Every finding on record at Delaware Hospital F/T Chronically Ill (Dhci)

Based on document review, interviews, observations, and facility policy review, the facility failed to ensure that four of 10 residents (Residents (R) 5, R4, R71, and R6) reviewed for unsupervised smoking, smoked safely. In addition, all residents refused to don (put on) a smoking apron for protection and would hold onto their cigarettes and/or lighters instead of nursing staff securing the smoking paraphernalia safely. In addition, R34 was identified as a resident who smoked and had a lighter in her room. R34 used an oxygen concentrator, while in her room and while her lighter was kept in her room. This placed all residents who smoke of an increased opportunity for burns.The facility's Administrator and Director of Nursing (DON) were notified on 01/07/26 at 6:40 PM that Immediate Jeopardy existed related to the failure to assess and monitor three residents R5, R71, and R6 who smoked. The Immediate Jeopardy began on 01/07/26 at 6:40 PM when the three residents were identified with upper extremity impairments In addition, the facility failed to supervise these three residents while they smoked. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 01/08/26 at 3:01 PM. The survey team validated implementation of the removal plan through observations, interviews, and review of training records. Immediate Jeopardy was removed on 01/09/26 at 11:30 AM. After removal of the Immediate Jeopardy, the deficiency remained at a ''E'' scope and potential for more than minimal harm.Findings include:1. Review of R5's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 06/13/02 with a diagnosis of quadriplegia. Review of R5's EMR titled Care Plan located under the Care Plan tab dated 11/07/23 indicated the resident voiced that it was important for him to be independent to do things on my own and to practice safe smoking habits. The care plan identified that the resident was paralyzed and required assistance, at times, for retrieving and/or lighting his cigarettes. The interventions for R5's care plan revealed that the nurses were to provide the resident with his cigarettes upon his request and preferred to keep his lighter with him. Also, the care plan indicated the resident preferred to smoke at his leisure and he declined to don a smoking apron. Review of R5's EMR titled Smoking Safety Assessments located under the Assmts (Assessments) tab dated 11/26/24 indicated that the resident had total or limited range of motion in hands or arms. Review of R5's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 12/05/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The resident was identified with bi-lateral impairment of both upper extremities. Review of R5's EMR titled Smoking Safety Assessment located under the Assmts tab dated 01/06/26 indicated that the resident had total or limited range of motion in hands and arms. During an interview on 01/07/2026 at 8:42 AM, Certified Nurse Aide (CNA) 2 confirmed R5 kept his cigarettes and lighter with him. During an interview on 01/07/2026 at 8:43 AM, Office Associate (OA)1, who worked on the same unit where R5 lived, stated the resident kept his own cigarettes and lighter with him. OA1 stated the staff will take R5 to the front smoking area and will then leave the resident so he can smoke on his own. During an interview on 01/07/2026 at 8:47 AM, Registered Nurse (RN) 8 stated that R5 kept his cigarettes and lighter with him. During an interview on 01/07/2026 at 9:03 AM, Licensed Practical Nurse (LPN) 5 confirmed R5 kept his cigarettes on him but not the lighter. During an interview on 01/07/2026 at 10:14 AM with RN6, who was the current nurse supervisor on the same unit where R5 lived, confirmed the staff would take R5 out to the front smoking area and allow the resident to smoke on his own. During an interview on 01/07/2026 at 11:10 AM with CNA5, who was the receptionist for the front lobby, confirmed R5 does smoke on his own., but she keeps an eye on him. During an interview on 01/07/2026 at 11:35 AM, the Activity Aide (AA)1 confirmed that R5 liked to keep his cigarettes and lighter with him. AA1 stated the resident wore a cross-body bag and that was where the resident kept his cigarettes and lighter. AA1 stated at times he would bring the resident out to the front smoking area but that the receptionist kept an eye on the resident from inside the building. During an observation on 01/07/26 at 11:41 AM, the front smoking area had multiple areas to sit. There were two black plastic buckets which contained sand and cigarette butts. There was a large metal ashtray next to one of the columns. Upon entrance back into the lobby from the front smoking area were two desks. One desk was positioned next to the large window which faced the smoking area. The second desk was closer to the main hallway entrance. During an observation at 12:23 PM, staff brought R5 to the outside front smoking area. The resident was positioned next to the large metal ashtray, and he faced the window which faced the front lobby. The resident retrieved a packet of cigarettes and pulled one cigarette with his right hand. The resident placed the cigarette in his mouth and then retrieved his lighter and lit his cigarette. These items were retrieved from the resident's green cross body bag. The resident's fingers on his right hand were severely contracted but he had slight movement in his arm to move the cigarette to and from his mouth. CNA5 was present during this observation and was reading a magazine. CNA5 pointed to a fire extinguisher which was hanging on a wall directly in front of CNA5 and stated she was not aware of a smoking blanket in case of a fire. The observation ended at 12:30 PM. 2.Review of R6's admission Record located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with a diagnosis of tobacco use, cataract, and vascular Dementia. Review of R6's Annual MDS located under the MDS tab in the EMR with an ARD of 01/24/26 revealed R6had a BIMS score of 15 out of 15 indicating cognitive intact. Review of R6's Care plan located under the Care Plan tab in the EMR with a revision date of 01/05/26 revealed the resident had the potential to harm himself while smoking, declines to use a smoking apron, and has burned holes in his clothes and gloves, and to report changes in mood and demeanor that may cause him harm. Review of R6's Smoking Safety Evaluation located under the Assessment tab in the EMR, dated 01/24/25 revealed R6 utilizes tobacco; has poor vision or blindness; balance problems while sitting or standing; drops ashes on self; unable to light a cigarette safely; unable to hold a cigarette safely; unable to extinguish a cigarette; unable to use ashtray to extinguish a cigarette. During an interview on 01/05/26 at 11:28 AM, R6 confirmed he was a smoker, held his own cigarettes and lighter and that he smoked in the smoking section. During an observation on 01/07/26 at 11:01 AM, R6 came out of his room and confirmed he had his cigarettes. R6's cigarettes were observed in a cup holder on the side of his wheelchair in a green plastic holder. During an observation on 01/07/26 at 11:03 AM, LPN2 wheeled resident out to the smoking area. The resident did not have an apron on and was not offered one. The staff member went back into building and left the resident outside the 500 unit in the smoking area. The resident had his own cigarettes and lighter, and he lit his own cigarette. During an observation on 01/07/26 at 11:03 AM, no fire extinguisher or fire blanket was present on the 500-unit smoking area. No fire safe ash trays were present, just large metal cans. During an interview on 01/07/26 at 11:14 AM, R6 confirmed staff do not come outside to supervise him when he smokes. During an observation on 01/07/26 at 11:24 AM, R6 put his cigarette butt on the ground and went into building. During an interview with on 01/07/26 at 11:27 AM, LPN2 revealed she did not supervise the resident during smoke break because he did not require supervision. She also stated the resident was permitted to have his smoking materials. 