delusions was added to R31's diagnosis list. 3/19/25 - A significant change MDS assessment documented that R31 had diagnoses of dementia, anxiety disorder and a psychotic disorder. 4/30/25 - A physician's order was written for R31 to receive an antipsychotic medication every evening at bedtime. 6/11/25 - A quarterly MDS assessment documented that R31 had diagnoses of dementia, anxiety disorder and a psychotic disorder with use anti-anxiety and anti-psychotic medications. 7/23/25 3:11 PM - During an interview E11 (SW) confirmed a referral for a PASRR review was not completed for R31 following a new diagnoses and medications. 7/24/25 2:44 PM - E2 (DON) provided a copy of the new PASRR assessment completed for R31 that day. This PASRR screening was updated to include anxiety disorder, and psychotic disorder with delusions to the diagnoses. Medications added to this PASRR included the use of an antipsychotic. 2. Review of R10's clinical records revealed: 1/20/25 – R10 was transferred to this long term care facility from another long term care facility. R10's diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance and anxiety disorder. 1/21/25 – A new diagnosis of delusional disorder was added to R10. 7/23/25 – A review of R10's medical record revealed a PASRR Level II screen dated 10/5/23, which documented, Level II - Excluded from PASRR – Primary Neurocognitive Disorder. There was no diagnosis of neurocognitive disorder during R10's stay at the facility and a lack of evidence for resubmitting a PASRR for a new diagnosis of delusional disorder. 7/30/25 10:33 AM – During an interview, E20 (SW) stated that they were unaware if there was a PASRR resubmission for R10 due to the added diagnosis of delusional disorder. 7/30/25 1:00 PM – E20 entered the PASRR resubmission for R10 and the document was dated as 7/30/25. 7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on observation, interview, and record review, it was determined that for two (R98 and R18) out of four residents reviewed for respiratory care, the facility failed to ensure the oxygen tubing and humidifier bottle were changed weekly for R18. Also, R98's BiPAP equipment was not stored in a protective plastic bag. Findings include: Review of the facility's policy and procedure titled Oxygen Administration, dated 10/1/24, documented .Keep delivery devices covered in plastic bag when not in use. 1. Review of R98's clinical record revealed: 12/19/24 – R98 was readmitted to the facility. 7/23/25 – A care plan documented R98 as receiving oxygen therapy related to COPD, respiratory failure, obesity and hypoventilation. R98 has a BiPAP for OSA (obstructive sleep apnea). 7/14/25 – An annual MDS documented R98 as using oxygen and a non-invasive mechanical ventilator such as a BiPAP. 7/16/25 - A physician order for R98 documented to encourage and apply BiPAP every night at bedtime. The resident needs encouragement to use BiPAP. Ensure that the humidifier chamber is filled with sterile water. BiPAP settings at: IPAP 20/EPAP 8. 7/21/25 8:50 AM – An observation noted R98's BiPAP mask sitting on top of the bedside table. There was no bag for the BiPAP to be placed into. 7/21/25 8:57 AM – An observation of E13 (RN Educator) entering R98's room with clear bags. E13 proceeded to take out a clear plastic bag and label it with R98's name. E13 then put R98's BiPAP mask into the clear plastic bag and set it back down on the bedside table. During an interview, E13 stated that the BiPAP should probably be in a bag. 2. Review of R18's record revealed: 3/14/25 - R18 was admitted to the facility with a diagnosis including but not limited to COPD and interstitial lung disease. 7/25/25 - A physician's order for R18 documented change mask, nasal cannula tubing, and humidifier bottle every night shift on Fridays. 7/21/25 9:23 AM - An observation of R18's nasal cannula oxygen tubing and the humidifier bottle undated. 7/21/25 9:26 AM - During an observation and interview with E4 (LPN), it was confirmed there were no dates on R18's oxygen tubing and the humidifier bottle, and she replaced and dated them immediately. 7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on interview and record review it was determined that for one (R3) out of twenty eight residents reviewed the facility failed to develop a care plan to address an identified need. Findings include:Review of R3's clinical record revealed: 5/7/25 - R3 was admitted to hospice. 5/26/25 - A significant change MDS assessment documented that R3 had a poor prognosis and was receiving the specialized service of hospice. 7/23/25 - R3's care plan for ADL's was reviewed. The care plan focus documented that on 5/21/25 a significant change MDS was opened due to R3 signing with hospice. Review of R3's care plans lacked development of a care plan for hospice that included individualized objectives, goals, and timeframes to meet R3's needs. 7/28/25 1:13 PM - During an interview E2 (DON) confirmed the findings. 7/30/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on record review and interview, the facility failed to ensure for four (R13, R88, R108 and R165) residents of seven reviewed were free from a significant medication error when staff failed to administer insulin. Additionally, staff failed to conduct finger stick blood sugar monitoring, some of which included sliding scale insulin coverage based on the results. The facility's failure placed the residents at risk for a serious adverse outcome, hypogycemia and hyperglycemia. Due to this failure an Immedicate Jeopardy (IJ) was called on 8/2/24 at 1:40 PM. The IJ waws abated on 8/6/24 at 3:05 PM. Findings include: The manufacturer's instructions documented that Basaglar is a long-acting insulin used to control high blood sugar in adults with Type 1 or Type 2 diabetes. The manufacturer's instructions documented that Insulin Lispro Injection are fast-acting insulins used to control high blood sugar in adults . with diabetes. The manufacturer's instructions documented that NovoLog® is a man-made insulin used to control high blood sugar in adults and children with diabetes mellitus. 1. Review of R13's July 2024 MAR revealed the following orders: 7/2024 - Basaglar Subcutaneous Solution Pen-injector 32 100 Unit/ml (Insulin Glargine) inject 32 units subcutaneous one time a day related to Type 2 Diabetes Mellitus without complications. 7/2024 - Insulin Lispro Subcutaneous Solution Cartridge 100 unit/ml (Insulin Lispro) inject 12 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. 7/2024 - A glucose meter check before meals and at bedtime. 7/6/24 - No evening or night blood sugar checks were completed. Insulin Lispro was not administered at 4:00 PM. 7/7/24 - No morning, pre-lunch, evening or night blood sugar checks were obtained. Basaglar insulin was not administered at 8:00 AM. Insulin Lispro was not administered at 8:00 AM, 11:00 AM and 4:00 PM. 2. Review of R88's July 2024 MAR revealed the following orders: 7/2024 - Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 10 units subcutaneously one time a day for diabetes. 7/2024 - Novolog FlexPen Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale as follows: if 0 - 140 = 0 . 141 - 180 = 6u; 181 - 220 = 8u; 221 - 260 = 10u 261 - 300 = 12u; 301 - 350 = 14u; 351 - 399 - 16u . . subcutaneously before meals and at bedtime for Diabetes Mellitus. 7/6/24 - No afternoon or evening blood sugar check was completed. The MAR reflected that the sliding scale injection of Novolog Flex Pen insulin was not administered at 4:30 PM and 8:00 PM. 7/7/24 - No morning, pre-lunch or evening blood sugar check was obtained. Insulin Glargine was not administered at 12:00 PM. The sliding scale injection of Novolog Flex Pen insulin was not administered at 7:30 AM, 11:30 AM, 4:30 PM and 8:00 PM. 3. Review of R108's July 2024 MAR revealed the following orders: 7/2024 - Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) Inject 8 units subcutaneously at bedtime for Diabetes Mellitus. The MAR also had a space labeled BS (blood sugar) where the blood sugar result should be referenced. 7/2024 - Insulin Lispro with Transport Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) Inject 4 units subcutaneously before meals for Diabetes Mellitus. The MAR also had a space labeled BS (blood sugar) where the blood sugar result should be referenced. 7/6/24 - No evening or night blood sugar checks were obtained. Lantus was not administered at 9:00 PM. Insulin Lispro was not administered ad 4:00 PM. 7/7/24 - No evening or night blood sugar checks were obtained. Lantus was not administered at 9:00 PM. 4. Review of R165's July 2024 MAR revealed the following orders: 7/2024 - Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) Inject 14 units subcutaneously at bedtime for Diabetes Mellitus. MAR also had a space labeled BS (blood sugar) where the blood sugar result should be referenced. 7/2024 - Novolog FlexPen Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale . if 151 - 200 - 0u 201 - 250 = 2u; 251 - 300 = 4u; 301 - 350 = 6u; 351 - 400 = 8u; 401 - 450 = 10u . .subcutaneously before meals and at bedtime for Diabetes Mellitus. 7/6/24 - No evening or night blood sugar checks were obtained. Insulin Aspart was not administered at 6:00 PM. Lantus was not administered at 9:00 PM. 7/7/24 - No pre-lunch, evening or night blood sugar checks were obtained. Insulin Aspart was not administered at 11:00 AM or 4:00 PM. Lantus was not administered at 9:00 PM. 8/1/24 approximately 2:04 PM - In an Interview, E2 (DON) and E3 (ADON) stated when they were alerted that several residents stated their medications were not administered, they conducted an immediate investigation and notified family members. The nurse involved, E18, was terminated and was also reported to the State. A review of the MAR's show that E18 gave all the oral medications, but did not give any insulin or check blood sugars. They stated that they cannot prove whether the oral medications were given, although they were signed off as being given. None of the residents had any adverse outcome. 8/2/24 1:40 PM - Based on interviews and review of the facility documentation and other sources, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON) and E3 (ADON). 8/2/24 3:25 PM - E1 (NHA), E2 (DON), and E3 (ADON) submitted evidence of an acceptable completed Abatement Plan signed, dated and timed. 8/6/24 3:05 PM - The facility's Immediate Jeopardy was abated at this time. The acceptable abatement plan included documentation of an updated Policy for Reviewing Medication Administration Records (MAR), Drug Administration Records (DAR), and Treatment Administration Records (TAR) at Shift Change; Sign Off Sheet to be completed at shift change; education presented to staff entitled Mandatory Completion of Medication Administration and Treatments for All Staff; and sign in sheet for the aforementioned training. All current licensed nursing staff were educated beginning on August 2, 2024 and finishing on August 5, 2025. Review of training records, sign in sheets and interview with DON revealed that the above abatement plan was completed. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on record review and interview, it was determined that for eight (R3, R71, R99, R106, R366, R98, R14 and R47) out of twenty-three residents reviewed for assessments, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments and admission progress notes. 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 . 1. Review of R3's clinical record revealed: 1/5/24 - R3 was admitted to the facility. A review of R3's clinical record revealed the following 1/6/24 facility admission forms generated by E14 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 7/1/24 - R3 was readmitted to the facility after a hospitalization . A review of R3's clinical record revealed the following 7/1/24 facility admission forms generated by E15 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 2. Review of R71's clinical record revealed: 11/1/23 - R71 was admitted to the facility. A review of R71's clinical record revealed the following 11/2/23 facility admission forms generated by E16 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 3. Review of R99's clinical record revealed: 2/4/24 - R99 was admitted to the facility. A review of R99's clinical record revealed the following 2/4/24 facility admission forms generated by E16 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 4. Review of R106's clinical record revealed: 2/27/24 - R106 was admitted to the facility. A review of R106's clinical record revealed the following 2/27/24 facility admission forms generated by E21 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 5. Review of R366's clinical record revealed: 7/12/24 - R366 was admitted to the facility. A review of R366's clinical record revealed the following 7/12/24 facility admission forms generated by E20 (LPN): Demographics/Orientation to facility, ADLs, Skin Integrity, Oral/Nutrition, Neurological, Respiratory, Cardiovascular, Gastrointestinal, Reproductive, Bladder/Bowel, Sleep, Pain, Mobility/Safety, and Sensory evaluations. 40260 6. Review of R98's clinical record revealed: 9/26/23 - R98 was admitted to the facility. 9/26/23 - E31 (LPN) completed the Prestige Admit/Readmit Screener, Fall Risk, Dehydration Risk, Wander Elopement screener, Assistive Device & Bed Safety Evaluation, and Respiratory Infection screener. 7. Review of R14's clinical record revealed: 7/9/24 - R14 was admitted to the facility. 7/10/24 - E20 (LPN) completed the Prestige Admit/Readmit Screener, Fall Risk, Dehydration Risk, Wander Elopement screener, Assistive Device & Bed Safety Evaluation, Pain Evaluation, Functional Abilities Assessment and Respiratory Infection screener. An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission assessments for R14. 8/1/24 9:55 AM - During an interview, E23 (DON) stated, The admission paperwork is done by the nurse assigned to the room. Sometimes, the supervisor or charge nurse helps out. Usually they (supervisor/charge nurse) put the orders in. The admission assessments in the Admit/Readmit screener include: demographics/orientation, ALDs, oral/nutrition, neuro, respiratory, cardiovascular, GI (gastrointestinal), reproductive, bladder/bowel, sleep, pain, mobility/safety, dehydration and sensory evaluations. The nurse also does an admission progress note. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on clinical record review and interview, it was determined that for four (R14, R90, R100, R47 and R366) out of five residents reviewed for unnecessary psychotropic medications, for R14, the physician failed to ensure that that an appropriate diagnosis was reflected in the resident's chart while antipsychotic medications were being administered. For two residents (R90 and R100), the facility failed to limit an as needed (PRN) psychotropic medication to 14 days. For R366, the facility failed to ensure adequate monitoring (AIMS assessments) and adequate indication for quetiapine (Cross refer to 645). Findings include: 1. Review of R14's clinical record reevealed: 7/9/24 - R14 was admitted to the facility. 7/8/24 - A Preadmission screening and Resident Review (PASARR) Level 1 was completed and revealed that R14 has a diagnosis of generalized anxiety disorder for which Seroquel (Quetiapine Fumarate) is prescribed. 7/9/24 - Discharge Instructions from R14's previous rehabilitation center revealed that R14 was prescribed Seroquel for generalized anxiety disorder. 7/9/24 - An order for Quetiapine Fumarate Oral Tablet 50 MG . Give 1 tablet by mouth in the evening for generalized anxiety was added to R14's MAR. 8/8/24 10:18 AM - In an interview, E12 (MD) stated that the absence of generalized anxiety disorder from R14's list of diagnoses was an oversight and needed to be fixed. E12 stated that the diagnoses at least need to match those from the previous facility. 47142 2. Review of R90's clinical record revealed: 3/8/23 - R90 was admitted to the facility with diagnoses including but not limited to Alzheimer's disease. 6/14/23 - A new diagnosis of Generalized anxiety disorder for R90. 5/7/24 - R90 had a Physician's order for xanax 0.5 mg, give 1 tablet by mouth every 6 hours as needed for restlessness/agitation, please renew every 14 days while in use. The aforementioned order did not have an end date. 8/6/24 10:19 AM - During an interview E12 (MD) stated that they begin a resident for 14 days and then the order will renew every 180 days. After reading the order to E12 with the order saying to renew every 14 days, E12 stated, We need to take a look at that. There was a lack of documentation by the facility for the rationale in the medical record to extend the order beyond 14 days and no evidence of an evaluation. 46988 3. Review of R100's clinical record revealed: 10/16/23 - R100 was admitted to the facility with the following diagnoses: generalized anxiety disorder, major depressive disorder, and adjustment disorder with depressed mood. 2/20/24 - A review of R102's physician's orders revealed an order for Alprazolam (anti-anxiety medication) 0.25 mg give one tablet every eight hours as needed for anxiety/tearfulness for 180 days. 8/8/24 10:27 AM - An interview with E12 (MD) confirmed that PRN (as needed) medications are prescribed initially with a 14 day stop date and change to 180 day stop date. E12 confirmed that R102's alprazolam order did not have a rationale for continued use and will update the order. 4. Review of R47's clinical record revealed: 6/19/18 - R47 was admitted to the facility. 9/29/18 - A review of R47's medical diagnoses revealed R47 has insomnia. 5/24/24 - A review of the physician's orders revealed an order for Trazadone 100 mg at bed time for restlessness. 8/8/24 10:29 AM - An interview with E12 (MD) revealed that restlessness is not a common diagnosis for the use of trazadone and most likely was provided by an outside provider. E12 agreed that the provider using sleeplessness is a more appropriate diagnosis. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference. 47621 5. Review of R366's clinical record revealed: Facility's Policy for Utilization of Psychotropic Medications in Skilled Nursing Facility - .1. Assessment and Indication - Clear Indication: Psychotropic medications should only be prescribed for specific, documented indications such as major psychiatric disorders, severe behavioral symptoms, or significant distress where non-pharmacological interventions have been insufficient . 3. Monitoring and Evaluation: Regular Monitoring: Monitor the resident regularly for effectiveness and side effects, including changes in behavior, cognitive function and overall well-being . 7/12/24 - R366's discharge summary from [hospital] documented, . Hospital Course: .He [R366] also required a sitter due to sundowning episodes . Prescription Medications: Seroquel (Quetiapine) 25 mg oral tablet, 50 mg = 2 tabs . 7/12/24 - R366 was admitted to the facility. 7/12/24 5:40 PM - E12 (MD) ordered in R366's EMR, Quetiapine 50 mg - give 1 tablet by mouth one time a day for delirium. 7/14/24 - R366's admission MDS documented in Section N Medications that antipsychotics were received on a routine basis only. 7/18/24 - E27 (Consultant pharmacist) documented in R366's July Medication Regimen Review (MRR), . 