3.Review of R71's admission Record located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with a diagnosis of epilepsy, hereditary and idiopathic neuropathy, neurosyphilis, hemiplegia and hemiparesis affecting non-dominate side, traumatic subarachnoid hemorrhage. Review of the Smoking Safety Evaluation located under the Assessments tab located in the EMR dated 03/07/25, revealed R6 utilizes tobacco; had balance problems while sitting or standing; total or limited ROM in arms or hands. Review of R71's quarterly MDS located under the MDS tab in the EMR with an ARD of 11/07/25, revealed R71 had impairment of upper extremity on one side. R71 had a BIMS score of 15 out of 15 indicating cognitively intact. Review of Care plan located under the Care Plan' tab in the EMR with a revision date of 11/07/25 revealed the resident had the Potential to have skin injuries because he smokes cigarettes and declines to wear a smoking apron. The care plan also revealed for aides to report any injury, changes, or abnormalities to the nurse. During an observation on 01/07/26 at 8:43 AM, R71 wheeled himself down the 500-unit hallway with a cigarette in his mouth and lighter in his right hand. The resident did not have on smoking apron. Activity Director (AD) offered him smoking apron and resident refused. R71 and AD went out in smoking area, with staff assisting resident outside. R71 smoking a cigarette without a smoking apron. During an observation on 01/07/2026 at 8:45 AM, the AD left the smoking area where R71 was smoking, went to the farthest side of the facility van approximately 50 feet away from smoking area. During an observation on 01/07/26 at 8:47 AM, the AD went back into the facility and left R71 outside smoking alone. During an observation on 01/07/26 at 8:48 AM, no fire extinguisher or fire blanket was present on the 500-unit smoking area. No fire safe ash trays present just large metal cans. During an observation on 01/07/26 at 8:49 AM, R71 wheeled himself back into the facility and to his room. No staff accompanied him. R71 confirmed he kept his cigarettes and lighter. There were metal non fireproof cans for cigarette butts and R71 placed his cigarette butt in one of the cans. During an interview on 01/07/26 at 12:12 PM, the AD revealed that R71 did not require supervision during smoking and had a right to decline to wear the smoking apron. AD also revealed R71 was permitted to keep his cigarettes and lighter in his possession. 4.Review of R4's Smoking Safety Evaluation located under the Assessments tab in the EMR dated 12/05/25 revealed R4 utilizes tobacco; has balance problems while sitting or standing; burns skin, clothing, furniture or other; drops ashes on self; does not follow the facility's policy on location and time of smoking; unable to extinguish a cigarette safely; unable to use ashtray to extinguish a cigarette. Review of R4's annual MDS located under the MDS tab in the EMR with an ARD of 12/05/25 revealed the resident had impairment of upper extremity on one side. R4 had a BIMS score of 13 out of 15 indicating cognitively intact. Review of R4's Care Plan located under the Care Plan tab of the EMR dated 12/16/25 revealed R4 had the Potential to injure himself when because he had a stroke, smoke cigarettes, and has seizure disorder, declines to wear a smoking apron and drops ashes on clothing. The care plan revealed that R4 often Declines to wear a smoking apron, is to keep cigarettes at the nurse's station, does not always follow the smoking schedule and needs reminders to smoke in the designated smoking area, and sometimes needs assistance by one person to push him to the smoking area. During an observation on 01/05/26 at 11:03 AM, R4 was in his room sitting in a wheelchair with a pack of cigarettes in a red plastic holder and a cigarette on the outside of the pack. The resident confirmed he had a lighter that was located under a white washcloth on the arm rest of the wheelchair. During an interview on 01/07/26 at 12:12 PM, the AD stated residents are permitted to have their cigarettes and lighter in their possession as long as they are care planned and that R4 and R6 are care planned to keep them. She revealed staff are only present during smoke break if the resident is care planned for supervision. The AD revealed she was not familiar with the results of the residents smoking assessments. The AD confirmed there were no fire extinguisher or smoking blanket near the 500-unit smoking area. During an observation on 01/08/26 at 11:15 AM, R4 was sitting outside of the 500 unit in the smoking area smoking a cigarette. There was no staff present for supervision. R4 confirmed he kept his cigarettes and lighter. 5. Review of R34's quarterly MDS with an ARD date of 12/10/25 and located in the MDS tab of the EMR, revealed R34 was admitted on [DATE]. The resident had a BIMS score of 14 out of 15 indicating R34's cognition was intact. The MDS also indicated that the resident received oxygen therapy, and had diagnoses of chronic obstructive pulmonary disease, unspecified, personal history of nicotine dependence, and Wernicke's encephalopathy. Review of R34's care plan, revised 09/08/25, located in the EMR under the Care Plan tab revealed Safety: Smoking, I need: to practice safe smoking habits by following my smoking schedule and smoke in authorized areas. An intervention included I need my aides to assure proper storage of my smoking materials. (Cigarettes and lighter. I keep them at the nurse's station and also have some cigarettes kept in my room and can have whenever I want to go outside to smoke. I need everyone to report changes in my abilities to my nurse. Review of R34's Smoking Safety Evaluation, dated 12/02/25, located in the EMR under the Assessment tab revealed R34 utilized tobacco and Note: Supervision will be required for all Residents during designated smoking times. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated. The evaluation determined that R34 was able to light a cigarette safely, was able to hold a cigarette safely, was able to extinguish a cigarette safely, and was able to use ashtray to extinguish a cigarette. During an interview on 01/07/26 at 9:03 AM, Certified Nurse Aide (CNA)4 stated, Yes, R34 smokes and CNA4 then picked up the sign-out sheet on a clip board at the nurse station with R34's signature when she went outside to smoke. CNA4 stated R34's cigarettes are kept in a drawer at the nurse station but R34 keeps her lighter. On 01/07/26 at 9:05 AM, R34 was in her bed with covers over her head and unwilling to talk. The oxygen concentrator was observed at R34's bedside. During an interview on 01/07/26 at 10:23 AM, Unit manager RN4 stated R34 was a smoker and occasionally needed assistance with wheeling in her wheelchair. RN4 stated R34 signed herself out to smoke and refused to wear a smoking apron. RN4 stated staff always supervised her and could be seen through the window and there are outside cameras. RN4 stated R34's cigarettes were kept at the nurse station and R34 kept her lighter as R34 had a private room. On 01/07/26 at 12:25 PM, R34 was sitting in a wheelchair at the lunch table in the dining room feeding herself with no difficulty. R34 confirmed she kept her lighter, but