2. Current Order: High Risk Medication Monitoring: Antipsychotic Medication (Quetiapine): Routine Antipsychotic use must be evaluated by MD on admission for potential dose reduction or discontinuation; Perform AIMS (a tool to assess involuntary movements caused by antipsychotic medicine) test within 30 days of admission & every 6 months. Please provide rationale for use with diagnosis of delirium. 7/31/14 - E12 documented on the July MRR that he agreed with recommendation #2 but did not order AIMS test or provide a rationale for the use of quetiapine with the diagnosis of delirium. 8/5/24 4:06 PM - During a telephone interview, E12 confirmed that he did not order the AIMS test in R366's EMR and he did not document a rationale for the usage of quetiapine in the setting of delirium in R366's EMR. 8/5/24 - E13 (PA) ordered in R366's EMR, AIMS test every 6 months .for anti-psychotic usage. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on record review and interview, it was determined that for four (R71, R101, R165, R368) out of twenty-one residents reviewed for infection control, the facility failed to implement an antibiotic stewardship program that monitored the final result of cultures to ensure antibiotics were utilized for the correct indication and duration. Findings include: McGeer Criteria for Infection Surveillance: Syndrome - UTI without indwelling catheter Criteria- Must fulfill both 1 and 2. 1. At least one of the following sign or symptom: -Acute dysuria (pain on urination) or pain, swelling or tenderness of testes, epididymis or prostate -Fever or leukocytosis (elevated white blood cell count), and greater than 1 of the following: --acute costovertebral angle pain or tenderness --suprapubic pain --gross hematuria --new or marked increased in incontinence --new or marked increase in urgency --new or marked increase in frequency -If no fever or leukocytosis, then greater than 2 of the following: --suprapubic pain --gross hematuria --new or marked increased in incontinence --new or marked increase in urgency --new or marked increase in frequency 2. At least one of the following microbiologic criteria -greater than 10 to the fifth CFU/ml of no more than 2 species of organisms in a voided urine sample -greater than 10 to the second CFU/ml of any organism(s) in a specimen collected by an in-and-out catheter. 1. Review of R71's clinical record revealed: 11/1/23 - R71 was admitted to the facility with diagnoses including, but not limited to, dementia and congestive heart failure. R71 was documented as having allergies to: hydrocortisone, Bactrim, Iodinated contrast media, sulfa antibiotics, seafood, shellfish in the EMR. 4/7/24 - E33 documented in R71's progress note, Resident noted to have difficulty holding a lucid conversation today. Husband thinks there is a change. Incontinent of urine. Urine in brief was odorous with red tinge. Will obtain a UA specimen for testing. Afebrile. 98.5. Based on McGeer's UTI without indwelling catheter criteria, this progress note provided documentation that met criteria for a UTI, hematuria and new incontinence in the setting of no fever. 4/10/24 - R71's microbiology urine culture final report documented. Final ESBL-producing organism .>100,000 CFU/ml. Attention: ESBL producing organism, contact isolation required .1. Klebsiella oxytoca ESBL. The report then listed that the pathogen was resistant to eight antibiotics. 4/10/24 - E12 ordered in R71's EMR, Augmentin oral tablet 500-125 mg (Amoxicillin & pot Clavulanate) - give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days. Of note, Augmentin was not a drug that the final microbiology report tested for sensitivity. Levaquin, a fluroquinolone antibiotic, was the only drug listed on the microbiology sensitivities that came in an oral form and did not contain sulfa, which R71 was allergic to. It was unclear why the physician chose to use Augmentin rather than Levaquin, which was documented as an effective antibiotic for this pathogen. 4/11/24 10:05 AM - E34 (LPN) documented in R71's progress note, Resident has continued to decline physically and mentally, recently diagnosed with UTI 1st dose of antibiotic administered. MD assessed and advised to send resident to ER for further evaluation r/t (related to) tachycardia and low-grade fever. Resident will be transported via ambulance to [hospital]. POA (power of attorney) advised. R71 was hospitalized for UTI and encephalopathy from 4/11/24 to 4/15/24. 2. Review of R101's clinical record revealed: 11/29/23 - R101 was admitted to the facility with diagnoses including, but not limited to, dementia. 4/19/24 - E13 (PA) documented in R101's progress note, . Chief complaint: Behaviors/increased confusion . Diagnosis, Assessment and Plan: . Mood disorder - increased confusion, rule out UTI. UA, C&S requested . 4/19/24 - E13 ordered in R101's EMR, UA C&S one time. Review of R101's documented temperatures from 4/21/24 to 4/30/24 revealed R101 to have no documented fevers during this time span. Review of R101's orders during April 2024 revealed that no CBC lab work was ordered so the provider was not able to confirm any elevation in WBCs. 4/21/24 4:48 AM - E35 (LPN) documented in R101's progress notes, Resident had no complaints of discomfort with urination . 4/22/24 12:21 PM - E36 (LPN) documented in R101's alert charting, .No s/s of UTI. Afebrile . Based on McGeer's UTI without indwelling catheter criteria, the documentation in R101's EMR does not meet criteria for UTI without indwelling catheter. 4/24/24 - R101's microbiology urine culture final report documented. Final ESBL-producing organism . >50,000 CFU/ml. Attention: ESBL-producing organism, contact isolation required .1. Klebsiella pneumoniae ESBL. The report then listed that the pathogen was resistant to six antibiotics. The microbiology urine culture final report revealed that R101 was colonized for Klebsiella pneumoniae ESBL. 4/24/24 - E13 ordered in R101's EMR, Ciprofloxacin HCL Oral tablet 500 mg - give 1 tablet by mouth two times a day for UTI for 7 days. Based on McGeer's Criteria for Infection Surveillance, R101 did not meet the criteria for an infection and should not have been treated with antibiotics. R101 met criteria for colonization with an ESBL pathogen. 8/7/24 2:16 PM - During a telephone interview, E12 (MD) stated, The pathogen with growth of greater than 100,000 CFU/ml is universally considered an infection. Infections are treated with antibiotics; colonizations are not. 3. Review of R165's clinical record revealed: 4/11/24 - R165 was admitted to the facility with diagnoses, including but not limited to, osteomyelitis of the right ankle and diabetes. 4/11/24 - E12 (MD) ordered in R165's EMR, Piperacillin-Tazobactam in Dex (dextrose) intravenous solution 2-0.25 gm (grams)/50 ml. use 50 ml intravenously every 6 hours for osteomyelitis. This order had a documented end date of 5/2/24. 4/11/24 - E12 ordered in R165's EMR, Contact and droplet precautions x 10 days. Resident to remain in room every shift for ESBL. This order ended on 4/16/24. 4/16/24 - E12 ordered in R165's EMR, Contact precautions for ESBL in urine every shift. This order ended on 7/16/24. Review of the provided facility line listings for April, May and June 2024 revealed no documentation of the ESBL pathogen in R165's urine. The antibiotic ordered on 4/11/24 has an indication of osteomyelitis so it was unclear if this antibiotic also treated the ESBL pathogen in R165's urine. The facility line listing failed to document the ESBL pathogen in R165's urine and therefore also failed to monitor if the antibiotic prescribed for the osteomyelitis would also treat the ESBL UTI. 4. Review of R368's clinical record revealed: 3/4/24 - R368 was admitted to the facility. 3/5/24 - E12 (MD) ordered in R368's EMR, Foley catheter care every shift. This order was discontinued on 4/1/24. 3/28/24 - E13 (PA) ordered in R368's EMR, Remove foley catheter for trial void. 3/28/24 - E24 (LPN) documented in R368's progress notes, [foley] removed for trial void, 400 ml noted in collection bag and Pt (patient) urinated immediately after removal. 3/29/24 11:58 AM - E37 (LPN) documented in R368's progress notes, . resident verbally requested to go to the restroom to urinate . urinated in toilet . Resident denies any pain/discomfort. 3/30/24 10:42 PM - E38 (LPN) documented in R368's progress notes, . voided large amount yellow urine, denies urinary pain or discomfort. 3/31/24 3:01 AM - E39 (RN) documented in R368's progress notes, . Resident voiding large amounts without difficulty, no pain . 4/3/24 - E12 ordered in R368's EMR, UA, C&S d/t (due to) decline in ADLs . 4/4/24 9:48 PM - R368's lab results report documented a WBC of 5.5 with a normal range of 3.7 to 8.9. R368 had a normal white blood cell count. 4/5/24 12:22 AM- E33 (LPN) documented in R368's progress notes, . No complaints of pain with urination . Review of R368's progress notes from 3/28/24 to 4/12/24 revealed no documentation noting any fevers, increased incontinence, frequency or urgency. 4/6/24 - R368's Microbiology urine culture final report documented. Final - >25,000 CFU/ml .1. Proteus mirabilis. The report then listed that the pathogen was resistant to two antibiotics. This pathogen was sensitive to Ciprofloxacin. 4/6/24 - Cipro oral tablet 250 mg (Ciprofloxacin) (antibiotic) - give 250 mg by mouth two times a day for UTI for 5 days entered in R368's EMR as a verbal order from E12 (MD). 4/6/24 6:46 PM - E22 (LPN) documented in R368's progress notes, . Report received positive UTI on call notified with N.O. (new order) for Cipro 250 mg BID x 5 days . 4/8/24 - E13 documented in R368's progress notes, .Vital signs: . T 97.6 . History of present illness: . daughter noticed increased confusion so UA culture was sent on 4/5/24. Culture result positive, Cipro started . This provider note did not document the pathogen or the isolate count. 4/9/24 - E12 documented in R368's progress notes, .Vital signs: . T 97.7 . Chief complaint: COPD . All labs, images, reports and previous notes reviewed . E12's 4/9/24 progress note failed to mention R368's UTI, lab results or course of antibiotics. Based on McGeer's Criteria for Infection Surveillance, R368 did not meet the criteria for an infection and should not have been treated with antibiotics. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on observation and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. It was determined that for two (R101, R165) out of twenty-one residents for infection control, the facility failed to initiate enhanced barrier precautions on residents with MDRO colonization. The facility 's IPCP surveillance program failed to meet national standards and was lacking in process surveillance of staff practices. Findings include: Cross refer F881 and F842. Facility's Infection Surveillance Policy . Procedure: . 2. Identify individual cases and trends of significant infections to intervene and prevent the spread to other residents and staff 5. When infection or colonization with epidemiologically important organisms is suspected, culture may be sent, if appropriate, to a laboratory for identification or confirmation . 9. The Attending physician will determine the treatment plan for the resident . 10. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will ensure staff are educated and interventions are in place . 12. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data . The data may include: a. lab reports, including culture and sensitivities . d. vital signs, especially temperature . 13. All multidrug- resistant reports require immediate attention . Facility's Enhanced Barrier Precautions (EBP) Policy . Procedures: 1. EBP will be used in addition to standard precautions and when: a. A resident has an infection or colonized CDC-targeted MDRO and Contact Precautions do not otherwise apply or; b. A resident has a chronic wound or indwelling medical device even if the resident is not known to be infected or colonized with a CDC-targeted MDRO . Per the CDC document, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multidrug- esistant Organisms (updated July 12, 2022), focusing only on residents with active infections fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g months) which contributes to the silent spread of MDROs. McGeer Criteria for Infection Surveillance: Syndrome- UTI without indwelling catheter Criteria- Must fulfill both 1 and 2. 1. At least one of the following sign or symptom: -Acute dysuria (pain on urination) or pain, swelling or tenderness of testes, epididymis or prostate -Fever or leukocytosis (elevated white blood cell count), and greater than 1 of the following: --acute costovertebral angle pain or tenderness --suprapubic pain --gross hematuria --new or marked increased in incontinence --new or marked increase in urgency --new or marked increase in frequency -If no fever or leukocytosis, then greater than 2 of the following: --suprapubic pain --gross hematuria --new or marked increased in incontinence --new or marked increase in urgency --new or marked increase in frequency 2. At least one of the following microbiologic criteria -greater than 10 to the fifth CFU/ml of no more than 2 species of organisms in a voided urine sample -greater than 10 to the second CFU/ml of any organism(s) in a specimen collected by an in-and-out catheter. 1. Review of R21's clinical record revealed: 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Report dated 4/9/24, which the facility provided as part of their infection line listing, R21 was documented . with infection ESBL no location of this infection was noted on Macrobid 100 mg BID thru (sic) 4/14. This line listing did not specify the name of the pathogen, its location or describe R21's signs and symptoms of infection. The line listing did not document the infection as healthcare-associated infection (HAI) or community-acquired. The line listing also did not document that R21 was on contact precautions. 2. Review of R71's clinical record revealed: 11/1/23 - R71 was admitted to the facility with diagnoses including, but not limited to, dementia and congestive heart failure. 4/7/24 - E33 documented in R71's progress note, Resident noted to have difficulty holding a lucid conversation today. Husband thinks there is a change. Incontinent of urine. Urine in brief was odorous with red tinge. Will obtain a UA specimen for testing. Afebrile. 98.5. 4/8/24 - E12 (MD) ordered in R71's EMR, STAT UA (urinalysis) . CBC (complete blood count) and BMP (basic metabolic panel) r/t (related to) change in mental status . 4/10/24 - R71's microbiology urine culture final report documented. Final ESBL- producing organism . >100,000 CFU/ml. Attention: ESBL producing organism, contact isolation required . 1. Klebsiella oxytoca ESBL. The report then listed that the pathogen was resistant to eight antibiotics. Based on McGeer's UTI without indwelling catheter criteria, this progress note along with the microbiology culture results provided documentation that met criteria for a UTI due to hematuria and new incontinence in the setting of no fever. 4/10/24 - E13 (PA) ordered in R71's EMR, Contact precautions for ESBL (extended-spectrum beta-lactamases) in urine until end of abt therapy . 8/7/24 2:16 PM - During a telephone interview regarding R71's urinary tract infection, E12 (MD) stated, Yes, we knew it was an MDRO. When asked about differentiating an infection from a colonization, E12 stated that pathogen had growth of greater than 100,000 CFU/ml is universally considered an infection. 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Report dated 4/9/24, which the facility provided as part of their infection line listing, R71 was documented . with infection UTI on Augmentin 500-125 BID thru (sic) 4/17. This line listing did not specify the name of the pathogen or describe R71's signs and symptoms of infection. The line listing did not document the infection as healthcare- associated infection (HAI), which it was since R71 had not left the facility since being readmitted after a hospitalization on [DATE]. 3. Review of R95's clinical record revealed: 3/5/24 - R95 was admitted to the facility. 5/11/24 3:52 PM - R95's EMR in the Results tab documented, Collection date 5/9/24 7AM, Received date: 5/9/24 12:03 PM, Reported date: 5/11/24 3:52 PM Urine cath - 1 Organism growth final status. This lab result report was documented as Reviewed by E13 (PA) on 6/24/24 at 8:46 AM. The surveyor was not able to find any documentation in R95's EMR of the specific pathogen that grew from this sample. The only documentation of a pathogen was 1 organism growth' in the Results tab of R95's EMR. Upon request for the final microbiology culture with sensitivities, the surveyor was provided the document below. 5/11/24 - R95's microbiology urine culture final report documented. Final: .>100,000 CFU/ml. Attention: Multi drug resistant organism, contact isolation required .1. Methicillin Resistant Staphylococcus aureus. The report then listed that the pathogen was resistant to two antibiotics. The microbiology urine culture final report revealed that R95 's urine was infected with MRSA. Of note, both the lab report in the Results tab of R95's EMR and R95's microbiology urine culture final report are dated 5/11/24. It is unclear why the final microbiology culture report was not uploaded into R95's EMR under the Results tab. 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Reports dated 5/14/24, 5/21/24, and 5/28/24, which the facility provided as part of their infection line listings, R95 was documented . with infection UTI on Macrobid 100 mg BID (twice a day) thru (sic) 5/29. This line listing did not specify the name of the pathogen or describe R95's signs and symptoms of infection. The line listings did not document whether R95 was on the required contact precautions. The line listing did not document whether the infection was healthcare-associated infection (HAI) or community-acquired. 4. Review of R101's clinical record revealed: 11/29/23 - R101 was admitted to the facility with diagnoses including, but not limited to, dementia. 4/19/24 - E13 (PA) documented in R101's progress note, . Chief complaint: Behaviors/increased confusion . Diagnosis, Assessment and Plan: . Mood disorder- increased confusion, rule out UTI. UA, C&S requested . 4/19/24 - E13 (PA) ordered in R101's EMR, UA C&S one time. 4/21/24 4:48 AM - E35 (LPN) documented in R101's progress notes, Resident had no complaints of discomfort with urination . 4/22/24 12:21 PM - E36 (LPN) documented in R101's alert charting, . No s/s (signs and symptoms) of UTI. Afebrile . 4/24/24 - R101's microbiology urine culture final report documented. Final ESBL- producing organism .Isolate 1:>50,000 CFU/ml. Attention: ESBL producing organism, contact isolation required .1. Klebsiella pneumoniae ESBL. The report then listed that the pathogen was resistant to six antibiotics. The microbiology urine culture final report revealed that R101 was colonized for Klebsiella pneumoniae ESBL. 4/24/24 - E13 (PA) ordered in R101's EMR, Ciprofloxacin HCL Oral tablet 500 mg - give 1 tablet by mouth two times a day for UTI for 7 days. 4/24/24 - E13 (PA) ordered in R101's EMR, Contact precautions for ESBL in urine. D/C (discontinue) when ABT is completed . The end date for contact precautions documented in R101's EMR was 5/5/24. Based on McGeer's Criteria for Infection Surveillance, R101 did not meet the criteria for an infection and should not have been treated with antibiotics and contact precautions. R101 met criteria for colonization with an ESBL pathogen and therefore required ongoing enhanced barrier precautions. 