the pack of cigarettes are returned to the nurse station. R34 had oxygen in use via nasal cannula and an oxygen concentrator plugged into the wall. During an interview on 01/08/26 at 3:37 PM, RN2 was asked if a resident used oxygen in their room should they keep a cigarette lighter in their room. RN stated, No. During an interview on 01/08/26 at 4:07 PM, CNA8 and CNA9 stated R34 was a smoker. They stated the residents' cigarettes and lighter are stored in the nursing station. The CNAs stated R34 had her own lighter, but it was not okay to have a lighter in her room because she used oxygen in her room. During an interview on 01/08/26 at 6:10 PM, CNA10 stated the facility's new policy was that R34 had to be supervised. CNA10 stated cigarettes were kept at the nurse station. CNA10 then opened a drawer in the nurse station and a pack of cigarettes with R34's name was in the drawer but there was no lighter observed. During an interview on 01/09/26 at 9:23 AM, RN9 stated R34, should not keep a cigarette lighter in her room since she uses oxygen. During an interview on 01/07/26 at 1:33 PM, the Administrator, DON , the Medical Director, Quality Assurance, Social Services Chief Administrator, and RN 4, who was responsible for the development of resident care plans, were in attendance. The Administrator stated all residents who smoked were supervised. RN4 stated R5 was a resident who lived in the facility for a long time and if he needed assistance with smoking, he would request this from the staff to help him. The Administrator confirmed there were no smoking blankets for the front smoking area or the smoking area in the back of the facility. The Administrator also stated the residents from the 500 unit who utilized the back smoking area did not require supervision. During an interview on 01/09/26 at 9:00, the Maintenance Director stated the necks to the ash tray bottoms were located behind the facility and verified that they were not attached to the safety ash trays in the front and back smoking areas. Review of the facility's policy titled, Smoking Policy dated 05/31/24, noted Procedures/ Responsibilities: .In the case of residents who are excluded/ grandfathered by this policy, they will be monitored and assessed as needed for unsafe smoking behaviors. Notwithstanding this policy, other residents may be excluded from this policy once they have been deemed in need of a special non-pharmacological approach to behavior modification management. Upon admission, each resident will be assessed for tobacco use and any safety concerns regarding tobacco use. The assessment for tobacco use will be utilized to determine a resident's plan of care for tobacco cessation. Individuals are responsible for ensuring that they clean up any and all tobacco product waste, such as cigarette butts, after use. Review of the NFPA (National Fire Protection Association) 99(12), Sec. 11.5.1.1.1 requires that smoking materials (e.g., matches, cigarettes, lighters, lighter fluid, and tobacco in any form) be removed from patients receiving respiratory therapy. Review of the NFPA 99(12), Sec. 11.5.3.2.1 requires that smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read No Smoking or shall be posted with the international symbol for no smoking.

Based on observation, interview, and record review, the facility failed to utilize menus with portion sizes for regular, mechanical soft, and puree diets for two of two meals. This failure could potentially cause residents to become malnourished or experience weight loss or weight gain.Findings include:Review of the week-two menus for Spring 2025 did not include portion sizes for the regular, mechanical soft and pureed diets.Review of the individual resident's pre-selected menu sheets for lunch on 01/06/26 and 01/07/26 did not include portion sizes.Review of the facility diet type report, dated 01/09/26, provided by the facility, revealed 35 regular diets, 18 mechanical soft diets, and nine pureed diets.On 01/06/26 at 12:10 PM, the tray line on the 200 unit was observed in progress. Food Service Worker (FSW)1 read each resident's pre-selected menu and plated the food accordingly with no portion sizes to follow. FSW1 confirmed he followed the resident's pre-selected menu items. No portion sizes were listed on the food items, and no other menus were being used to determine portion sizes. The food items that were served included a cold turkey submarine sandwich, salmon square, chips, roasted potatoes, mixed vegetables, mashed potatoes with gravy, pureed mixed vegetables, and puree salmon. On 01/07/26 at 12:07 PM, the tray line on the 200 unit was observed in progress. FSW1 read each resident's pre-selected menu and plated the food accordingly with no portion sizes to follow. FSW1 confirmed he followed the resident's pre-selected menu items. No portion sizes were listed on the food items, and no other menus were being used to determine portion sizes. The food items included roast beef slices, stuffed pasta shells, gravy, pureed soup, pureed stuff pasta shells, pureed asparagus, mechanical soft roast beef, rice, pureed beef, pureed mix vegetables, regular mix vegetables, baked potato halves, asparagus, regular soup, mashed potatoes, French fries, and garlic bread. FSW1 was asked how he knew what serving utensils to use since the menus did not have portion sizes. FSW1 stated they have a list of portion sizes in the main kitchen they go by for proteins, mashed potatoes, etc.During an interview on 01/07/26 at 12:08 PM, the Dietary Manager (DM) confirmed the portion sizes were not included on the facility's week-two Spring 2025 menus or pre-selected menus. DM stated the dietary staff used a list of portion sizes available in the main kitchen that included general food groups and items. DM then provided the list titled Standard Serving Sizes, the dietary staff used when determining serving utensils or amounts to serve. The list only included generalized food groups such as protein, starches, vegetables, and breakfast foods. The list did not include mechanical soft or pureed foods. During a follow up interview on 01/09/26 at 12:40 pm, the DM stated they had menus with serving sizes that could have been used. The week-two menus for Spring 2025 with portion sizes were provided.During an interview on 01/09/26 at 12:42 pm, the Registered Dietitian (RD) stated she was not aware menus without portion sizes were being utilized. The RD stated, she was aware of the requirement for menu portion sizes, So to ensure the menus were balanced. When comparing lunch on 01/06/26 according to the week-two Spring 2025 menus with portion sizes it was revealed: The portion size for the regular roasted potatoes was 4 ounces (oz) but 3.25oz was served, andThe portion size for the puree salmon was 4 oz but 3.25oz was servedWhen comparing lunch on 01/07/26 according to the week-two Spring 2025 menus with portions sizes it was revealed: The portion size for the pureed soup was 6 oz, but 3 oz was served, The portion size for the pureed stuff pasta shells was 4 oz but 3oz was served, The portion size for the pureed asparagus was 4 oz, but 3 oz was served, The portion size for the mechanical soft roast beef was 4 oz, but 3.25 oz was served,The portion size for the rice was 4 oz, but 3.25 oz was served,The portion size for the pureed roast beef was 4 oz, but 3 oz was served,The portion size for the baked potatoes was one potato, but one half was served,The portion size for the asparagus was 4 oz, but it was served with tongs, andThe portion size for the regular soup was 6 oz, but 3 oz was servedA policy for menus was requested and the facility stated they did not have one.