8/7/24 2:16 PM During a telephone interview, E12 (MD) stated, The pathogen with growth of greater than 100,000 CFU/ml is universally considered an infection. Infections are treated with antibiotics; colonizations are not. 8/8/24- E13 (PA) ordered in R101's EMR, Enhanced barrier precautions for high contact care activities including gown and gloves every shift for transmission precautions for ESBL in urine. There were 94 days (from 5/6 to 8/7/24) that R101 with a known ESBL colonization received direct care in the facility without the appropriate EBP precautions. 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Report dated 4/23/24 and 4/30/24, which the facility provided as part of their infection line listing, R101 was documented . with infection UTI on Cipro (Ciprofloxacin) 500 mg BID thru (sic) 5/1. This line listing did not specify the name of the pathogen. The line listing did not document whether the infection was healthcare-associated infection (HAI), which it was since R101 had not left the facility. 5. Review of R165's clinical record revealed: 4/11/24 - R165 was admitted to the facility with diagnoses, including but not limited to, osteomyelitis of the right ankle and diabetes. 4/11/24 - E12 (MD) ordered in R165's EMR, Piperacillin-Tazobactam in Dex (dextrose) intravenous solution 2-0.25 gm/50 ml. use 50 ml intravenously every 6 hours for osteomyelitis. This order had a documented end date of 5/2/24. 4/11/24 - E12 (MD) ordered in R165's EMR, Contact and droplet precautions x 10 days. Resident to remain in room every shift for ESBL. This order ended on 4/16/24. 4/16/24 - E12 (MD) ordered in R165's EMR, Contact precautions for ESBL in urine every shift. This order ended on 7/16/24. Of note, R165 had an indwelling medical device, a PICC line so R165 required enhanced barrier precautions while this central line was present. Review of the provided facility line listings for April, May and June 2024 revealed no documentation of the ESBL pathogen in R165's urine. The antibiotic ordered on 4/11/24 has an indication of osteomyelitis so it was unclear if this antibiotic also treated the ESBL pathogen in R165's urine. 5/2/24 - E12 (MD) ordered in R165's EMR, Invanz injection solution (Ertapenem Sodium) Use 500 mg intravenously one time a day for wound care until 5/16/24. The only time that R165 was not receiving IV antibiotics was from 5/16 to 7/16/24. 7/10/24 - E13 (PA) ordered in R165's EMR, Biopsy RLE (right lower extremity) Send to ER (emergency room ) [hospital]. 7/10/24 to 7/16/24 - R165 was hospitalized for further management of her right ankle osteomyelitis. R165's discharge summary from the 7/10 to7/16/24 hospitalization documented, . Brief Hospital Course - . status post bone biopsy on 7/12. Patient continues to remain asymptomatic. Normal WBC. Biopsy specimen grew MRSA (methicillin resistant staphylococcus aureus) and gram-negative staph therefore started on Vancomycin by infectious disease during the weekend . Home medications: . Vancomycin 750 mg in 150 ml 5% dextrose IVPB (intravenous piggyback) daily for 5 days. 7/16/24 - E13 ordered in R165's EMR, Contact precautions: MRSA to wound bed RLE every shift . There were 90 days (from 4/16/ to 7/15/24) that R165 with an indwelling medical device received direct care in the facility without the appropriate EBP precautions. 7/17/24 - E12 ordered in R165's EMR, Vancomycin HCL intravenous solution 750 mg/150 ml. Use 750 mg intravenously one time a day for wound for 42 days. Infuse over 60 minutes. This order has an end date of 9/12/24. 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Report dated 4/16/24, which the facility provided as part of their infection line listing, R165 was documented as housed in room K03, with infection osteomyelitis on Piperacillin-Tazobactam (antibiotic) 2-0.25 q (every) 6 hrs (hours) with no end date. The 4/23/24, 4/30/24 line listing documented the Piperacillin-Tazobatam ended on 5/12/24. The 5/7/24, 5/14/24, and 5/21/24 line listings documented the antibiotic was changed to Invanz 500mg IVPB with an end date of 5/16/24. This line listing did not specify the name of the pathogen or describe R165's signs and symptoms of infection. There were some lab results listed on the 4/16/24 line listing. The line listing did not document whether the infection was healthcare-associated infection (HAI) or community-acquired. None of the line listings documented whether R165 was on any precautions. The facility failed to update the line listing to reflect that R165 was diagnosed by biopsy on 7/12/24 with MRSA infection and again failed to document on the line listing that R165 required contact precautions. The facility failed to include documentation of R165's ESBL pathogen in her urine on their line listings. 6. Review of R367's clinical record revealed: 5/8/24 - R367 was admitted to the facility with diagnoses including, but not limited to, heart failure. 5/14/24 - E12 (MD) ordered in R367's EMR, Urinalysis C&S r/t UTI one time for burning, urgency, frequency. 5/18/24 - R367's microbiology urine culture final report documented. Final ESBL- producing organism .Isolate 1:>100,000 CFU/ml. Attention: ESBL producing organism, contact isolation required .1. Klebsiella pneumoniae ESBL. The report then listed that the pathogen was resistant to six antibiotics. The microbiology urine culture final report revealed that R367's urine was infected with Klebsiella pneumoniae ESBL. Based on McGeer's UTI criteria, the documentation met the criteria for a UTI with increased urgency and frequency. 5/19/24 - E12 ordered in R367's EMR, Macrobid oral capsule 100 mg (nitrofurantoin) give 1 capsule by mouth two times a day for UTI/ESBL. This order had an end date of 5/28/24. 5/19/24 - E12 ordered in R367's EMR, Contact precautions + ESBL in urine every shift. 8/8/24 10:27 AM - Review of the IP (Infection Prevention) Weekly Antibiotic Report dated 5/21/24, which the facility provided as part of their infection line listing, R367 was documented as housed in room K01d, with infection UTI/ESBL on Macrobid 100 mg BID thru. There was no end date documented. This line listing did not specify the name of the pathogen or describe R1367's signs and symptoms of infection, which included burning, urgency and frequency. The line listing did not document whether the infection was healthcare-associated infection (HAI) or community-acquired. The line listing did not documented whether R165 was on any precautions; R367 was ordered contact precautions on 5/19/24. 8/7/24 1:58 PM - During an interview, E31 (IP) stated, Ultimately, it is up to the provider to determine if the resident is colonized. I suspect that it would be noted in the chart if the resident is colonized. Then the facility would put the resident on EBP precautions if it is an MDRO. 8/8/24 10:27 AM - Review of the facility's ongoing infection prevention program system of surveillance (infection line listing) revealed the data collection tool lacked multiple significant data points. The data collection tool provided was a weekly document that failed to capture the specific name of the pathogen that was causing the infection, the infection site, the signs and symptoms of the infection such as temperature and elevated white blood cell (WBC) count, the start and stop date of any antibiotics prescribed, precautions (if any) that were implemented, invasive procedure/risk factors, and whether the infection was community-acquired or healthcare-associated infections (HAIs). It should be noted that the document that the facility provided as the facility's infection line listing was titled IP (infection Prevent) Weekly Antibiotic Report. The surveillance documents provided by the facility for April, May and June 2024 failed to have the necessary monthly summary, analysis and interpretation of the data. These documents did not identify any infection trends or patterns. The facility infection surveillance policy lists tools called Facility-Wide Monthly Infection Report by Pathogen, Facility-Wide 12-Month Pathogen Trends and Facility-Wide 12-Month Infection Site Trends. The facility was not able to provide these documents for review. The surveillance documents that were provided did not include any documentation of any follow-up activities such as staff education or random observations on all shifts of the staff appropriately implementing enhanced barrier or contact precautions on residents who were ordered those precautions. 8/9/24 9AM - In an email correspondence, E31 (Infection Preventionist) stated the facility utilizes McGeer's Criteria for Infection Surveillance. E31 also stated, It is the provider who ultimately makes the diagnosis. Our lab provider interfaces with PCC (facility's EMR). They also email results of which our providers are part of the email thread. Regarding final culture reports, E31 stated, We are aware they are having technical problems with their interfacing. They are working on a resolution. It is also why they email the results. It's my understanding that they are moving and when they get set up in their new spot theses (sic) issues should resolve. The paper copies we receive are placed in the paper chart. 8/9/24 9:32 AM - During a telephone interview, E12 (MD) stated, No, the providers do not have access to the [laboratory provider]'s website to look up results when the physician is out of the facility. the providers are not given the final culture report. Regarding colonization, E12 clarified, Anything less than 100,000 CFU/ml is considered colonized unless the resident is symptomatic. The facility uses McGeer's criteria to determine if it is an infection with regard to symptoms. 8/9/24 10:05 AM - In an email correspondence, E2 (ADON) stated the status date on the [lab] report is what day they are in in (sic) the culture series for whatever they are growing. The date we receive is when they email us. The providers are on the email blast, and E13 (PA) is in the facility 5 days a week. The supervisor is responsible for calling the provider with any updates and confirming they received the reports if they are not on site at that time and if it has not yet been addressed. 38302 7. 7/30/24 1:29 PM - E5 (Laundry Aide) was observed placing soiled laundry into the washing machine using ungloved hands. An interview revealed that E5 was not aware of safe handling practices for general soiled laundry or for laundry belonging to residents who were on various types of precautions due to illness. During the interview, E5 stated that since being transferred to the laundry several months ago, no training regarding the safe handling of soiled laundry, including the proper use of PPE when processing the soiled laundry has been provided. 8/9/24 11:33 AM - Findings were reveiwed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on observations and interview, it was determined that the facility failed to ensure the dietician approved menus are followed to meet the nutritional needs of the residents and for two (R49 and R97) out of ten sampled residents, the facility failed to ensure that residents received the selected food from the menu. Findings include: 7/30/24 11:20 AM - During a tour of the kitchen, the posted menu indicated that the lunch option for that Tuesday was ravioli, green beans, and mashed potatoes with gravy. Review of the facility submitted menu for the week of July 28th through August 3rd indicated that the planned lunch for July 30 was baked beef patty, green beans, mashed potatoes and gravy. An interview with E6 (Dietary Director) revealed that the ravioli was a substitution for the baked beef patty listed on the original menu. 8/7/24 10:23 AM - An interview with E7 (Dietician) revealed the substitution of ravioli on July 30, 2024 was not brought to the attention of the dietician for approval as an adequate substitute as part of that meal. 47142 2. 7/31/24 9:18 AM - A random observation of R49's breakfast tray revealed missing almond milk and cranberry juice. R49 stated he doesn't get what is on the meal ticket and that he receives fruit punch instead of cranberry juice. The meal ticket showed R49 was supposed to have the almond milk and cranberry juice. 8/1/24 9:13 AM - A random observation of R49's breakfast tray revealed missing breakfast ham, cranberry juice and almond milk. There were no substitutions on the tray form the missing breakfast ham or the almond milk. Instead of cranberry juice there was apple juice on the tray. 8/1/24 9:16 AM - An observation of R49 telling E9 (CNA) that he did not receive what he wanted, E9 apologized and stated she would call the kitchen. 8/1/24 9:23 AM - An interview with E9 revealed that she called the kitchen and they did not have cranberry juice. 8/1/24 12:54 AM - A random observation of R49's lunch tray revealed missing creamed corn and mechanical soft refried beans. The meal ticket showed R49 was supposed to have the creamed corn and mechanical soft refried beans and there were no substitutions provided. 8/2/24 11:14 AM - A interview with E7 (Dietician) revealed that what is printed on the meal ticket should be on the resident's tray. E7 stated that they did not have creamed corn in the kitchen and the facility just recently stopped carrying almond milk, which confirmed there was none in the facility. E7 stated since the kitchen did not have any refried beans they were supposed to substitute mashed potatoes. 46988 3. 8/7/24 1:38 PM - A random observation of R97's lunch tray revealed that chocolate ice cream and iced tea were missing from the tray. A review of the printed lunch ticket confirmed chocolate ice cream and iced tea were on R97's menu order for lunch. 8/7/24 1:42 PM - An interview with E11 (CNA) confirmed that the chocolate ice cream and iced tea were missing from the tray. E11 called down to the kitchen to have the missing items sent to the unit. E11 confirmed that items are consistently missing on trays during meal time. 8/8/24 1:04 PM - A random observation of R97's lunch tray revealed that six ounces of beef and barley soup, four ounces of carrot raisin salad, one cookie, and one carton of milk was missing off the tray. A review of the printed lunch ticket confirmed that the soup, salad, cookie, and milk were on R97's menu order for lunch. 8/8/24 2:00 PM - An interview with E11 (CNA) confirmed the above mentioned items were not delivered on the tray. E11 stated that R97's visitor had provided food that he brought for R97. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on observation, interview and record review it was determined that for four (R47, R55, R61 and R100) out of five residents reviewed for bowel and bladder, the facility failed to provide services to restore bladder continence. Findings include: 1. Review of R47's clinical record revealed: 6/19/18 - R47 was admitted to the facility. 2/6/24 - A review of a quarterly MDS assessment revealed that R47 is always incontinent of bladder and frequently incontinent of bowel. No toileting program was indicated. 2/2024 - A review of the February CNA task flow sheet revealed that R47 was incontinent of bowel nine out of ninety opportunities. 3/2024 - A review of the March CNA task flow sheet revealed that R47 was incontinent of bowel two out of ninety opportunities. 4/2024 - A review of the March CNA task flow sheet revealed that R47 was incontinent of bowel seven out of ninety opportunities. 5/1/24 - A review of a quarterly MDS assessment revealed that R47 was always incontient of bladder and always incontinent of bowel. No toileting program was indicated. 8/6/24 12:16 PM - An interview with E4 (MDS LPN) revealed that the MDS coordinators are responsible for monitoring residents bowel and bladder continence and establishing toileting programs for the residents who need it. E4 confirmed that R47 was not on a toileting program at this time. 8/7/24 10:50 AM - An interview with E11 (CNA) confirmed that R47 was continent prior to last admission to the hospital and was able to use a bed pain prior. E11 confirmed that R47 is now more incontinent and does not request the bed pan. 2. Review of R55's clinical record revealed: 4/13/22 - R55 was admitted to the facility. 2/28/24 - A review of the annual MDS assessment revealed that R55 was occasionally incontinent of bladder and was always continent of bowel. No toileting program was indicated. 2/2024 - A review of the February CNA task flow sheet revealed that R55 was incontinent of bladder ten out of ninety opportunities. 3/2024 - A review of the March CNA task flow sheet revealed that R55 was incontinent of bladder twenty-seven out of ninety opportunities. 4/2024 - A review of the April CNA task flow sheet revealed that R55 was incontinent of bladder twenty-four out of ninety opportunities. 5/2024 - A review of the May CNA task flow sheet revealed that R55 was incontinent of bladder thirty-three out of ninety opportunities. 5/29/24 - A review of a quaterly MDS assessment revealed that R55 was frequently incontinent of bladder and occasionally incontinent of bowel. No toileting program was indicated. 8/6/24 12:16 PM - An interview with E4 (MDS LPN) revealed that the MDS coordinators are responsible for monitoring residents bowel and bladder continence and establishing toileting programs for the residents who need it. E4 confirmed that R55 was not on a toileting program at this time. 3. Review of R61's clinical record revealed: 3/12/21 - R61 was admitted to the facility. 12/21/23 - A review of a quarterly MDS assessment revealed that R61 was always incontinent of bladder and frequently incontinent of bowel. No toileting program was indicated. 12/2023 - A review of the December CNA task flow sheet revealed that R61 was incontinent of bowel thirty-nine out of ninety opportunities. 1/2024 - A review of the January CNA task flow sheet revealed that R61 was incontinent of bowel twenty-four out of ninety opportunities. 2/2024 - A review of the February CNA task flow sheet revealed that R61 was incontinent of bowel twelve out of ninety opportunities. 3/2024 - A review of the March CNA task flow sheet revealed that R61 was incontinent of bowel twenty out of ninety opportunities. 3/19/24 - A review of an annual MDS assessment revealed that R61 was always incontient of bladder and always incontinent of bowel. 8/6/24 12:16 PM - An interview with E4 (MDS LPN) revealed that the MDS coordinators are responsible for monitoring residents bowel and bladder continence and establishing toileting programs for the residents who need it. E4 confirmed that R55 was not on a toileting program at this time. 8/7/24 11:04 AM - An interview with E28 (CNA) confirmed that R61 was dependent on staff for toileting and no toileting program was in place. E28 confirmed that R61 was toileted every two hours. 4. Review of R100's clinical record revealed: 10/16/23 - R100 was admitted to the facility. 4/9/24 - A review of a quarterly MDS assessment revealed that R100 was always continent of bladder and always continent of bowel. No toileting program was indicated. 5/2024 - A review of the May CNA task flow sheet revealed that R100 was incontinent of bladder five out of ninety opportunities. 6/2024 - A review of the June CNA task flow sheet revealed that R100 was incontinent of bladder four out of ninety opportunities. 