Based on observation, record review, review of facility policy, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for four of five residents (Resident (R) 2, R5, R1, and R24) reviewed for care plans, out of a survey sample of 28. The failure to develop a care plan increased the risk for care to be incomplete and/or inconsistent related to the residents taking psychotropic medications.Findings include: 1. Review of R2's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/23/25. Review of R2's EMR titled physician Orders located under the Orders tab dated 09/29/25, indicated the resident was ordered an intramuscular injection one time per month for his diagnosis of schizophrenia. Review of R2's EMR titled admission Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 09/29/25 indicated the resident had a Brief Interview of Mental Status (BIMS) score of 0 out of 15, which revealed the resident was severely cognitively impaired. The resident was on an antipsychotic medication on a routine basis. Under the Care Area Assessment (CAA), the resident triggered the use of psychotropic medications and directed the staff to develop a care plan. Review of R2's EMR titled Care Plan located under the Care Plan tab failed to contain evidence that the resident was care planned for the use of the aripiprazole. 2. Review of R5's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 06/13/02. Review of R5's EMR titled physician Orders located under the Orders tab dated 07/17/23, indicated the resident was to be administered an oral medication for the treatment of bi-polar disorders. Review of R5's EMR titled physician Orders located under the Orders tab dated 07/17/23 indicated the resident was to be administered an oral medication for major depressive disorder. Review of R5's EMR titled annual MDS located under the MDS tab with an ARD of 09/12/25 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The resident was on an antipsychotic medication on a routine basis. Under the CAA, the resident triggered for the use of psychotropic medications and directed the staff to develop a care plan. Review of R5's EMR titled Care Plan located under the Care Plan tab failed to contain evidence that the resident was care planned for the use of quetiapine fumarate or the use of escitalopram. 3.Review of R1's admission Record located under the Profile tab of the EMR, revealed R1 was admitted on [DATE] with a diagnosis that included major depressive disorder. Review of R1's Order Summary Report located under the Orders tab of the EMR revealed a physicians order for an oral medication for a diagnosis of major depressive disorder. Review of R1's annual MDS located under the MDS tab in the EMR with an ARD of 09/26/25, a BIMS score of 10 out 15 which indicates he was moderately intact. The MDS indicated that R1 takes antipsychotic medication. Review of R1's CAA located under the MDS tab in the EMR dated 12/19/25, revealed the resident was administered antipsychotic medication for seven days prior to the assessment. Review of R1's Care Plan located under the Care Plan tab of the EMR dated 12/29/25 did not address the resident's use of the antipsychotic medication. Review of R1's Medication Administration Record (MAR) located under the Orders tab of the EMR dated January 2026 revealed the resident had been administered the medication twice daily. 4. Review of R24's annual MDS with an ARD date of 05/09/25 and located in the MDS tab of the EMR, revealed R24 was admitted on [DATE]. The resident had a BIMS score of 15 out of 15 indicating R24's cognition was intact. The resident received an antipsychotic medication and had a diagnosis of schizophrenia. The CAA Summary revealed Psychotropic Drug Use triggered for care planning. Review of R24's orders, located in the EMR under the Order tab revealed the resident was ordered oral medications for her diagnoses of schizoaffective disorder and depression related to the schizoaffective disorder. Review of R24's care plan, revised 11/04/25, located in the EMR under the Care Plan tab revealed Neurobehavioral Health but there was no care plan for antipsychotic medications.During an interview conducted on 01/08/2026 at 10:35 AM MDS Coordinator (MDSC) 1 and MDSC2 were present. MDSC1 stated the MDSCs complete the CAA and then decide on whether or not they develop a care plan or not. MDSC1 stated the EMR for the development of the care plan does not have the capacity to specifically address the use of psychotropic medications. MDSC1 stated the care plans were individualized for each resident's needs. MDSC1 stated if there was an associated black box warning with the medication the care plan does not have the ability to add this information for a resident. During an interview conducted on 01/09/25 at 12:29 PM, the Director of Nursing (DON) stated the care plans for residents were individualized for their specific needs and the information about the use of psychotropic medications were in the residents' consents. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/24 indicated .The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers. After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT (Interdisciplinary Team) must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer five of eight residents (Residents (R) 20, R21, R22, R11, and R57) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 28 sample residents. This practice had the potential to increase the risk for this resident to contract pneumonia. In addition, the facility policy did not reflect current CDC recommendations. Findings include:1. Review of R20's electronic medical record (EMR) titled admission Record located under the profile tab indicated the facility admitted the resident on 01/24/25. The resident was over the age of 55 at the time of his admission. Review of R20's EMR titled Immunization located under the Immun (Immunization) tab failed to indicate that the resident received a pneumococcal vaccine. There was no evidence in the clinical record that the resident and/or his representative were given the opportunity to receive the PCV20 or the PCV21. 2. Review of R21's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 02/21/24. The resident was over the age of 65 at the time of his admission.Review of R21's EMR titled Immunization located under the Immun tab failed to indicate that the resident received a pneumococcal vaccine. There was no evidence in the clinical record that the resident and/or his representative were given the opportunity to receive the PCV20 or the PCV21.3. Review of R22's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 09/21/16. The resident was [AGE] years of age at the time of her admission.Review of R22's EMR titled Immunization located under the Immun tab indicated the resident received (Pneumovax23) PPSV23 on 12/26/16. There was no evidence in the clinical record that the resident and/or her representative were given the opportunity to receive the PCV20 or the PCV21.4. Review of R11's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 12/30/08. The resident turned [AGE] years of age during his stay at the facility. Review of R11's EMR titled Immunization located under the Immun tab indicated the resident received the PPSV23 on 03/13/15. There was no evidence in the clinical record that the resident and/or her representative were given the opportunity to receive the PCV20 or the PCV21.5. Review of R57's EMR titled admission Record located under the Profile tab indicated the facility admitted the resident on 04/16/08. The resident turned [AGE] years of age during his stay.Review of R57's EMR titled Immunization located in the Immun tab indicated the resident received the PPSV23 on 09/10/15. There was no evidence in the clinical record that the resident and/or his representative were given the opportunity to receive the PCV20 or the PCV21.Review of a document provided by the facility and referred to as a pharmacy report indicated that in 2023 four residents received the PCV20 vaccination. In 2024, two residents were identified who received the PCV20 vaccination. Finally, in 2025 two residents were identified who received the PCV20 vaccination. During an interview on 01/06/2026 at 11:49 AM, the Pharmacist stated the facility ordered the PCV20 in 2025 and would need to run a report which identified how often the PCV20 was ordered. During an interview on 01/06/26 at 1:02 PM, the Director of Nursing (DON), who was also the facility's Infection Preventionist (IP)1, confirmed the facility failed to offer the PCV20 vaccine to the following residents: R20, R21, R22, R11, and R57. During an interview on 01/07/2026 at 1:56 PM, the Medical Director stated there had been no communication regarding the pneumococcal vaccines for the residents for at least six months. The Medical Director stated that he has not updated the facility's policy on the current CDC recommendations. Review of the CDC website titled PneumoRecs VaxAdvisor App (Application) for Vaccine Providers dated 01/15/25 indicated . Administer PCV15, PCV20, or PCV21 for all adults 50 years or older.Who have never received any pneumococcal conjugate vaccine.Whose previous vaccination history is unknown. Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both.PCV13 (but not PCV15, PCV20, or PCV21) at any age and . PPSV23 at or after the age of [AGE] years old.Review of a facility policy titled Protocols for Influenza and Pneumococcal Vaccinations dated 02/08/23 indicated . It shall be the policy for the Long-Term Care Sector of the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD)to have a standardized procedure/protocol for administering vaccinations. Pneumococcal Conjugate Vaccine (PCV13} is recommended for all adults 65 years or older.Pneumococcal Polysaccharide Vaccine (PPSV23) is recommended for all adults 65 years or older.

Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three of eight residents (Resident (R) 22, R57, and R11) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. (Cross Reference F883)Findings include:1. Review of R22's electronic medical record (EMR) titled admission Record located under the Profile tab, revealed the facility admitted the resident on 09/21/16.Review of R22's EMR titled quarterly MDS located under the MDS tab with an Assessment Reference Date (ARD) of 12/12/25 indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment revealed that the resident was up to date on her pneumococcal vaccine. Review of R22's EMR titled Immunizations located under the Immun (Immunization) tab indicated the resident received the PPSV23 on 12/26/19. There was no evidence that the resident or her representative was offered the PCV13 prior to the age of 55 or the PCV20 or the PCV21 after the age of 55. 2. Review of R57's EMR titled admission Record located under the Profile tab revealed the facility admitted the resident on 01/31/18.Review of R57's EMR titled Immunization located under the Immun tab indicated the resident received the PPSV23 on 09/15/15. There was no evidence that the resident or his representative was offered the PCV13 during his stay at the facility. There was no evidence that the resident or his representative was offered the PCV20 or the PCV21 during his stay when the resident turned [AGE] years of age. Review of R57's EMR titled quarterly MDS located under the MDS with an ARD of 10/31/25 indicated the resident had a BIMS score of 12 out of 15 which revealed the resident was moderately cognitively impaired. The assessment revealed that the section that identifies if the resident was offered a pneumococcal vaccine or was up to date with the pneumococcal vaccine was blank. 3. Review of R11's EMR titled admission Record located under the Profile revealed the facility admitted the resident on 12/30/08.Review of R11's EMR titled Immunization located under the Immun tab indicated the resident received the PPSV23 on 03/03/15. There was no evidence that the resident or his representative was offered the PCV13 during his stay at the facility. There was no evidence that the resident or his representative was offered the PCV20 or the PCV21 during his stay when the resident turned [AGE] years of age. Review of 11's EMR titled quarterly MDS located under the MDS tab with an ARD of 12/05/25 indicated the resident had a BIMS score of nine out of 15 which revealed the resident was moderately cognitively impaired. The assessment revealed that the resident was up to date on his pneumococcal vaccine. During an interview conducted on 01/08/25 at 10:35 AM, the MDS Coordinator (MDSC)1 and MDSC2 were present. MDSC1 stated that she looked into each residents' clinical record to retrieve the information from the EMR. MDSC1 stated that she relied on the accuracy of the clinical record for the status of the pneumococcal vaccine status. MDSC1 stated it was easy to locate accurate information for the influenza vaccine for the residents since that information was in the residents' Medication Administration Records. MDSC1 stated she was not familiar with the CDC recommendations for the pneumococcal vaccine. Review of the Resident Assessment Instrument (RAI) manual, dated 10/2024 and located at Minimum Data Set (MDS) 3.0 RAI Manual | CMS, revealed Pneumococcus is one of the leading causes of community-acquired infections in the United States, with the highest disease burden among the elderly. Adults [AGE] years of age and older and those with chronic medical conditions are at increased risk for invasive pneumococcal disease and have higher case-fatality rates. Pneumococcal vaccines can help reduce the risk of invasive pneumococcal disease and pneumonia. Review of the CDC website: https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, dated 10/26/24 indicated . Based on shared clinical decision- making, adults 65 years or older have the option to get PCV20 [20-valent pneumococcal conjugate vaccine] or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both .PCV13 (but not PCV15, PCV20, or PCV21) at any age and . PPSV23 at or after the age of [AGE] years old.