7/2/24 - A review of a quaterly MDS assessment revealed that R100 was occasionally incontinent of bladder and always continent of bowel. No toileting program is indicated at this time. 7/2024 - A review of the July CNA task flow sheet revealed that R100 was incontinent of bladder eight out of ninety opportunities. 8/6/24 12:16 PM - An interview with E4 (MDS LPN) revealed that the MDS coordinators are responsible for monitoring residents bowel and bladder continence and establishing toileting programs for the residents who need it. E4 confirmed that R55 was not on a toileting program at this time. 8/7/24 10:50 AM - An interview with E19 (CNA) confirmed that R100 was not on a toileting program. E19 stated R100 was always continent and does not require staff assistance for toileting. The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R47, R55, R61, and R100. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on record review and interview, it was determined that for two (R104 and R366) of four sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) Level I, the facility failed to have a currently dated PASARR Screening. Findings include: 1. Review of R104's clinical record revealed: [DATE] - A level I convalescence categorical admission was submitted for R104 and approved for sixty days. [DATE] - R104 was admitted to the facility with the following diagnoses: paranoid schizophrenia and intellectual disability. [DATE] - A review of a level I PASARR submitted to the state PASARR authority lacked evidence of R104's current diagnoses and services provided. [DATE] - R104's concalescence categorical admission PASARR expired. [DATE] 1:07 PM - An interview with E8 (SW) confirmed that the PASARR I submitted did not reflect R104's current condition. E8 confirmed that it lacked current diagnoses and services provided. 47621 2. Review of R366's clinical record revealed: Cross refer to F758. [DATE] - Notice of PASARR Level I Screen documented, .there are no known mental health symptoms affecting the individual's ability to think through or complete tasks which she/he should be physically capable of completing . Mental Health Medications - no medications . [DATE] - R366 underwent a psychiatry consult while hospitalized that documented R366 as having hallucinations and behaviors such as pulling out IV's and EKG leads. E29 (psychiatrist) documented, XXX[AGE] year old male with formal psychiatric history . developed hospital delirium. He was seen to adjust his medications because of more confusion and restlessness at night suggestive of sundowning . Level of care: Pharmacological: We can increase Seroquel to 50 mg at 6:00 PM to prevent sundowning, we can gradually increase the dose if the 50 mg is not working. Patient psychotic? No . [DATE] - R366's discharge summary from [hospital] documented, . Hospital Course: .He [R366] also required a sitter due to sundowning episodes . Prescription Medications: Seroquel (Quetiapine) 25 mg oral tablet, 50 mg = 2 tabs . [DATE] - R366's hospital discharge instructions documented, . Updates to Your Medications . Quetiapine (Seroquel) 25 mg (milligrams) 2 tabs by mouth every 24 hours for delirium . [DATE] - R366 was admitted to the facility. [DATE] 5:40 PM - E12 (MD) ordered in R366's EMR, Quetiapine 50 mg - give 1 tablet by mouth one time a day for delirium. [DATE] - R366's admission MDS documented in Section N Medications that antipsychotics were received on a routine basis only. [DATE] 9:47 PM - E13 (PA) documented in R366's progress note, . History of present illness: . Post-op course was complicated . he was also noted to have sundowning episodes . I spoke with patient son (sic) who stated at home he is AO X 3 (alert and oriented to person, place and time) but became very confused while hospitalized . He also stated that the confusion comes and goes . Diagnosis, Assessment and Plan: . Delirium ,d+[DATE] prolonged hospitalization - continue Seroquel 50 mg daily . [DATE] 8:50 PM - E12 (MD) documented in R366's History and Physical progress note, . Diagnosis, Assessment and Plan: . Delirium - Quetiapine. [DATE] 8:38 AM - Email correspondence with C1 (State PASRR supervisor), C1 stated, . He [R366] should have had a resident review submitted when the facility became aware that the PASARR was not an actual reflection of his current condition The PASARR evaluation would determine if further PASARR evaluation or a full level II would be required or not. It is the receiving facility's responsibility to ensure that the PASARR is an accurate reflection of the individual's current condition so they should be reviewing it prior to admitting the individual to their facility. If the PASARR is not accurate, then they should not be admitting the individual and asking the hospital to resubmit. If they do admit, then they must submit the resident review as soon as they are aware of the omissions . In this case, the Level I was not an accurate reflection of his current status at the time of admission. [DATE] 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on interview and record review, it was determined that for two (R37 and R47) out of four residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed. Findings include: 1. Review of R37's clinical record revealed: 2/24/17 - A PASARR level I was completed for R37 and determined that no further evaluation was needed. 3/1/17 - R37 was admitted to the facility. 7/30/18 - R37 was diagnosed with the following diagnoses: delusional disorder, bipolar disorder, and hallucinations. 3/23/23 - R37 was diagnosed with the following diagnoses: generalized anxiety disorder and dementia with psychotic disturbance. 5/8/24 - An annual MDS assessment revealed that R37 had the following diagnoses: anxiety disorder, depression, manic depression, and psychotic disorder. 8/05/24 12:39 PM - An interview with E8 (SW) revealed that that there was no evidence a level II was submitted when there was evidence of a serious mental disorder. 2. Review of R47's clinical record revealed: 5/16/18 - A PASARR level 1.5 was completed for R47 and indicated R47 has a serious mental illness but did not require a level II at this time. 6/19/18 - R47 was admitted to the facility with the following diagnosis: anxiety disorder. 3/31/20 - A PASARR level I was completed for R47 and indicated R47 has a serious mental illness but did not require a level II at this time. 4/21/24 - R47 was diagnosed with the following diagnoses: schizoaffective disorder, major depressive disorder, and dementia. 5/1/24 - A quarterly MDS assessment revealed that R47 had the following diagnoses: anxiety disorder, depression, manic depression, schizophrenia, and psychotic disorder. 8/05/24 12:39 PM - An interview with E8 (SW) revealed that there was no evidence a level II was submitted when there was evidence of a serious mental disorder. The facility lacked evidence of any updates submitted to the State PASARR authority for R37 or R47. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on record review and interview, it was determined that for one (R90) out of fourteen (14) sampled residents reviewed for abuse, it was determined that the facility failed to immediately report an injury of unknown source. Findings include: A review of R90's clinical record revealed: 3/8/23 - R90 was admitted to the facility with diagnoses including but not limited to Alzheimer's disease. 6/8/24 11:57 AM - A nursing note documented by E17 (LPN) stated that R90 had a large bruise on the left inner bicep with measurements of 8.5 cm x 6.4 cm, resident is complaining of pain from the area. The note documented the supervisor was notified and the bruise documented in the doctor's book. 6/8/24 10:55 PM - A nursing note documented by E18 (RN former employee) stated that around 7:45 PM the area on R90's left bicep was larger and tight and R90 was guarding her arm. R90 was sent to the emergency room around 8:15 PM. Around 10:40 PM, the emergency room reported R90 had a broken right upper arm. The nursing note documented that a report was given to the DON and the oncoming supervisor. 6/9/24 2:41 PM - A facility reported incident was submitted by the facility to the State Agency that alleged R90 was sent to the emergency room for an evaluation. R90 was observed guarding her left arm. The report stated there was no bruising initially but developed throughout the day and R90 exhibited signs and symptoms of pain. 8/6/24 11:40 AM - An interview with E17 revealed that on 6/8/24 around 7:30 AM, R90 had a discolored area on left upper arm that was not bruised. E17 stated around 10:30 AM, the area on the left upper arm was turning purple in color but not swollen. At approximately 6:30 PM, the area was spreading and remained purple in color. At 8:00 PM, the area was purple in color and spread from the upper arm down to the elbow. 8/7/24 10:05 AM - An interview, E2 (ADON) confirmed that a bruise of unknown origin was a reportable event and she was not sure why there was a delay. E2 stated the DON was on-call that weekend and it should have been reported. 8/0/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R27) out of twenty-eight (28) residents reviewed for dignity, the facility failed to promote dignity. Based on a review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 12/14/23. Findings include: The facility policy titled Resident Dignity, last updated 10/2020, indicated that . Residents shall always be treated with dignity and respect . means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Staff shall promote, maintain, and protect resident privacy . The facility policy titled Cell Phones, last updated 4/2020, indicated that . At no time is it considered courteous or professional to use your cell phone while you are in the department providing care and/or services to the residents in the facility . A review of R27's clinical record revealed: 7/4/15 - R27 was admitted to the facility with diagnoses including, but not limited to, Alzheimer's disease. 9/27/23 - A quarterly MDS for R27 documented a BIMS score of 2, which showed severe cognitive impairment. 12/8/23 - A complaint was submitted by the facility to the State Agency that alleged an agency nurse posted a video to a social media website showing the agency nurse with a resident. Review of facility documentation related to the above complaint revealed the video was posted on the social media website for about 20 minutes, received 45 likes and 4 comments to the video. 8/7/24 9:14 AM - A review of the video that was posted to the social media website revealed E10 (RN, former employee) sitting next to R27 in the common area. R27 was leaned her head towards E10's right side of head, placing her forehead against the right side of E10's head. The video is about 4 seconds long and is repeated on a loop 4 times. There is music playing in the background of the video. There is a caption that stated, When the lazy nurse complains about having to answer your [favorite] resident call bell at night. 8/7/24 10:05 AM - An interview with E2 (ADON) confirmed the findings and stated staff are not supposed to have their cell phones on the floor and E10 was terminated from the facility. All employees were educated on topics such as HIPAA (Health Insurance Portability and Accountability Act), Cell Phones and Rules for Use of Technology, Treatment of Residents/Resident Rights and Abuse Prevention. The facility had audited all employees to make sure education was completed on the previous topics. Based on the review of the facility's thorough investigation, documented response, completion of in-service training and audits, staff interviews and no further incidents related to the dignity of residents, R27's incident was determined to be past non-compliance. The plan of correction was initiated on 12/8/23 and completed on 12/14/23. 8/9/24 11:33 AM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (QA RN) and E4 (MDS LPN) during the exit conference.

Based on record review and interview, it was determined that for one (R8) out of three residents reviewed for accidents, the facility failed to adequately supervise, accurately evaluate and identify R8's risk for falling, analyze R8's recurrent falls, do complete neurological (neuro) checks and implement new interventions after R8 sustained multiple recurrent unwitnessed falls, including four within a 12- hour span. For two of the falls, R8 sustained harm and was hospitalized . One fall resulted in a left side brain bleed and in another he sustained a finger fracture. An additional fall with injury occurred when R8 sustained a hematoma to the right side of his forehead which resulted in a transfer to the Emergency Department. Findings include: Cross refer F690 A facility policy (last revised 4/2006) entitled Urinary Continence and Incontinence - Assessment and Management included: - The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. - As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. - Toileting programs will start with a 3-5 day toileting assistance trial. - Incontinence care should be individualized at night in order to maintain comfort and skin integrity and minimize sleep disruption. A facility policy (last revised 9/26/17) entitled Fall Management Policy and Procedure included: Neurological checks will be completed as follows: -every 15 minutes x (times) 4. -every 30 minutes x 2. -every 1 hour x 2. -every 4 hours x 5. -When a resident is sent to an acute care setting post fall for an evaluation, upon return to the facility neurological checks will begin at hourly intervals. A facility policy (last revised 3/2018) entitled Falls and Fall Risk, Managing included: Resident conditions that may contribute to the risk of falls include: - delirium and other cognitive impairment. - incontinence. Resident-Centered Approaches to Managing Falls and Fall Risk: - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. A facility policy entitled Neurological Policy and Procedure (last revised 3/1/22) included: Neurological assessments are indicated: -Following an unwitnessed fall. Review of R8's clinical record revealed: 5/27/22 - R8 was admitted to the facility with dementia, psychosis, orthostatic hypotension, and a history of prostate cancer. 5/27/22 - R8's incontinence care plan included: -Bowel and Bladder assessment on admission, significant changes and prn (as needed). -Toileting plan as ordered. Monitor for effectiveness and revise as needed. -Three day trial bowel and bladder diary schedule. Offer toileting every two hours. -Complete voiding diary on admission and as needed for changes in condition. -Check and change pads/briefs as appropriate. 5/27/22 - R8's impaired mobility care plan included: -Walk in room with one staff assistance with rolling walker. 5/27/22 - R8's fall care plan included: -Attempt to engage resident in meaningful activities such as music, companionship, crafts, 1 on 1 interactions, etc. -Encourage non-skid footwear/non-skid socks. -Reinforce the need to call for assistance. -Provide a well lit, clutter free environment as able. -Provide and encourage resident to use handrails or assistive devices properly as ordered. 5/27/22 4:28 PM - R8's fall risk assessment documented a score of 15 which indicated that R8 was at moderate risk for falls. R8 sustained multiple falls prior to admission to the facility. 5/27/22 - Review of R8's clinical record revealed that the facility had evidence of a three day voiding diary on admission, but the facility lacked evidence that a bowel and bladder assessment was completed at that time. In addition, after R8's voiding diary was completed, the facility lacked evidence that the voiding trial diary was analyzed and that an individualized toileting plan was developed and implemented for R8. 5/31/22 - R8's admission MDS assessment documented that R8 was severely cognitively impaired, he required extensive assistance of two staff members for bed mobility and transfers, assistance of one staff member for walking, extensive assistance of one staff member for toileting, he was not steady for transfers and ambulation and was only able to stabilize with staff assistance. R8 was also frequently incontinent of bowel and bladder. 6/1/22 9:56 AM - An interdisciplinary progress note documented: Review of event: (R8 had an) unwitnessed fall 6/1/22 at 2:00 AM from bed attempting to get up, no injuries noted. Current interventions included: -gripper socks; -bed/chair pad alarm; -diagnosis of orthostatic hypotension with medications. Follow-up action: -education provided to call for assistance (R8 is cognitively impaired and has memory problems); -ensure call bell within reach (R8 is cognitively impaired and has memory problems); -hipsters (impact-absorbing pads worn under clothes to minimize potential damage that can occur from a fall); -keep bed at appropriate height for transfers; -provided reacher (R8 is cognitively impaired and has memory problems); -currently on PT (Physical Therapy) caseload; -neuros initiated (neurological checks); -s/p (status post) fall assessment in place; -Ortho (orthostatic) BPs (blood pressures) for three days. Although interventions were put into place, some were not appropriate due to R8's dementia. 6/1/22 - Review of R8's clinical record revealed that the facility lacked evidence that R8 was toileted for many hours and he sustained a fall at 2:00 AM. 8/10/22 and 8/13/22 - R8 was assessed to be at high risk for falls with scores of 23 and 21 consecutively. 8/10/22 12:40 AM - A facility incident review note documented that R8 sustained an unwitnessed fall attempting to toilet himself. R8 was hospitalized after the fall and found to have a subdural hematoma (brain bleed). The facility lacked evidence that R8 was toileted on the 11-7 shift and he sustained harm at the time of the fall. Although baseline vital signs (temperature, pulse, blood pressure and respirations) were obtained at the time of the fall, the clinical record lacked evidence of an initial neurological assessment (neurocheck). 8/12/22 - A new approach was added to R8's careplan although R8 remained in the hospital after his 8/10/22 fall. 8/13/22 8:30 PM - R8 returned from the hospital. In response to R8's 8/10/22 fall, his care plan was revised to include the following new interventions: - Bed at appropriate height when resident in bed; - Encourage use of soft helmet for safety; - Bed/chair pad alarm (different from a clip alarm). 8/15/22 - A facility Bowel and Bladder screening assessment revealed that R8 was a candidate for scheduled toileting. This was the first bowel and bladder assessment that was completed for R8 since admission. 8/17/22 - R8's care plan was revised to include: Safety hazard to self as evidenced by attempting to get out of bed/transfer/ambulate without assistance. 8/17/22 - A therapy screen was sent for OT (Occupational Therapy) to focus on toileting. The facility failed to identify that R8's fall on 8/10/22 occurred while there was not a toileting plan in place. 8/22/22 12:42 PM - A Physician's progress note documented: Patient still requires staff assistance with adl's (activities of daily living). 8/23/22 - A Physician's order included: monthly bowel and bladder program and offer toileting last rounds 11-7 shift, before lunch, after lunch, before dinner and at bedtime. The intervention was added to R8's care plan. This was the first time since 5/27/22 when R8 was admitted to the facility that an individualized toileting plan was implemented. 8/24/22 - A quarterly MDS assessment documented that R8 was moderately cognitively impaired, required assistance of one for activities of daily living (including toileting) and was occasionally incontinent of urine. 9/6/22 7:37 PM - An incident report to the State Agency documented that R8 sustained an unwitnessed fall on the floor face downward and was documented as stating that he slipped on his floor (in his room). R8 required the assistance of one staff for transfers (although R8's initial MDS assessment, dated 5/31/22, listed that he required extensive assistance of two staff for transfers) and for ambulation (walking). R8 sustained a mouth injury and was bleeding from his nose. R8 was hospitalized and returned to the facility on [DATE]. The hospital assessment notes documented that R8 had a small laceration to the inside surface of his upper lip and some blood in his right nostril. Although baseline vital signs were obtained at the time of the fall, R8's clinical record lacked evidence of an initial neurocheck despite obvious facial trauma. 9/7/22 12:18 AM - R8 was admitted to the first hospital and found to have a subacute left subdural hematoma (comparable to 28 milliliters of liquid) that had increased in size. R8 was transferred to another hospital for further evaluation. 9/7/22 4:24 AM - A hospital Physician's note documented: Patient is an [AGE] year-old male .who is presenting to the Emergency Department as a transfer from another hospital for a subdural hematoma following a fall. Physical exam is significant for a fourth right digit (finger) ecchymosis (bruising) and limited range of motion, concern for fracture. 9/7/22 5:26 AM - A hospital Physician's assessment included: x-ray right hand. Disposition: Admit to inpatient status Subdural hematoma. Plan: admit for observation. Chronic subdural hematoma. 9/7/22 7:15 AM - A hospital Physician's note documented: Hand x-ray showing evidence of fourth digit fracture. 9/9/22 - Review of R8's fall risk reassessment revealed that his high risk medications weren't listed and consequently, R8 had a low and inaccurate fall risk score of 15 which indicated that R8 was only at moderate risk for falling, although he was at high risk on 8/10/22 and 8/13/22 with scores of 23 and 21 consecutively a month ago. 9/12/22 4:27 PM - A Physician's progress note documented: .ambulatory dysfunction due to recent hip surgery. 9/13/22 - A five day MDS assessment documented that R8 was occasionally incontinent of urine. Although R8's incontinence improved, the facility failed to identify that the resident continued to fall during the night with further falls occurring on 9/28/22 and 9/29/22 related to attempting to toilet himself unassisted. The facility failed to review and revise his care plan for nighttime toileting after continuation of R8's attempts with unassisted toileting at night. 9/22/22 1:49 AM - A nursing progress note documented: Resident was witnessed getting OOB (out of bed) and standing at bedside using the urinal then sitting back down. Resident redirected and assisted for toileting. The facility failed to recognize the need for R8 to have a nighttime toileting schedule. 9/28/22 3:06 AM - R8 sustained an unwitnessed fall. R8 was documented as stating, I rolled out of bed trying to go pee. R8 was noted to have a hematoma to the right side of his forehead. R8 was transferred to the ER and returned the same morning at 7:00 AM with a diagnosis of a large right scalp hematoma. The facility lacked evidence that R8 was toileted from 9/27/22 at 8:06 PM until 9/28/22 at 3:06 AM (at the time of the fall 7 hours later) and they failed to identify the need for R8 to have a nighttime toileting schedule. Although neurochecks were not ordered by the Physician, the facility failed to reinitiate hourly neurochecks per facility policy upon R8's return from the hospital. 9/29/22 11:04 PM - R8 sustained an unwitnessed fall without injury. R8 was documented as stating that He was standing up to use the urinal and drink water. 9/29/22 1:04 AM, 2:04 AM and 3:04 AM - The facility lacked evidence that R8's neurochecks were completed; sleeping was documented. 9/30/22 1:20 PM - A physician's progress note documented: Patient with noted recurrent falls, noted with left orbital eye black/blue bruises from a previous fall when seen and examined today. Patient is very impulsive, fixated on going to the bathroom frequently per nursing staff. 9/30/22 5:14 PM: A Physician's order included: Orthostatic blood pressures for 3 days. 10/3/22 2:17 - A facility Physician progress note documented: Patient of this facility who presented (name of second hospital) as a transfer from (name of first hospital) after sustaining an unwitnessed fall here at the nursing facility, found to have a left sided subdural hematoma measuring 5-6 mm in thickness without midline shift or herniation. CT was repeated on arrival and was stable .Hospital stay was complicated by left hip pain: Incidental finding of lucency (an area on an x-ray where the bone is less dense) of hip prosthesis in CAT (CT) scan .left hip suspicious of loosening. 10/7/22 1:39 PM - A nursing progress note documented: Resident found by nurse supervisor on the floor (in his room) while responding to bed alarm and hearing resident call out for help. Unwitnessed (fall), resident states he did not hit his head. Upon inspection, no bruising/skin tears present, c/o (complained of) pain to buttock and back. R8 was documented as stating that he was walking from the door. Review of R8's toileting records revealed that the resident had not been toileted prior to or after lunch per his Physician's ordered toileting schedule on 8/23/22. 10/7/22 2:00 PM - A facility Fall Scene Investigation Report documented that R8's fall on 10/7/22 at 1:39 PM was due to R8's behavior. 10/15/22 4:57 PM - A nursing progress note documented that R8 sustained an unwitnessed fall in his room next to his bed and was noted to have a skin tear on his left elbow. 10/18/22 12:17 AM - A nursing progress note documented that R8 sustained an unwitnessed fall in his room without noted injury and stated he was Trying to get up but was unaware of where he was going. 10/18/22 5:10 AM (approximately five hours since last fall) - A nursing progress note documented that R8 sustained an unwitnessed fall in his room without injury and stated, He was going to the sofa. R8 did not have a couch in his room. The facility lacked evidence that R8 was toileted on the 11-7 shift. 10/18/22 7:15 AM (approximately two hours since last fall) - A nursing progress note documented that R8 sustained an unwitnessed fall without injury attempting to Transfer from bed to couch. 10/18/22 11:30 AM (this was the 4th fall in less than 12 hours) - A nursing progress note documented that R8 sustained an unwitnessed fall and was transferred to the ER. R8 stated that He was trying to go to the park. The facility survey started on 10/17/22 so Surveyors were onsite for some of the 10/18/22 falls. 10/18/22 11:50 AM - During an interview, E2 (RNAC) confirmed that R8 had not had his toileting program re-evaluated since 8/23/22. 10/18/22 2:35 PM - During an interview, E2 (RNAC) confirmed missing entries, not applicable entries, and long intervals of missed toileting in R8's toileting documentation. 10/18/22 4:59 PM - A Physician's order included: Location checks every fifteen minutes. The facility lacked evidence of increased supervision despite multiple falls, some requiring hospitalization , until this order was obtained. 10/18/22 8:30 PM - R8 returned from the hospital. R8 sustained 11 falls, all of which were unwitnessed, from 6/1/22 through 10/18/22. Four of the falls occurred on 10/18/22 in less than 12 hours. Three of R8's falls were related to attempting to toilet himself unassisted. R8 was transferred three times to the hospital due to significant injury. There was lack of evidence that the facility not only failed to provide adequate supervision, but they also failed to analyze and implement interventions accordingly to prevent falls. 10/21/22 10:05 AM - During an interview, E1 (NHA) confirmed the neurochecks were not completed, were incomplete or were not reinitiated upon return from the hospital as per facility policy. 11/29/22 8:50 AM- During an interview, E3 (DON) confirmed that although R8 had a three day voiding diary completed on admission, the facility lacked evidence of R8 having a bowel and bladder assessment completed on admission. 11/29/22 11:00 AM - During an interview, E3 confirmed R8's clinical record lacked evidence of consistent toileting as per the Physician's order. Additionally, E3 confirmed that on 10/7/22 the resident record lacked evidence of toileting at 11:00 AM and 1:30 PM and that R8 sustained a fall at approximately 1:30 PM. 11/29/2022 12:55 - During an interview, E3 (DON) confirmed the correlation of the falls and the lack of toileting. 11/29/22 approximately 4:00 PM - Findings were reviewed with E1 (NHA) and E3 during the exit conference.

Based on record review, staff interview, and review of other facility documentation, it was determined that the facility failed to ensure that one (R1) out of eight residents reviewed for medication errors were free from significant medication errors. R1 received another resident's medication causing harm, which required R1 to be transferred to the hospital where R1 became unresponsive and hypotensive in the emergency department requiring hospitalization for treatment and monitoring. This was identified as a past non-compliance Immediate Jeopardy situation. Findings include: Review of a facility policy titled Medication Administration - General Guidelines (effective date 9/1/15) included: 5) Medications are administered without unnecessary interruptions. 6) The person who prepares the dose for administration is the person who administers the dose. 7) Residents are identified before medication is administered. Review of CMS guidance stated, .accepted standards of practice that require the following be confirmed prior to each administration of medication (often referred to as the 'five rights' of medication administration practice) include: The right patient, the right time, the right dose, the right route, and the right drug. (https://www.cms.gov/Regulations-and Guidance/Guidance/Transmittals/Downloads/R116SOMA.pdf) 4/12/21 - R1 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4/16//21 - R1's admission Minimum Data Set Assessment (MDS - periodic assessment of resident needs) documented R1 was severely cognitively impaired. 5/27/21 10:02 PM - Review of information submitted to the State Agency included: During evening medication pass, medication was administered in error to [AGE] year-old female resident. NP (Nurse Practitioner) informed and order received to send resident to the ER (emergency room ) for further evaluation and treatment. 5/27/21 10:28 PM - A nursing progress note documented: Resident was given another resident's medication in error by this nurse. Resident received; [MEDICATION(S)] 75 mg (medication that prevents blood clots), [MEDICATION(S)] 100 mg (antipsychotic medication), [MEDICATION(S)] 15 mg (antidepressant medication), [MEDICATION(S)] 40 mg (cholesterol lowering medication), [MEDICATION(S)] 10 mg (antipsychotic medication), Lorazepam 1 mg tab (antianxiety medication), (and) Tylenol 650 mg (pain and fever medication). Resident swallowed medication at time of administration. E5 (NP) made aware. Resident to be transferred to (said hospital) ER for evaluation and monitoring. 911 EMS made aware need for transport to ER. Although the facility documented the medication error in the progress notes, the documentation lacked evidence of the mental status of R1 (such as alert, drowsy, or unresponsive) upon transfer out of the facility. 5/27/21 10:45 PM - Review of E3's (RN) statement revealed that he administered another male resident's (R2) medication to R1. 5/28/21 2:39 AM - A nursing progress note documented: Spoke with (named nurse at named hospital), resident admitted to the ICU with dx (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5/28/21 - Review of E4's (RN) statement revealed that E3 (RN) came to the medicine cart to help give the medications that were set aside for R2. E4 thought that E3 (RN) was going to administer the medications to R2 (a male resident next to R1), but instead administered them in error to R1. 5/28/21 12:10 PM- A doctor's consult progress note (at the hospital) documented: Since presentation to the hospital, patient received IV (intravenous) fluids, 1500 ml (milliliters) of normal saline and currently is getting IV (intravenous) infusion. This morning she went into SVT (Supraventricular Tachycardia - an abnormally fast heart rate) with a rate of 140 to 150 beats per minute (normal heart rate is 60 - 100) and she has remained unresponsive. She is on (a) [MEDICATION(S)] drip (medication to help maintain a constant blood pressure). 5/30/21 2:20 PM - A hospital discharge summary documented: Presented at the ED (Emergency Department) at the behest (sic) of staff at her living facility .where they report that she was found to be unresponsive soon after receiving the wrong medication . In the ED she is unresponsive and hypotensive. She was given 1500 cc of normal saline bolus and blood pressure improved. The assessment and plan included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/3/21 12:15 - 12:25 PM - During an interview, E3 (RN) confirmed that he did not prepare the medications that were on E4 (RN's) medication cart and he was just trying to help. E3 stated that there was a lot going on and there were multiple residents in the common area who were agitated. E3 thought in error that R2's medications were for R1. E3 reported that when he administered the medications to R1 (the wrong resident), E4 yelled out that the medications were not for R1, but it was too late. R1 had already swallowed them. 6/3/21 1:45 PM - During an interview, E4 (RN) stated that the medications were on her cart by her computer while she was attempting to chart on R2, who she had just given [MEDICATION(S)] gel because R2 would not take his medications by mouth due to being too agitated. E4 reported that she put the meds on her cart next to her and was going to attempt to administer them to R2 after he calmed down from the [MEDICATION(S)] gel. E3 (RN) took the medication cup off of E4's medication cart and said that he would help administer them. E4 thought that E3 was administering them to R2, but he administered them to R1. E4 stated it was just a few seconds until she looked up, but it was too late. E4 had already administered the medications to the wrong resident. Past non-compliance Immediate Jeopardy was revealed to E1 (NHA) and E2 (DON) on 6/4/21 at approximately 3:30 PM. Immediately after the medication error, the facility created a corrective action plan that include: re-education of licensed nursing staff on the five rights of medication administration, nurse to nurse support with medication administration during an emergency, and how to respond to a medication error with a completion date of 6/2/21 and a plan was in place to educate staff not currently working before they return to work. The facility instituted medication competency with facility Nurse Supervisors with a completion date of 6/3/21. Review of facility documentation, staff interviews and medication observations revealed that the corrective action was fully implemented and completed by 6/3/21, at which time, the Immediate Jeopardy was removed. The facility failed to ensure that R1 was free of a significant medication error, which resulted in a serious adverse outcome to the resident and required a transfer and admission to the ICU (Intensive Care Unit) at the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/4/21 approximately 3:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, staff interview, review of medical literature and review of other facility documents, it was determined that the facility failed to ensure that one (R1) out of four sampled residents was free from significant medication errors. The facility incorrectly transcribed a physician's orders [REDACTED]. R1 sustained harm when he/she suffered a two-minute [MEDICAL CONDITION] after not receiving an ordered [MEDICAL CONDITION] medication for eight doses. This significant medication error was not discovered by the facility until after the [MEDICAL CONDITION] occurred. Findings include: Drug information documented the purpose of [MEDICATION NAME] Acid was to treat [MEDICAL CONDITION] disorders. Do not stop using [MEDICATION NAME] Acid without your doctor's advice. Stopping suddenly may cause a serious, life-threatening type of [MEDICAL CONDITION]. Do not stop using [MEDICATION NAME] Acid suddenly, even if you feel fine. Follow your doctor's instructions about tapering your dose. (https://www.drugs.com/mtm/[MEDICATION NAME]-acid.html) Review of the facility's document entitled Chart Check Policy and Procedure (dated 1/25/19), stated: Realizing the seriousness of medication compliance, the facility has developed an objective system for completing chart checks daily to ensure a second review of medication changes is completed. This process allows administration to ensure order entry accuracy. The procedure for chart checks was to review each resident's medication changes daily by: 1. Print order listing report and review for accuracy: ensure each resident's medication/treatment is a complete order, review 24 hour report for confirmation of medication changes, confirm order in EHR (electronic health record) and obtain clarification orders as needed. 2. Print resident specific order recap report. Once order is confirmed in EHR, place in resident chart. 3. Nurse to initial Chart Check Form and inform shift supervisor immediately of any variances in chart check. The following was reviewed in R1's clinical record: 10/7/16 - Progress notes documented R1 was admitted to the facility with a primary admitting [DIAGNOSES REDACTED]. 10/7/16 - 2/25/19: Review of physician orders [REDACTED]. 1/17/17 - Care plan created (last revised 3/8/19): The resident has a [MEDICAL CONDITION] disorder and has had a recent [MEDICAL CONDITION] with a goal that the resident will be free from injury from [MEDICAL CONDITION] activity. The interventions included: -Follow up with neurology as scheduled. Date Initiated: 1/17/17. -Give [MEDICATION NAME] Acid as ordered by doctor. Monitor/document side effects and effectiveness. Date Initiated: 1/17/17. -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 1/17/17. 3/21/18 (Annual) and 12/11/18 (Quarterly) - MDS with active [DIAGNOSES REDACTED]. 1/30/19 - Lab result: [MEDICATION NAME] Acid level was 95.3 ug/mL (therapeutic level is 50.0 - 100.0) (the last level prior to the 3/5/19 [MEDICAL CONDITION]). 2/25/19 - Neurologist's Report of Consultation after office visit: Decrease [MEDICATION NAME] Acid to (one thousand) 1000 mg. at bedtime. D/C (discontinue) AM 500 mg dose. 2/25/19 at 1:09 PM: Telephone order to discontinue AM 500 mg dose of [MEDICATION NAME] Acid from E12 (Nurse Practitioner) was given to E4 (RN on orientation). 2/25/19 at 1:09 PM: physician's orders [REDACTED]. 2/25/19 at 1:14 PM - Progress note by E4 (RN on orientation): Resident seen at Neurology office today with family present. Recommendations made to d/c [MEDICATION NAME] Acid dose in the morning and keep the [MEDICATION NAME] Acid 1000 mg at bedtime .Called E12 (Nurse Practitioner) for the discontinued morning order of [MEDICATION NAME] Acid. 2/25/19 - Review of 11 PM - 7 AM shift's 24 hour chart check sign off sheet indicated R1's chart check was completed by E5 (LPN) with no errors found. 