Based on record review, interview, and facility policy review, the facility failed to ensure that one resident (R) 8 out of a survey sample of two, had a complete tracheostomy (trach) change. This has the potential for residents to have their airway compromised and potentially develop severe infection that could be life-threatening.Findings include:Review of R8's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the facility admitted the resident on 04/28/21, with a diagnosis of anoxic brain injury. The resident required the use of a tracheostomy (a device that was placed in the opening of the windpipe [trachea] to provide an airway for breathing). Review of R8's EMR titled physician Orders located under the Orders tab dated 07/17/23 indicated the physician or the respiratory therapist (RT) was to change the tracheostomy every three months, each April, July, October, and January. The tracheostomy change included a size six trach, with an extra-long Shiley, with a cuffed trach tube with a disposable inner cannula.Review of R8's EMR titled TAR located under the Orders tab dated 01/06/25 was blank. Review of R8's titled respiratory Progress Notes located under the Prog (Progress) Notes tab dated 01/15/25 revealed the RT completed tracheostomy care. Review of R8's EMR titled Treatment Administration Record (TAR) located under the Orders dated 04/06/25 indicated Registered Nurse (RN) 6 changed R8's tracheostomy. Review of R8's EMR titled respiratory Progress Notes located under the Prog Notes tab dated 04/15/25 revealed that the RT completed trach care only. Review of R8's EMR titled respiratory Progress Notes located under the Prog Notes tab dated 05/05/25 revealed the RT completed the resident's tracheostomy change. Review of R8's EMR titled TAR located under the Orders tab dated 07/06/25 indicated RN8 changed the resident's tracheostomy.Review of R8's EMR titled respiratory Progress Notes located under the Prog Notes tab dated 07/08/25 revealed the RT completed trach care only. Review of R8's EMR titled respiratory Progress Notes located under the Prog Notes tab dated 07/24/25 revealed the RT completed trach care only. Review of R8's EMR titled respiratory Progress Notes located under the Prog Notes tab dated 09/05/25 revealed the RT completed the resident's tracheostomy change. Review of R8's EMR titled TAR located under the Orders tab dated 10/06/25 was blank.There were no corresponding RT progress notes which would address when the resident's tracheostomy change was completed per physician order.Review of R8's EMR titled Medical Professional Note [written by the RT] located under the Prog Notes dated 12/24/25 revealed the RT completed the resident's tracheostomy change. Two months later the physician orders specifically indicated the resident was to have a complete tracheostomy change in October. There was no documentation in the clinical record that the physician was notified of the late tracheostomy change. During an interview on 01/06/26 at 2:20 PM, RT stated she tries to come to the facility each week and it has not happened recently due to medical issues. RT stated the last time she was in the facility was during the month 12/25 and she changed R8's tracheostomy. RT stated nursing was not to change the tracheostomy only the RT. RT stated nursing can change the Velcro ties, clean the trach site, and suction the resident's trach. RT stated she was not aware of the physician orders to change R8's tracheostomy for the specific months identified in the orders for the resident. During an interview on 01/06/26 at 3:06 PM, RT stated that a tracheostomy change was the removal of the tracheostomy and only the RT can do this. During an interview on 01/06/26 at 3:16 PM, RN 6 reviewed the entry he made on 04/06/25 documenting that he had completed R8's tracheostomy change. RN6 stated that there was an error in his documentation and only the physician or the RT could complete the tracheostomy change. During an interview on 01/07/26 at 8:47 AM, RN 8 reviewed the entry she made on 07/06/25 and stated that she never would remove a resident's inter cannula and this was the responsibility of the RT. RN8 stated the entry was a mistake. During an interview on 01/07/26 at 10:43 AM, the Director of Nursing (DON) stated her expectation was the TAR was to reflect the care for R8, but that nursing needed to ensure that the documentation was correct and that care was provided to the resident. During an interview on 01/07/26 at 1:33 PM, the Medical Director stated the clinical staff were to follow his orders and to notify him if the orders could not be implemented. In addition, the Medical Director stated the reason that a complete tracheostomy change was required for R8 was to maintain patency, to prevent infections, and to provide cleanliness.

Based on observation, interview, and record review, the facility failed to assess the need for side rails and obtain informed consent for two (Resident (R)9 and R27) of two residents reviewed for side rails. This had the potential to place residents at risk of injury or death.Findings include:1. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/10/25 and located in the MDS tab of the electronic medical record (EMR), revealed R9 was admitted on [DATE]. R9's cognition was severely impaired, and had diagnoses of epilepsy, traumatic brain injury, and tracheostomy status.Review of R9's orders located in the EMR under the Order tab revealed no order for side rails.Review of R9's care plan, revised 09/08/25, located in the EMR under the Care Plan tab revealed Basic Care Needs: I can't complete my cares on my own; I am totally dependent for all care. Because I have had a subdural hematoma, post-traumatic brain injury, seizures, and encephalopathy. I am nonverbal, nonambulatory and have the potential to have skin impairment and weight gain or loss. I show this by: not participating in myADLs [activities of daily living] total dependent and not being able to tell you what I want or need and being incontinent. Interventions included I use a wide low air loss mattress, bilateral side rails. I reposition in bed: with the help of 2 staff and use my wedge for effective turning off my back Review of R9's Bed Rail Assessment, dated 03/14/25, located in the EMR under the Assessment tab revealed 3a. Side Rail Placement: a. Side Rails/Assist Bar are indicated and serve as an enabler to promote independence. The assessment included the resident representative's signature and date but no documentation about if the risks versus benefits were explained, no risk for entrapment was assessed or if alternatives were tried before using the bed rails.On 01/05/26 at 10:38 AM, R9 was observed asleep in bed with a tracheostomy in place, the head of the bed was up, and side rails in use. R9's bed was in a low position with fall mats in place. On 01/08/26 at 9:24 AM, Certified Nurse Aide (CNA)4 was observed bringing in a shower bed into R9's room. CNA3 was standing at R9's bedside. CNA3 stated regarding the use of side rails, To keep her in bed so she doesn't fall. CNA3 stated the resident had not fallen from the bed and could not grab or used the side rails. 2. Review of R27's quarterly MDS with an ARD date of 01/07/26 and located in the MDS tab of the EMR, revealed R27 was admitted on [DATE]. R27's cognition was severely impaired. The resident was coded for functional limitation in range of motion in her upper and lower extremity, had a feeding tube, and had diagnoses of Alzheimer's disease, epilepsy, unspecified, and cerebral vascular accident.Review of R27's order, dated 11/18/24, located in the EMR under the Order tab revealed Bilateral upper side rails for safety. No directions specified. Review of R27's care plan, revised 07/16/25, located in the EMR under the Care Plan tab revealed Safety: Falls. I: have the potential to fall and injure myself. Because I: have dementia/Alzheimer's disease. In the past: I have fallen; I have fractured my right hip. An intervention included have bilateral side rails to ensure my safety.Review of R27's Bed Rail Assessment, dated 12/15/25, located in the EMR under the Assessment tab revealed 12. Reason(s) for Side Rail Use: a. Used to keep resident in bed. The assessment included the resident representative's signature and date but no documentation about if the risks versus benefits were explained, no risk for entrapment was assessed or if alternatives were tried before using the bed rails.On 01/05/26 at 10:39 AM, R27 was observed asleep in a low bed with the head of bed up, a fall mat in place, and both hands contracted with cloth rolls in place. On 01/08/26 at 9:15 AM, R27 was observed being transported back to her room from the shower room on a shower bed by CNA3 and CNA4. R27's hands were contracted and positioned on her chest. During an interview on 01/08/26 at 9:20 AM, CNA3 stated the resident had side rails For falling. CNA 3 stated the resident could not grab or use the side rails. During an interview on 01/09/26 at 10:27 AM, Registered Nurse (RN)4 stated she or another RN completes the side rail assessments. RN4 stated she will be discontinuing the side rails for both residents (R9 and R27). RN4 stated, The only reason they should have side rails is if the residents use them to reposition. RN4 stated the residents' responsible parties signed the assessments, but it didn't include risks versus benefits. RN4 stated when she started her employment, the side rails were already in place for both residents. RN4 stated she thought maybe at one time the residents could use them as enablers. RN4 stated R9 and R27 had not been assessed for the risk of entrapment. She also acknowledged the assessments didn't include it. RN4 stated she was not sure what alternatives were tried before the installation of the side rails. She also stated, both residents have low beds with fall mats and R9 had a wide mattress. RN4 stated she wasn't sure if they should have a physician's order for the use of side rails. RN4 stated they don't have a policy for side rails.A facility policy for side rails was requested and not provided.