2/25/19 - 3/5/19: Review of MAR indicated [REDACTED]. 3/5/19 at 6:02 AM - Progress note by E6 (RN supervisor): At 5:00 AM this RN was called to resident's room by E10 (LPN) for [MEDICAL CONDITION] activity and responded to resident's room immediately, on entering room noted resident lying in bed with his/her eyes closed, no [MEDICAL CONDITION] activity at that time, postictal deep respirations noted. Per E10 and E11 (CNA) resident had approximately 2 minutes of whole body tremors . 3/5/19 at 6:16 AM Progress note by E6 (RN supervisor): On review of medications, this RN noted hours sleep dose of [MEDICATION NAME] Acid was discontinued on 2/25/19. 3/5/19 at 7:19 AM - Progress note by E6 (RN supervisor): At 7:05 AM E7 (Medical Director) aware of [MEDICAL CONDITION] activity and medication error. No new orders at this time. 3/5/19 at 7:38 AM - Progress note by E6 (RN supervisor): E7 (Medical Director) gave new orders to restart [MEDICATION NAME] Acid 1000 mg every night at bedtime per neurologist consult 2/25/19 and obtain [MEDICATION NAME] Acid level in 2 weeks. 3/5/19 - physician's orders [REDACTED]. 3/5/19 at 11:44 AM - Progress note by E4 (RN on orientation): E7 (Medical Director) visit. New orders .Continue [MEDICATION NAME] Acid 1000 mg every night at bedtime. 3/5/19 at 1:46 PM - Progress note by E4 (RN on orientation): Per family request, called Neurologist's office to notify of medication error. Left message for return call with physician assistant. 3/5/19 - Progress note by E7 (Medical Director): [MEDICAL CONDITION] disorder with breakthrough since dose reduction and missed doses. [MEDICATION NAME] Acid restarted at 1000 mg every night at bedtime. Levels in 1 week and revisit the need for titration . 3/7/19 at 1:00 PM - During an interview with E1 (NHA) and E2 (DON), E2 explained that E4 (RN on orientation) was on the 6th day of orientation when this medication error occurred and was being oriented by E9 (RN). Neither E4 nor E9 realized that the [MEDICATION NAME] Acid order was incorrectly transcribed into the Electronic Health Record (EHR) resulting in both the AM and bedtime doses being discontinued when the actual physician's orders [REDACTED]. E1 explained that when the medication error was identified on 3/5/19 both E4 and E9 were educated that: After input into the EHR, read and print out orders to use as a comparison against written order, and compare the EHR order against consults, physician/nurse practitioner progress notes, etc. to ensure orders match. E2 stated that E5 (LPN) did complete the 24 hour chart check according to facility's procedure and did not identify the error, so the procedure has been revised and staff have been educated to compare the EHR orders against consults, physician/nurse practitioner progress notes, etc. to ensure orders match during the 24 hour chart check. E2 stated that all the orders that E4 transcribed during orientation have been audited and no other error was found. The facility is in the process of completing a 30-day order reconciliation of medications for all residents in the facility and educating all nurses on the procedure for transcribing orders and conducting 24 hour chart checks. 3/11/19 - Lab result: [MEDICATION NAME] Acid level was low at 10.0 ug/mL (therapeutic level is 50.0 - 100.0). 3/11/19 at 8:14 PM - Progress note by E8 (RN supervisor): E7 (Medical Director) made aware of [MEDICATION NAME] Acid level of 10.0. Also made aware of Neurologist to review on 3/12/19. New order received for [MEDICATION NAME] Acid 500mg tonight only. 3/11/19 - 5-day follow up report submitted to State Agency by E3 (ADON): .Neurologist made aware. No further [MEDICAL CONDITION] activity has been observed. Neuro checks are being completed. The resident's care plan has been updated to reflect any new orders and interventions. 3/12/19 - Lab result: [MEDICATION NAME] Acid level was still low at 10.0 ug/mL (therapeutic level is 50.0 - 100.0). 3/12/19 at 9:00 AM - An interview with E2 (DON) confirmed that R1's last [MEDICAL CONDITION] prior to 3/5/19 was on 9/30/18 and that the last [MEDICATION NAME] Acid level prior to 3/5/19 was on 1/30/19 and was 95.3 ug/mL (therapeutic level is 50.0 - 100.0). E2 also confirmed that between 2/25/19 and 3/5/19 none of the facility's nurses caring for R1 questioned why the Valporic Acid was suddenly completely stopped (which is against recommendations for Valporic Acid). E2 stated that the facility completed a 30-day (from 2/1/19 to 3/6/19) order reconciliation of medications for all residents in the facility (resident census was 130) and found six medication errors that have been corrected. R1 sustained harm when he/she suffered a two-minute [MEDICAL CONDITION] after not receiving an ordered [MEDICAL CONDITION] medication for eight doses. The significant medication error was not discovered by the facility until after the [MEDICAL CONDITION] occurred. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) on 3/12/19 during the exit conference beginning at 10:30 AM.

Based on record review, interview and review of other facility documents it was determined that the facility failed to ensure that for two (R138 and R109) out of 53 sampled residents received the care and services necessary to meet dietary needs. R138 sustained harm when s/he received an incorrect diet that resulted in 2 choking episodes, aggressive suctioning and was transported to the emergency room for evaluation. R109 did not have a completed nutritional assessment after hospitalization to reassess for meal consistency and supplement use. Findings include: The following was reviewed in R138's clinical record and facility incident investigation documents: [DATE] Hospital history - Described R138 at home, had a history of [REDACTED]. R138 was not eating well and during meals would cough after each bite of food and bring it up. [DATE] - Admission to the facility and code status at that time was do not resuscitate, do not intubate, and no tube feeding. [DATE] - Physician ordered diet - Puree diet - thin liquids. [DATE] - ID (interdisciplinary note) Note - Speech Evaluation - R138 was evaluated per family request and speech did recommend a diet upgrade from the puree diet. R138 refused a diet upgrade and wanted to remain on the puree diet. [DATE] - Annual MDS indicated R138 ate independently and was a one person assist for support. [DATE] - Quarterly MDS indicated R138 required supervision for eating and was a one person assist for support and was moderately impaired for decision making. [DATE] - A guide for staff located on the unit in a book and also inside of the resident's closet door documented the diet was pureed and thin liquids. [DATE] at 5:50 PM - Progress Note - E14 (RN) responded to the choking episode with a suction machine. On arrival R138 was coughing up copious amounts of mucous E15 (LPN) began suctioning with a hard plastic suction tip and then changed that out for a flexible catheter and began deep suctioning. At that time 400 mL of red tinged mucous was removed. R138 began to speak and clear mucous with a cough and proceeded to cough up small pieces of a pear. Vital signs at this time were: 97.9 temp, Respirations 22, pulse 92, oxygen level 93% without oxygen, and blood pressure of ,[DATE] (high). [DATE] at approximately 6:00 PM - a photograph was taken by the facility of the dinner plate with a pureed meal with a small saucer of diced pears, and about 50% of the pears were consumed. The dining slip (displayed in the picture) indicated pureed texture and under notes indicated R138 was on aspiration precautions. [DATE] at 8:10 PM - Progress Note - R138 had difficulty breathing and coughed up more food and fluid. E15 suctioned again with a positive effect of small amount of food and fluid was removed. E14 was called to R138's room a staff nurse was suctioning, R138 exhibited pallor and responded verbally. R138 Vital signs at this time were: Temp 98.1, Respirations 18, Pulse 101, oxygen level 88% (low) without oxygen, blood pressure ,[DATE] (high). R128 was placed on 3 liters of oxygen by mask. At this time the family was notified and approval to send R138 to the hospital for treatment was obtained. [DATE] at 8:20 PM - Progress Note - Resident was picked up by ambulance and transported to the hospital. [DATE] at 8:45 PM - Statement from E20 (CNA) I took R138 tray into her and I saw that her tray was pureed food so I popped the top off of the desert not thinking that it was not pureed food. [DATE]/18 at 9:09 PM - Doctors Note from hospital - The family does not wish to treat they did not want x-rays, lab work, or antibiotics to prolong life. R138 will return to the facility. [DATE] at 9:14 PM - Doctors note from hospital - R138 appears to have aspirated may have some underlying pneumonia. with the history consistent with aspiration R138 is comfort care, do not hospitalize, do not treat. [DATE] at 9:17 PM - Triage notes from hospital - Aspirated thin pureed diet suctioned and R138 is gurgling. [DATE] at 1:01 AM - Progress Note - E17 (RN) received report from hospital emergency room that included: R138 was deep suctioned and does have aspiration pneumonia, family does not want to treat the pneumonia, and request a hospice consult. R138 will return to the facility and family will sign paper work. [DATE] at 1:10 AM - Progress Note - R138 arrived back at the facility and was on 15 liters of oxygen non-rebreather mask. [DATE] - The guide for staff was updated after return from the hospital to include honey thick liquids. [DATE] at 5:47 AM - R138 expired at the facility. [DATE] at 10:34 AM - During an interview with E16 (RN) it was revealed that the guide provided the instruction on diet. The document could be found in a binder on the unit and it was on the door inside the residents' closet. [DATE] - Meeting with E1 (NHA) and E2 (DON) regarding clarification from facility about the diet revealed that R138 was evaluated by speech and was allowed a regular diet. R138 requested and chose to eat the downgraded diet of pureed consistency. The facility did agree that R138 should not have received diced pears. They further revealed the tray delivered to R138 had been been handled by two dietary personnel and one CNA who did not identify that the pears were diced and not the ordered pureed diet. The facility failed to serve the ordered pureed diet to R138 which resulted in harm from choking requiring suctioning and transport to the hospital. Findings were reviewed with E1, E2 and E3 (ADON) during the exit conference beginning at approximately 4:15 PM. 2. The following was reviewed in R109's clinical record: [DATE] - Admission to facility for rehabilitation after hospitalization . [DATE] - Care plan for nutrition (last revised [DATE]) included RD to evaluate and make diet change recommendations PRN. [DATE] - Significant Change MDS Assessment documented that R109 required extensive assistance for eating and had severe cognitive impairment. [DATE] - Initial nutrition assessment recommendation included a nutritional supplement (Glucerna) if less than 50% of the meal was eaten. R109 was on precautions to prevent aspiration and was receiving mechanical soft diet with nectar thick liquids due to trouble swallowing regular thin liquids. [DATE] - Physicians' orders included to give 1 can of Glucerna if less than 50% meal consumed. [DATE] - [DATE] - R109 hospitalized and returned to facility without an order for [REDACTED].>There was no evidence in the record that a nutrition assessment was completed to determine if the nutritional supplement was still needed. [DATE] - [DATE] - Resident hospitalized for [REDACTED]. There was no evidence in the clinical record of a nutrition assessment following the downgrade of diet in the hospital. [DATE] - Physicians' orders included comfort care with no weights, no tube feeding. [DATE] at 2:39 PM - Interview with E2 (DON) and E33 (RD) confirmed that a nutrition reassessment had not been performed after R109 returned from the hospital in (MONTH) and June. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference beginning at approximately 4:15 PM.

Based on clinical record review, interviews and the review of facility documentation, it was determined that for 1 (one) (R13) out of 37 sampled residents, the facility failed to ensure that R13 received adequate supervision to prevent an accident when the resident was left on the toilet unsupervised and had a fall that resulted in a broken ankle. Findings include: Review of the facility policy and procedure entitled Residents Falls last updated 2/17/16 documented; -residents who are identified at risk for falls will have appropriate interventions implemented -all staff providing care to the resident will be familiar with the care plan and the necessary interventions to provide for the residents safety. Review of R13's clinical record revealed: Review of R13's risk to fall care plan initiated on 4/19/13 and last reviewed on 1/12/17, documented a goal of resident will have no fall related injuries. Interventions including but not limited to: fall precautions, follow facility fall protocol, frequent visual checks, ensure safety devices in place each time, resident moves motion sensor outside bathroom away from self. Resident self removes clip/pad alarms at times, gets up without assist at times, self removes alarm and hides alarms. Review of R13's behavioral issues care plan initiated on 6/5/13 and last reviewed on 1/12/17 had a goal that R13 will not attempt to transfer or ambulate unassisted. Interventions for the care plan included; check my safety devices ensure they are properly placed and working, redirect me when I remove safety devices or gets up without assitance, monitor me when I am not in supervised areas. 12/13/16 - an annual MDS assessment documented R13 required extensive assistance (resident involved in activity staff provide weight bearing support) and one person physical assitance for toileting and when moving on and off the toilet was not steady only able to stabilize with staff assistance. 2/17/17- 3/17/17 a monthly functional care summary documented in the toileting section: needs direct staff physical assitance and attendance during toileting. (In the summary section it was documented behaviors attempts to transfer.) 3/1/17 - a fall risk assesment was completed and documented R13 as a 20 indicating high risk. 3/6/17 - 2:30 PM A statement written by E17 (CNA) documented Around 2:15 PM .I assisted R13 to the toilet and let her aide know I put her there, she had her alarms attached. Around 2:25 PM, I heard R13 screaming from the bathroom .Once I got to the bathroom door R13 was leaning on the opposite door about to fall so I slid her to the floor and called for the nurse. 3/6/17 - 2:40 PM A nursing note in R13's clinical record documented this writer called to the room for 'she's on the floor', upon entering the room R13 was found to be sitting on her buttocks on the bathroom floor with the CNA who lowered her to the floor standing behind her, 4 person assist back to bed. 3/6/17 - A second statement written by E17 documented I entered the bathroom and R13 was already in the process of falling towards her door .I held on to her to lower her to the floor to keep her from hurting herself so she would not hit her head. Once on the floor she was sitting up with right leg extended and left leg slightly tucked under her. 3/6/16 - 4:30 PM A statement written by E13 (LPN) documented I went in to check on R13 due to recent fall and resident asked me to look at her ankle. Upon examination, this nurse discovered swelling and discoloration to the residents inner left ankle supervisor notified. 3/6/17 - 5:15 PM A nursing note in R13's clinical record documented cart nurse made this nurse aware of bruise and swelling to left ankle; ankle noted to be bruised tender to touch and swollen NP made aware new order for stat (immediate) x-ray. 3/6/17 - A radiology report of R13's left foot, documented in the conclusion section that R13 had a acute distal shaft fracture, a broken bone in the ankle. 3/6/17 - 10:53 PM A nursing note in R13's clinical record documented resident sent out via ambulance at 8:30 PM due to a fracture near ankle. 3/6/17 - 11:05 PM A nursing note in R13's clinical record documented that an x-ray result of an broken ankle (acute distal fibular shaft fracture) NP aware NO to send R13 to the ER . daughter aware and reported to the SA. 3/6/17 - 11:01 PM the facility reported a fall with serious injury to the SA. 3/23/17 - A follow up statement written by E25 (LPN) after, but in reference to R13's 3/6/17 fall, documented that staff lifted a floor mat with R13 onto the bed, once placed her on the bed, and vital signs obtained . no apparent injury at this time. During an interview on 5/4/17 at 9:38 AM with E6 (LPN) unit manager, expectations for staff toileting a resident on fall precautions were described as provide privacy if resident requested, but still be in an area that they could get to the resident. E6 then reported CNA's are made aware of residents fall precautions by the QCR (Quick Care Reference) guides hanging in the residents closet. During an observation on 5/4/17 at 9:43 AM with E19 (CNA) surveyor observed resident's closet and confirmed small index card on closet door was for identification of briefs for resident. There was no QCR hanging in the residents closet. Residents roommate did have one hanging and it detailed care for that resident including transfer and toileting. During an interview on 5/4/17 at 10:37 AM with E17 it was reported that she assisted R13 onto the toilet, clipped her personal alarms then notified E18 the resident was in the bathroom. E17 clarified that E18 was not present for the transfer on the toilet however E17 stated I told her you go ahead, and once I put the clip on, I'm going back to do my residents. E17 admitted she did not check R13's QCR guide, and reported she had alarms so I clipped them. During an interview on 5/04/2017 at 3:13 PM with E18 (CNA) it was reported that she was assigned to care for R13, however while busy with another resident E17 offered to toilet R13. E18 denies E17 disclosed that she would be leaving R13 alone on the toilet. E18 reported that she would not have left R13 alone during toileting because R13 transfers unassisted and confirmed that typically residents on fall precaution or with behaviors of transferring unassisted are not usually left alone during toileting. E18 reports she was called into R13's room and saw the resident on the floor, and several other staff present, two nurses and two CNAs. During an interview on 5/9/17 at 1:27 PM with E21 (CNA) it was reported that R13 would attempt to transfer herself unassisted. E21 then reported that for residents on fall precautions it is not appropriate to leave them alone during toileting and that whenever E21 toileted R13, she stayed in the bathroom with R13 because she had alarms so you had to stay in there with her. During an interview on 5/11/17 at 11:08 AM with E2 (DON) E2 confirmed that the expectation of staff would have been for R13 not to be left alone in the bathroom. E2 reported that following the incident, E17 was educated on fall protocol. These findings were reviewed with E1(NHA) and E2 on 5/11/17 at 2:30 PM.

Based on record review, staff interviews, and review of facility investigation documents it was determined that for one (1) of four (4) residents reviewed (R3) the facility failed to provide adequate supervision to prevent accidents. R3 had an unwitnessed fall from her wheelchair during the night shift and sustained a hematoma (blood filled bump) of the head and a fracture of the clavicle (collar bone). Findings include: R3 had [DIAGNOSES REDACTED]. According to a nursing note dated 8/13/12 and timed 12:30 AM, R3 was found lying on the floor next to her wheelchair with a 8.5 cm x 6.5 cm hematoma on the left side of her head and was sent to the emergency room for evaluation. R3 returned to the facility after being evaluated in the emergency room . After the emergency room evaluation, facility staff observed bruising of R3's shoulder area and an x-ray on 8/14/12 revealed a fracture of the left clavicle (collar bone). A note by the Nurse Practitioner (E4) dated 9/19/12 confirmed that R3 had fractured her left clavicle from the fall on 8/13/12 and was treated with a figure-eight wrap (a non-surgical method to support the fracture during healing). R3 had a care plan initiated on 7/12/12 addressing her fall risk. Approaches included the use of safety devices (a clip alarm and a chair pad alarm, devices intended to alarm and alert staff if a resident stands or moves from the seat of the wheelchair). There was no specific plan included to address night time supervision, however, staff interview (2/21/13 at 1 PM) with nurse E3 revealed that R3 was known by facility night-shift staff to often remain awake and in her wheelchair until 12:30 AM or later until she showed signs of being ready to go to sleep. E3 explained to the surveyor in a follow-up interview on 2/22/13 at 12:45 PM that R3 had a habit of pulling off her shoes and socks and frequently did so by leaning forward in her wheelchair. E3 stated that the staff would redirect R3 to sit back and give her something to hold (a doll). E3 stated that she had observed R3 leaning forward in her wheelchair on the night-shift on 8/13/12 prior to the fall and recalled that she (R3) had removed either her shoe or sock. E3 stated that she later saw R3 (minutes before she fell on [DATE]) and R3 was seated in her wheelchair alongside the table in the common area holding her doll. E3 stated that she recalled that R3 had both shoes or both socks on at that time so she thought a CNA (Certified Nursing Assistant) must have replaced the one R3 had removed. According to the Incident Report for R3's fall on 8/13/12, neither the clip alarm nor the chair pad alarm sounded when R3 fell from the chair while in the common area near the nursing station. The facility's internal investigation identified that a problem affecting the ability of the clip alarm to properly perform had been identified but not corrected prior to the fall. The facility failed to ensure that R3 received adequate supervision in the early morning hours when she was awake in her wheelchair and had been observed leaning forward to reach her shoes or socks. This was a behavior which was known by the staff but there was no plan in place to minimize the risk this presented to R3. Also, the safety devices implemented by the facility and required by her care plan (clip alarm and chair pad alarm) did not function properly at the time of the fall. Following R3's fall, the facility replaced the clip and chair pad alarms, implemented a facility wide plan for ensuring that all alarms were functioning at the beginning of each shift. The facility also added an anti-rollback device to R3's wheelchair. These findings were reviewed with E2 (Director Of Nursing (DON)) on 2/20/13 and with E2 and E1 (Administrator) during the exit conference on 2/21/13.

Based on record review, review of the facility's policy and procedures, review of other facility documents and interview it was determined that the facility failed to ensure that one (R6) out of 12 sampled residents was free of a significant medication error. The facility failed to ensure R6 received the correct doses of [MEDICATION NAME] in accordance with the most current physician's orders [REDACTED]. www.[MEDICATION NAME].com). Administration of the incorrect doses of [MEDICATION NAME] was a significant error which occurred on two separate re-admissions when R6 returned from the hospital on [DATE] and 4/28/12. These errors lead to R6 receiving significantly higher doses of [MEDICATION NAME] than ordered by the physician. This resulted in R6 having a hypoglycemic episode, significant change in status and being sent to the hospital 911 with a [DIAGNOSES REDACTED]. Findings include: R6 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. On 4/25/12 the facility received a preliminary report discharge summary by fax from the hospital timed 1:51 PM that was unverified and not signed by the hospital physician. This discharge summary contained a list of medication on discharge for R6 that included [MEDICATION NAME] 40 units sub q daily. At 2:05 PM a Final Clinical Discharge Summary was faxed to the facility. This report documented under "Continue these Medications: "Insulin [MEDICATION NAME] ([MEDICATION NAME] Pen) 14 units subcutaneous daily in AM before breakfast". The facility failed to identify the differences between these two summaries. E6 transcribed on R6's physician order [REDACTED].[REDACTED].) Review of R6's facility physician order [REDACTED]. Review of R6's MAR for April 2012 revealed on 4/26/12 and on 4/27/12 at approximately 7:30 AM R6 was administered [MEDICATION NAME] 40 Units sub-q instead of [MEDICATION NAME] 14 units sub-q. Review of R6's nurses notes revealed on 4/27/12 at 7:40 PM a CNA called the staff into the room. R6 was "moaning and no speech was noted". R6 was unable to follow direction. R6's vital signs were "temperature 98.1, pulse 47, respirations 18, blood pressure 198/100 oxygen saturation 93% on 2 liters of oxygen" and blood sugar was "73". R6 was "diaphoretic with pupils that were pinpoint and fixed, with movement that was sluggish in bilateral upper extremities, movements were at will not on request". At 8:00 PM R6 was sent to the hospital 911. Review of the Emergency Medical Service Report Record revealed R6 had a change in mental status and a blood sugar of 38. R6 was administered 1 [MEDICATION NAME] of D50 ([MEDICATION NAME] 50). R6 was in [MEDICAL CONDITION] with a heart rate of 47 and blood pressure of 198/100. R6's emergency room hospital records documented that on 4/27/12 R6 was brought to the hospital for a change in mental status with low blood sugar. It continued to state that R6 had a blood sugar in the 30s and was treated with intravenous D50 1 amp. Review of the documented medications on this sheet revealed the hospital had incorrect documentation that R6 had received "[MEDICATION NAME] 14 units sq in AM before breakfast instead of the [MEDICATION NAME] 40 units". R6 returned to the facility on [DATE] at 1:30 AM with discharge instructions for [MEDICATION NAME] 10 units sq in the AM. . Review of R6's MAR indicated [REDACTED]. Instead of the [MEDICATION NAME] 10 units as indicated in the hospital discharge instructions from earlier that morning. Review of R6's physician orders [REDACTED]. However, this occurred over 6 hours after the [MEDICATION NAME] 40 units sub-q was administered. Review of R6's nurses notes dated 4/28/12 at 1:40 PM revealed the physician was called and orders from the ER were verified. (The physician was not made aware that R6 received [MEDICATION NAME] 40 units that morning.) At 6:09 PM the notes documented R6 refused dinner and her vital signs were within normal limits. At 6:17 PM R6's physician was called about a possible allergy (however there was not mention of the medication error). At 11:30 PM R6 was documented as alert. On 4/29/12 at 1:15 AM the nurses notes document R6 had a change in status. R6 was assessed as groaning, having clonic (alternately contracting and relaxing the muscles. Tabers Cyclopedic Medical Dictionary Edition 19.) and tonic activity, (muscular tension or contraction. Tabers Cyclopedic Medical Dictionary Edition 19.) activity, unresponsive, diaphoretic, blood sugar was 77, with an oxygen saturation of 81 and was on oxygen 10 liters per minute via face mask. R6 "was not still enough to get a blood pressure..." At 1:30 AM R6's blood sugar was "40" a [MEDICATION NAME] of D50 was given. R6 was sent to the hospital 911. Review of statements written during the facility investigation and interviews conducted by the investigation unit revealed: -When R6 was admitted to the facility E6 (RN) transcribed the [MEDICATION NAME] order from the preliminary report/discharge instruction instead of the final report/discharge instructions to R6's physician order [REDACTED]. physician orders [REDACTED]. -R6 was administered the [MEDICATION NAME] 40 units. R6 had a hypoglycemic episode and was sent back to the hospital. The discharge instructions from the hospital stated to decrease the [MEDICATION NAME] to 10 units sub-q daily. -When R6 returned from hospital E8 (RN) was R6's nurse and E7 (RN 11-7 supervisor) was the supervisor on duty. E7 nor E8 called the physician to change the [MEDICATION NAME] order to [MEDICATION NAME] 10 units. E7 stated she told E9 (RN day supervisor) about the decrease in [MEDICATION NAME] in report, documented it on the 24 hour report and put it in the physician book. Both told E9 and E10 (LPN) R6's day nurse were told about the change in the [MEDICATION NAME] and that the doctor was not notified. No one checked R6's record to see what time the [MEDICATION NAME] was routinely given. On 8/10/12 at 6:10 AM this information was reviewed and confirmed with E7. -E10 checked R6's blood sugar on 4/29/12 before administering the [MEDICATION NAME] 40 units. E10 thought the [MEDICATION NAME] was to be decreased at night not in the morning. She did not realize that the [MEDICATION NAME] was ordered for once a day in the morning only. E9 called the doctor and received an order for [REDACTED]. E9 and E10 stated that they did not notify the physician about the medication error. The facility's policy and procedures for "Medication Errors" stated "When it is determined that a medication error has occurred, the following is to occur: d. Provide care, monitoring, etc as needed to assure patient safety" Review of R6's clinical record and the staff's written statements with E2 (DON) and E3 (ADON) on 8/8/12 at 2:00 PM and again on 8/9/12 at 11:00 AM confirmed that the facility failed to accurately administer the correct doses of [MEDICATION NAME] to R6. This resulted in R6 receiving a significantly higher doses of [MEDICATION NAME] than what was ordered. Consequently R6 was sent to the hospital on two different occasions for Diabetic hypoglycemic episodes due to the administration of significant error in Insulin. The facility failed to have a system in place whereby all staff compared the most recent physician orders [REDACTED].

Based on record review, observation, and interview it was determined that the facility failed to ensure that two (R104, R35) out of 40 sampled residents received the care and services necessary to attain their highest practicable level of well being in accordance with the comprehensive assessment and plan of care. R104 was assessed for choking with meals resulting in a diet change that included no pancakes or bread products. Despite this assessment R104 was served waffles and began choking requiring life saving procedures that included the [MEDICATION NAME] maneuver and aggressive suctioning. R35 was assessed for being at risk for pressure ulcers. R35 was observed in bed for several days with his heels not off loaded. Findings include: 1. R104 had [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and quarterly MDS dated [DATE] revealed R104 required set up help and supervision for eating. R104's November 2011 Physician orders [REDACTED]. Nurses notes dated 10/4/11 at 8:07 AM documented that R104 coughed and choked on pancakes but was able to clear her airway on her own. The nurse continued to document that a Dietary Communication Form was sent to Dietary indicating not to send pancakes for R104. A speech therapy communication form was sent to screen the resident. A dietary note dated 10/6/11 documented that R104 was "coughing/choking on pancakes. Resident experienced a choking episode on a pancake again therefore they have been discontinued from her diet." The speech therapy care plan dated 10/10/11 revealed "Pt (patient) will tolerate mechanical soft diet with thin liquids without signs or symptoms (s/s) of aspiration. Patient seen by speech therapy for dysphagia (Inability to swallow or difficulty in swallowing. Taber's cyclopedic Medical Dictionary Ed. 19). Pt tolerated soft solids with thin liquids without s/s aspiration.... The facility documented on 3 different care plans (Therapeutic Diet, Mechanically Altered Diet and Aspiration Precautions) an approach of No Bread products dated 11/7/11 for R104. This approach for No Bread Products was also documented on the outside of the care plan folder for quick review along with Aspiration Precautions. On 11/8/11 a physician order [REDACTED]. Review of R104's Speech therapy note dated 11/16/11 revealed she was to continue with a mechanical soft diet and no bread products. R104's nurses notes revealed on 11/20/11 at 8:40 AM R104 began choking on breakfast at 8:20 AM. The nurse saw resident was having trouble expelling what was caught in her throat. The [MEDICATION NAME] maneuver was performed unsuccessfully. Suctioning was started. R104 was suctioned with a 14 french naso tubing on the 4th attempt some food [MEDICATION NAME] came loose. They reattempted with the yanker and a large food [MEDICATION NAME] was removed. R104 was able to take deep breath and stated she could breathe much better. An interview conducted with E10 (Dietary) on 12/5/11 revealed E10 was on the tray line on 11/20/11. When R104's tray came down the line, E10 told the cook (E11) that R104 was on a Mechanical soft with no bread. The cook told her she could have pancakes. E10 told the cook R104 could not have bread. The E11 (cook and E10's supervisor) told her to give R104 the waffle. An interview was conducted with E11 (cook) on 12/5/11. E11 stated she thought R104 did not want bread but it did not click the waffle was a bread product. E11 confirmed she put the waffle on R104's tray. An interview with E9 (CNA) on 12/5/11 revealed she read the card and it said no bread products in the middle of the card. At the bottom of the card it had some foods that R104 could not have and pancakes was one of them. The card did not say "no waffles" so E9 stated she thought R104 could have the waffle. E9 stated she cut up the waffles for R104 and gave her the tray. A few minutes later R104 began choking on the waffle and the nurse was called. The nurse (E7) began doing the [MEDICATION NAME] maneuver. Interview with E7 (LPN) on 12/13/11 at 8:50 AM revealed the CNAs were yelling someone was choking while pulling the alarm. E7 stated she was doing her medication pass. She stopped ran in and began doing the [MEDICATION NAME] maneuver that was unsuccessful. So R104 was suctioned with the nasal cannula and yanker in order to dislodge the waffle. Interview with E18 (RN unit manager) on 12/12/11 at 9:00 AM confirmed R104 had a care plan indicating she was not to receive bread products/pancakes. Dietary staff and a CNA gave R104 the waffle which is considered a bread product. R104 began choking requiring the staff to perform the [MEDICATION NAME] maneuver. The staff also suctioned R104 to dislodge the food. While R104's care plan and communication slips between speech therapy, dietary and nursing identified R104's difficulty with swallowing the facility failed to incorporate this information into specific Physician orders. The physician order [REDACTED]. This lead to R104 choking requiring life saving measures that included the [MEDICATION NAME] maneuver and aggressive suctioning to remove the air way obstruction. 2. R35 was admitted to the facility with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] for R35 documented he was totally dependent on staff for all his activities of daily living. R35's MDS documented that he required one person to physically assist him with bed mobility. On 12/4/11 a pressure ulcer prediction assessment was completed using the Braden scale. This assessment documented that R35 scored a 13 making him a moderate risk for acquiring pressure ulcers. Review of R35's care plan for skin break down documented approaches/interventions that included to float heels at all times. The following observations were made during the survey of R35's heels not being floated: 12/6/11 11:15 AM in geri chair heels not floated 12/7/11 3:20 PM in bed with heels not floated 12/8/11 12:45PM in geri chair heels not floated 12/9/11 in bed all day sheets pulled back heels not off loaded An observation of R35 and interview with E20 (treatment nurse) revealed R35's heels were not floated. E20 assessed R35's mobility. R35 left arm moved purposely, left leg some contracture of knee with limited movement, and his right side of his body had no movement with contractures. E20 also looked at R35's heels and observed that his right heel had red blanching. Review of R35's nurses notes dated 12/12/11 at 9:30 AM stated Resident has 0.4 x 0.4 x0 cm. intact red blanchable area to right heel...nursing measure start puffy boots to bilateral feet at all times and off load heels at all times. During and observation and interview with E3 (ADON) on 12/13/11at 8:15 AM it was observed that R35's heels were not floated. E3 immediately instructed the CNA to float his heels. Review of the facility's policy and procedures for Skin Impairment Prevention and Treatment with E3 revealed the facility had a policy and procedure was documented for residents that scored at high risk for pressure uclers. There was not a policy and procedure for residents that are assessed as being moderate or low risk for pressure uclers.