Based on observation, interview, and record review, the facility failed to ensure medication was administered to one (Resident (R)35) of one resident observed for pharmacy services. This failure had the potential to compromise patient safety, efficacy of the prescribed treatment, and fulfill the legal and ethical responsibilities.Findings include:Review of R35's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/26/25 and located in the MDS tab of the electronic medical record (EMR), revealed R35 was admitted on [DATE], and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R35's cognition was intact. The resident had diagnoses of vitamin deficiency, unspecified, anemia, unspecified, and vitamin D deficiency, unspecified.Review of R35's orders, located in the EMR under the Order tab revealed orders for Ferrous Sulfate Tablet 325 (65 Fe [iron]) MG [milligram] Give 1 tablet by mouth one time a day for Anemia, Give before breakfast with orange juice, start date 12/23/25; Multiple Vitamin Oral Tablet (Multiple Vitamin) Give 1 tablet orally one time a day for Vit [vitamin] supplementation, start date 10/18/25, and Cholecalciferol Oral Tablet 25 MCG [microgram] (1000 UT [unit]) (Cholecalciferol) Give 2 tablet by mouth one time a day for Vit D, start date-10/18/25.Review of R35's care plan, located in the EMR under the Care Plan tab revealed Basic Care Needs: I need some assistance with my ADLs [activities of daily living] because I have arthritis and physical challenges.On 01/05/26 at 9:47 AM, R35 was observed awake in bed wearing a hospital gown and three (3) pills [a small white tablet, a medium off-white tablet, and a medium black tablet] were on her chest. R35 stated she was given her medication in a cup but must have missed her mouth. R35 then picked up a small medicine cup that was on her overbed table positioned over her lap. Licensed Practical Nurse (LPN)2 was in the hallway and was asked about the three pills. LPN2 entered the room and confirmed she gave the medication to R35 in a medicine cup but didn't notice she didn't take them. LPN2 stated the pills were a multivitamin, iron, and one to reduce fat. During an interview on 01/07/26 at 10:11 AM, Registered Nurse (RN)4 stated she was the Unit Manager. RN4 explained their procedure prior and during the administering of medications to a resident. RN4 was denied there were any residents who self-administered their medications. RN4 confirmed LPN2 should have stayed with R35 to ensure she took her medications. She stated, Yes absolutely, never leave the medication with the resident. During an interview on 01/07/26 at 4:21 PM, the Director of Nurse (DON) stated she was unaware of R35 spilling three of her medications on 01/05/26 during the morning medication pass and the nurse wasn't in the room but was in the hallway when it was discovered. DON stated there were no residents who self-administered their medications. DON stated, it was her expectation for the nurse to stay with the resident until the medications were taken. Review of the facility's policy titled Medication Administration, dated 12/04/23 provided by the facility revealed It shall be the policy of the Long-Term Care Section of the Division of Services for Aging and Adults withPhysical Disabilities (DSAAPD) that nursing services, in collaboration with pharmaceutical services, will administer medications in accordance with acceptable standards of practice. d. Medications should never be left at the bedside to be taken later. The policy did not include staff ensuring the residents take the medication.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE), specifically disposable gowns, and gloves, during the administration of medication through a percutaneous endoscopic gastrostomy (PEG) tube for one (Resident (R)27) of 10 residents who had PEG tubes. This deficient practice resulted in a risk of contamination and the potential spread of infection to the patient and other residents. Findings include:Review of R27's admission Record located under the Profile tab of the Electronic Medical Record (EMR), revealed R27 was admitted on [DATE] with a diagnosis of gastrostomy status.Review of R27's Minimum Data Set (MDS) located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/19/25 revealed R27 received nutrition through feeding tube.During an observation on 01/08/26 at 9:20 AM, Licensed Practical Nurse (LPN)1 administered medication to R27 through her PEG tube, and LPN1 did not wear PPE. There was no signage located on R27's door that indicated the resident was on Enhanced Barrier Precautions (EBP).During an interview on 01/08/26 at 9:20 AM, LPN1 revealed she thought the use of PPE was only for providing treatments to the resident such as cleaning the PEG tube area. LPN1 confirmed she should have worn PPE during the PEG tube medication administration.During an interview on 01/09/26 at 12:29 PM, with the Infection Preventionist (IP)2 and the Director of Nursing (DON), IP2 confirmed staff are to wear PPE during medication administration with a PEG tube resident. DON confirmed staff were trained to wear PPE and recently had a skills fair that addressed wearing PPE with residents who had PEG tubes.Review of the facility policy titled, Enhanced Barrier Precautions and Isolation Procedures (Contact Precautions) dated 12/31/25 revealed Policy/ Position Statement: . The facility shall utilize Standard Precautions, Enhanced Barrier Precautions (EBP), and Transmission Based Precautions, (e.g., Contact Precautions) as clinically indicated to prevent, identify, contain, and control infectious disease, including multi-drug-resistant organisms (MDROs). Precautions will be implemented using the least restrictive approach necessary to protect residents, staff, visitors, and others, while maintaining residents' rights, dignity, psychosocial well-being, and quality of life.