Based on record review, staff interviews, and other interviews as indicated, it was determined that for three (3) of thirteen (13) residents (R1, R13, and R9) reviewed the facility failed to provide the necessary care and services to attain or maintain the residents ' highest practicable physical well-being. On [DATE] when one resident (R1) experienced an airway emergency (coughing followed by cyanosis) in the dining room, facility staff failed to follow emergency procedures for the [MEDICATION NAME] Maneuver and choking intervention. Staff interviews during the survey revealed that prior to [DATE], facility staff observed R1 with signs of aspiration (coughing during meals) but did not report this to the physician in accordance with the plan of care or to the Speech Therapist who was treating the resident. As a result, R1 ' s coughing during meals was not addressed which resulted in aspiration during a meal on [DATE]and an airway emergency. Additionally when this emergency occurred facility staff did not follow emergency procedures correctly. For two current facility residents (R13 and R9), choking episodes were not reported to the facility ' s Speech Therapist to determine whether changes to the residents ' plan of care were indicated. Findings include: 1. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was on Aspiration Precautions and a pureed diet with nectar thick liquids and received skilled speech therapy five times a week for " diet consistency modification and compensatory swallow strategy training " (physician orders [REDACTED]. R1 ' s swallowing difficulty was documented throughout the clinical record including difficulty swallowing / impaired swallowing (Speech Therapy initial evaluation dated [DATE]); impaired swallowing and chewing (Nutritional assessment dated [DATE]); and dysphagia / chewing or swallowing difficulty (Nutrition Risk Screen dated [DATE]). R1 had an " Aspiration Precautions " care plan initiated on [DATE] which instructed staff to report any signs or symptoms of aspiration to the physician. R1 was receiving skilled Speech therapy for " compensatory swallow strategy training " but did not have individualized swallowing recommendations from the Speech Therapist included in her interdisciplinary care plan. E14 (Speech Therapist) explained to the surveyor on [DATE] at 3:03 PM that because R1 was on a pureed diet, there were no special compensatory techniques that she needed to use. E14 stated, however, that if a resident was coughing during meals specific compensatory techniques to implement would have to be determined on an individual basis and she (Speech Therapist) would have to train the staff on these techniques. The first nursing note in R1 ' s clinical record (dated [DATE] and timed 10:10 AM listed the report received by the facility regarding R1 ' s status prior to admission. This report included that a video swallow test performed prior to admission showed " flash penetration " . As explained to the surveyor on [DATE] at 3:03 PM by E14 (Speech Therapist), " flash penetration with thin and thick liquids, no aspiration " on the Modified [MEDICATION NAME] Swallow test means that during the test food made " quick and shallow " contact with R1 ' s airway but did not go deep into R1 ' s airway. When asked if this changed R1 ' s care, E14 responded that the test showed that R1 wasn ' t aspirating but clinical signs needed to be looked at. R1 required staff supervision with eating according to the Admission Nursing Evaluation dated [DATE] and the Admission MDS completed on [DATE]. " Aspiration Precautions " were ordered for R1 by the physician on [DATE] (date of admission) but there was no facility policy / procedure (in the manual or provided upon surveyor request) describing what was meant by this. Facility staff caring for R1 gave different answers when asked what " Aspiration Precautions " meant including E14, the Speech Therapist ([DATE] 3:03 PM); E20, the attending physician, ([DATE] 9:20 AM); E19, the day shift CNA, ([DATE] 9:25 AM); E21, the 3 PM to 11 PM CNA ([DATE] 10:35 AM); and E18, the substitute Speech Therapist ([DATE] 11:25 AM). A nursing note written by E11, the RN Supervisor on [DATE], described the following sequence of events: R1 " was in dining room (large) eating dinner. Coughing with meal. Nurses in and monitoring. Resident then slumped in chair with glass in hand. Cyanosis to full body. [MEDICATION NAME] ineffective to restore respirations. Pureed diet emitting onto clothing. Resident became unresponsive, no apical pulse or respirations. CPR (cardiopulmonary resuscitation) initiated in (R1 ' s) room. 911 en route " (nursing note [DATE] 6:40 PM). Staff interviews revealed that while eating dinner in the dining room on [DATE] (3 weeks after admission) R1 was coughing and then developed facial cyanosis (a bluish discoloration of the skin) and a loss of respirations and pulse. Suction equipment was available in the dining room according to the RN supervisor at the time, E11, (surveyor interview [DATE] at 11:25 AM) who showed the surveyor the cabinet where the suction machine and supplies were stored. Interview with the facility ' s Director of Nursing (E2) on [DATE] at 9:25 AM confirmed that suction equipment is always available in the dining room for anyone who might need their airway cleared. The suction machine was not used by the staff, instead two staff members (E15, an LPN and E17, a CNA) removed R1 from the dining room in her wheelchair. R1 ' s face became dark blue / purple while in the hallway between the dining room and the resident ' s room (located down the hall from the dining room and around a corner near the Kent nursing station). E11 determined that she (R1) had no breathing or heartbeat. The American Heart Association (AHA) BLS (Basic Life Support) for Healthcare Providers instructions utilized by the facility to train staff for emergencies was not followed. The AHA procedures for relief of choking instruct staff to call 911, lower the victim to the ground and begin CPR looking in the mouth for an obstruction every time the airway was opened to give breaths. This did not occur. The [MEDICATION NAME] Maneuver guidelines in the facility ' s policy / procedure manual were not followed. These guidelines instruct staff to ease an unconscious resident to the floor if possible, perform abdominal thrusts and perform the tongue-jaw lift to open the resident ' s mouth because " moving the lower jaw moves the tongue off the throat and opens the airway " . This did not occur. The [MEDICATION NAME] Maneuver was used on R1 in the hallway outside of the dining room while she was slumped in the wheelchair and developing blue / purple coloring. R1 had signs of a severe airway obstruction (poor or no air exchange and turning blue) and when the [MEDICATION NAME] Maneuver failed to improve her condition 911 was not immediately called and R1 was not lowered to the floor for CPR (cardiopulmonary resuscitation) to begin but was taken down the hall in her wheelchair to her room. E11 was interviewed by the surveyor on [DATE] at 11:25 AM and stated that she never saw R1 in the dining room during dinner on [DATE]. E11 stated that she was on the Sussex unit of the facility (opposite side of the building) when a CNA (E17) came to her and said she was needed in the main dining room. E11 stated that she left the Sussex unit and as she rounded a turn to go down the hall towards the dining room, she saw E15 (an LPN) and E16 (an RN) starting down the hall with R1 in a wheelchair. E11 stated that she saw R1 starting to turn blue and saw her whole face become dark blue. E11 stated that she listened with a stethoscope for respirations and an apical pulse and heard nothing and that R1 was slumped in the wheelchair with E15 holding onto her (R1). E11 stated that R1 ' s eyes were wide open and her mouth was opening and closing with some " agonal breathing " . E11 stated that the nurses took R1 to her room and put her into bed while another nurse obtained the emergency crash cart. E11 stated that when R1 was laid in bed on the backboard, the blueness of her face " went away " and her skin became pale. E11 stated that CPR was initiated at this time. E16, the RN seated across from R1 during dinner on [DATE] was interviewed on [DATE] at 2:20 PM. E16 stated that R1 was coughing often during dinner on [DATE] and since she wasn ' t familiar with R1 she asked generally of the other staff present in the dining room if the coughing was normal for R1. E16 recalled receiving a general response that R1 sometimes coughed during meals although she could not recall a specific staff member who said this. E16 stated that she observed liquid dribble from R1 ' s mouth during the meal and later observed thick liquid drooling from R1 ' s mouth when E15 did the [MEDICATION NAME] maneuver outside of the dining room. In a written statement dated [DATE], E16 documented that during the meal R1 was " doing a lot of coughing as if to clear her throat and then appeared to inhale deeply and go limp " before staff took R1 out of the dining room. When asked if there was a suction machine in the dining room, E16 replied not that she was aware of. E15 (an LPN) was interviewed on [DATE] at 2:50 PM and stated that she was entering the dining room because it was her turn to feed residents when she saw R1 coughing with some facial redness. E15 stated that R1 ' s cough was constant and strong. E15 stated that she asked E17 to help her take R1 back to her room. When asked why she was taking R1 back to her room, E15 initially stated that she was going to suction R1 in her room. E15 then stated she thought she had time to take R1 back to her room and assess her (listen to her lungs) and that she wasn ' t 100% sure R1 needed suctioning at the time. When asked if there was suction equipment available in the dining room, E15 stated that she thought so. E15 stated that when they (E15 and E17) exited the doors of the dining room R1 slumped back and was losing her color and " didn ' t seem to have an airway " . E15 stated that she told E17 to run and get help. E15 stated that she tried the [MEDICATION NAME] maneuver by putting her arms around R1 who was in the wheelchair and food was " still coming out " although she did not recall the color or texture of the food. E15 stated that as E11 and E17 were coming down the hall, R1 ' s face " turned purple " , E11 checked R1 ' s heart rate and respirations which were absent. R1 and told E15 to call 911. E15 recalled that she was in the hall near the dining room when she met with E11 and E17 and they took the resident down the hall and back to her room. E15 stated that she called 911 and reported that there was a full code at the facility and they thought the resident (R1) choked. E17, a CNA, stated that she was in the dining room during dinner on [DATE] but had never cared for R1 before. E17 stated that she was assisting residents at another table but had glanced over and saw that R1 seemed to be having a hard time feeding herself. E17 explained that R1 was moving the cup and spoon towards her mouth but never reached her mouth and she (E17) observed food dripping from the spoon. E17 stated that she approached R1 to help her and saw her head go back and she (R1) was " trying to catch her breath " . E17 stated that as this happened, E15 came over and they started to move R1 out of the dining room in her wheelchair. E15 stated that R1 ' s face was a bluish gray color that E17 had never seen before. E17 stated that it looked to her like R1 was trying to catch her breath and her eyes and mouth were open. According to the Basic Life Support Patient Care Report completed by the Emergency Medical Technicians (EMTs), they arrived at R1 ' s side at 5:28 PM and immediately inserted an oral airway. Paramedics (Advanced Life Support or ALS) arrived at 5:29 PM and R1 was transported to the hospital at 5:59 PM. A late entry nursing note dated [DATE] timed 8:30 PM indicated that the first responders (EMTs and paramedics) were " easily able to obtain airway, intubate, no foreign object or debris obstructing airway. Lung sounds clear to auscultation, Admit [DIAGNOSES REDACTED]. arrest " . E20, R1 ' s attending physician, documented in the Discharge Summary that R1 ' s final [DIAGNOSES REDACTED]. CPR initiated. 911 informed.....transferred to (name of hospital) via EMS " . The hospital discharge summary for R1 dated [DATE] stated R1 had " acute [MEDICAL CONDITION] secondary to witnessed aspiration " which caused respiratory arrest. R1 died at the hospital on [DATE] with the Certificate of Death identifying the cause of death as " hypoxic [MEDICAL CONDITION] due to choking / aspiration of foreign body (food) " . The manner of death was accidental with the date of injury given as [DATE] and the description of how the injury occurred listed as " choking or aspirating on food " . Staff interviews conducted during the survey revealed that prior to [DATE] R1 coughed during meals at times but the facility staff failed to recognize this as an overt sign of aspiration and as something that needed to be reported to E14 (Speech Therapist) and E20 (attending physician). According to R1 ' s care plan for " Aspiration Precautions " , staff should " report any signs or symptoms of aspiration or choking to nurses / MD " . This did not occur. The observations of R1 coughing during meals were not documented in the clinical record although staff reported to the surveyor that: -R1 had an intermittent cough during lunch which started shortly after admission which " kind of sounded like something was in her throat " , like a " clearance cough " . This occurred intermittently at 2 or 3 lunches per week and " we (staff) all recognized the cough. The nurse would check to see if she was ok " (surveyor interview with E19, R1 ' s usual day shift CNA [DATE] 9:25 AM); -R1 coughed a lot at meals (surveyor interview with E15 [DATE] 2:50 PM); and -R1 was observed coughing on two different occasions while eating lunch (surveyor interview with E11, [DATE] at 11:25 AM). The Speech Therapist, E14, did not reassess R1 to determine the reasons for coughing during meals or to see if any changes to R1 ' s care were needed because she was not aware of the coughing. E14 stated to the surveyor on [DATE] at 3:03 PM that she had received no reports from nursing about R1 coughing during any meals and if she had known about this she would have reassessed R1 to see if she needed a different diet (liquids honey thickened) or modification of the plan of care (different compensatory strategies for swallowing). E14 stated that reports from nursing could have been written or verbal and later confirmed to the surveyor that she found no written reports related to R1. E14 stated that the last time she saw R1 was on [DATE] because she (E14) went away. E18 was the covering Speech Therapist who treated R1 on [DATE]. E18 stated that R1 had no coughing during her treatment and explained that coughing is an overt sign of aspiration and indicated a need for further assessment. On [DATE] after discussion with the surveyor, the facility began conducting staff in-services on responding to airway emergencies in the dining room and aspiration precautions. The facility also added the following approaches to their standard Aspiration Precautions care plan: encourage small bites / sips; encourage to alternate between solids and liquids; encourage slow rate of intake. 2. R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on a regular diet. A speech therapy screening conducted on [DATE] indicated there were no swallowing problems identified. Review of nurses ' notes for [DATE] revealed that at 8:50 AM the resident was diaphoretic, short of breath, purse lip breathing and a respiratory wheeze was auscultated. The physician was notified and the resident was sent to the ER for evaluation. A note timed 12:55 PM noted the resident had returned from the ER with a [DIAGNOSES REDACTED]. An interview on [DATE] at 6 PM with nurse E13 revealed that on [DATE] R13 got " choked up " while taking her morning pills resulting in her becoming very anxious and short of breath. E13 revealed that due to her [MEDICAL CONDITION] and recent surgery with risk of [MEDICAL CONDITION] embolism she was sent out to the ER to be evaluated. E13 stated that at no point was the resident fully choked and in need of nursing intervention to remove the pills. Review of the ER records for [DATE] documented under chief complaint " Patient states that she choked on pills. States had done similar in past. No reported chest pain. States symptoms have completely resolved ... " . A temporary care plan was initiated on [DATE] for the problem of choking with a goal of no further dyspnea. Approaches included giving medications slowly. The care plan was resolved on [DATE]. Choking was not added as an approach to the comprehensive care plan. There was no evidence that R13 was referred to speech therapy for another screening. Review of the Interdisciplinary Care Plan Conference Team Note dated [DATE] lacked any documentation of the choking episode that had occurred on [DATE]. The meeting attendance list did not include anyone from the therapy department. Review of the Interdisciplinary Care Plan Conference Team Noted dated [DATE] under nursing review documented " [DATE] to BMC ER for SOB. Returned later in day [DATE] dx dyspnea and choking episode. No new orders " . A member of the therapy department did attend this meeting. An interview with the speech therapist E14 on [DATE] at 1:50 PM revealed that she was unaware of R13 ' s choking episode. E14 checked the communication/ meeting book and the screening book and found no evidence that therapy was made aware of the choking episode 3. R9 was admitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. R9 also had multiple medical [DIAGNOSES REDACTED]. A screening by the facility ' s Speech Therapist (E14) on [DATE] revealed no swallowing problem. Four weeks later, however, R9 was " noted with increased coughing while drinking milk, resident assessed by this nurse, right lung lower lobe noted with expiratory wheeze ....(R9) stated ' it went down the wrong pipe ' , resident noted with small amount of milk in tissues in basin, oxygen saturation 98% on room air (attending physician) aware, see new order for [MEDICATION NAME] (an inhaled [MEDICATION NAME][MEDICATION NAME] medication) as needed .....given with positive effects, lungs clear, no short of breath " . According to a temporary care plan initiated on [DATE], R9 " strangled while drinking- coughing " . Nurse E26 stated to the surveyor on [DATE] at 9:40 AM that following the choking episode on [DATE], R9 told her (E26) that the same thing happened often prior to her admission to the facility. The temporary care plan interventions included " speech therapy evaluation as needed " but the Speech Therapist, E14, was not notified of this incident or R9 ' s report of prior choking (before admission) and did not re-screen or evaluate R9 as a result (interview with surveyor [DATE] 10:10 AM).