Based on observation, interview, record review and other facility documentation, it was determined that for two (R1and R2) out of three residents sampled for accidents, the facility failed to ensure that R1 and R2 received adequate supervision to prevent accidents. R1, a severely cognitively impaired resident, was able to elope from the building on 9/26/25 during the 11:00 PM to 7:00 AM shift. R1 was found on 9/26/25 at 8:38 AM, approximately 17-20 miles from the facility. This failure put R1 at immediate risk for severe injury or death due to exposure to traffic and environmental hazards while walking on the road unsupervised. An immediate jeopardy (IJ) was called at 12:30 PM on10/1/25. The facility abated the IJ on 10/2/25 at 3:00 PM. R2, a completely dependent resident, sustained a right femur fracture from a fall from the bed to the floor while a staff member was providing care and the resident rolled off the bed. Findings include: 12/4/23 - A facility document entitled, Elopement of Resident, documented, .The facility provides a safe environment and adequate supervision that respects the residents' dignity and minimizes the residents' risk for accidents or harm. Residents identified as at risk for elopement requires the vigilance of all staff. Residents identified as being at risk for elopement will have person- centered interventions to monitor and manage their risk as reflected in the care plan.1. Review of R1's clinical records revealed:10/24/24 - R1 was admitted to the secured unit of the facility with diagnoses including but not limited to mild cognitive impairment, major neurocognitive disorder and impaired decision making. R1's elopement assessment documented a score of 4, indicating a high risk for elopement.10/30/24 - R1's admission MDS assessment documented a BIMS score of 99, indicating the inability to conduct a cognitive interview. 10/31/24 (revised 1/29/25) - R1's elopement care plan documented, . Unaware of safety risk.at risk for wandering and eloping. want to return to the community. The interventions included, .Complete frequent face to face checks.1/22/25 7:33 AM - R1's clinical record documented, Resident was noted to be up at the nurses' station, fully dressed, with his shoes on. Resident repeatedly asked to leave his unit so he could walk to [previous place of residence] to get his hair cut. Resident informed that we could cut his hair but refused, insisted that he needs to go to [previous place of residence.] Resident remained near the nurses' station repeatedly asking people to let him out so he can walk to [previous place of residence].1/22/25 7:46 AM - R1's clinical record documented, Resident standing in front of the unit manager's office pleading with all the staff that passed by to let him out of the door.1/23/25 12:28 PM - R1's clinical record entitled Plan of Care Note, included, Risk for elopement due to recent talk of going to [name of recent place of residence.]1/23/25 2:54 PM - R1's clinical record documented, .Stated multiple times.been a year. want to go to [name of previous residence.] Please help [R1's name.]8/12/25 10:19 AM - R1's clinical record documented, Resident pacing up and down the hallway.8/15/25 4:44 PM - R1's clinical record documented, Resident was observed in the back hallway by the emergency exit door.9/4/25 12:02 PM - R1's clinical record documented, Resident expressed desire to leave the facility, per resident, it's been two years since he was taken to the hospital and then brought here. He stated, I am not sick, I want to go to [previous place of residence.]9/4/25 9:01 PM - R1's clinical record documented, Resident expressed desire to leave the facility to go [previous place of residence.]9/8/25 1:03 PM - R1's clinical record documented, Resident requested to speak with someone about getting out of this facility. Stated, I am not sick, I don't need to be here. Social Services came to speak with resident, reassured him that everything is being done to help him. Resident pulled out a piece of paper with his address written on it and stated, That's where I live. Resident spoke very clearly, explaining his experience in the hospital and how he got there and how he came to be at this facility. Resident expressed that he is very eager to get out of [name of current facility.]9/13/25 11:06 AM - R1's clinical record documented, Resident up out of his room, pacing around more than usual and expressing verbally the desire to leave, saying he's been here too long and wants to go back to where he used to live.9/14/25 8:53 PM - R1's clinical record documented, .Continues to stand in the hallway staring at the back and side doors.9/15/25 2:57 PM - R1's clinical record documented, Engaged in conversation with resident during which resident expressed his interest in going back to live the community.9/16/25 1:08 AM - R1's clinical record documented, . Ambulating back and forth in the hallway asking to go to [place of previous residence.]9/22/25 1:33 PM - R1's clinical record documented, . [R1] very vocal about his wants. Stated that he was brought to [name of facility] from the hospital and was supposed to stay here for a bit.9/23/25 - R1's annual MDS documented a BIMS score of 99, indicating the inability to conduct a cognitive interview.9/25/25 2:38 PM - R1's clinical record documented, Resident noted with slight agitation, kept saying he needs to get to [previous place of residence] to see his family. Redirected with little success. Noted to be standing by front doors of unit but no attempt to leave.9/26/25 6:00 AM - R1's clinical record documented, During unit rounds at 6:00 AM, resident was not noted to be in his usual sleeping position in his room. After a brief search of resident's room and his usual unit locations, still unable to locate resident, resident's window noted to be opened. 9/26/25 8:38 AM - The facility's investigation documented, E5 (QA) successfully located [R1] walking on the road. E5 was trying to convince him to get into the vehicle and he went into the [NAME]. Later, more staff came from [the facility] including the police. We searched the [NAME] for approximately 45 minutes but could not locate him. After 45 minutes to one hour, a driver passing by stopped and asked if we were searching for someone. We said yes, and he described the person and said he fit the description of someone he had just passed about two miles down from the location where we were searching. We saw [R1] walking on the road.and he was brought back to the facility. An alarm was put on the window, and he was placed on 1:1 close supervision for safety.9/30/25 11:00 AM - The Surveyor observed that R1's bedroom window had a device that sounded an alarm when the window was opened. A check of the windows on the secured unit revealed that 8 out of 10 windows were unlocked and easily opened by the Surveyor. There was a total of 18 residents who resided on this secure unit. 9/30/25 12:00 PM - During an interview E1 (NHA) stated, We knew that the resident [R1] was an elopement risk on admission. He was placed in the secure unit for close monitoring. He placed on 1:1 supervision for 72 hours from 9/26/25 through 9/29/25 after the elopement, then hourly visual checks. Window limiters were approved by the fire marshal and will be installed on all the windows on [name of unit] upon delivery.9/30/25 12:30 PM - A review R1's clinical records from his admission to the date of the elopement lacked evidence of a person-centered care plan for elopement despite multiple episodes of exiting seeking and verbalization of wanting to leave the facility.9/30/25 1:00 PM - A review the facility's video recording from 9/26/25 at 12 midnight to 6:30 AM revealed:12:03 AM - R1 was observed exiting his room and entering the hallway.12:08 AM - R1 was observed returning to his room.12:21 AM - Staff member was observed walking past the resident's room, did not enter.12:25 AM - Staff member was observed looking at the resident's room from the end of the hallway.12:58 AM - Staff member was observed walking past the resident's room, did not enter.1:39 AM - Staff member was observed walking past the resident's room, did not enter.1:52 AM - Staff member was observed walking past the resident's room, did not enter.2:20 AM - Staff member was observed walking past the resident's room, did not enter.2:45 AM - Staff member was observed walking past the resident's room, did not enter.3:44 AM - Staff member was observed walking past the resident's room, did not enter.4:02 AM - Staff member was observed walking past the resident's room, did not enter.4:26 AM - Staff member was observed walking past the resident's room, did not enter.4:41 AM - Staff member was observed walking past the resident's room, did not enter.4:46 AM - Staff member was observed walking past the resident's room, did not enter.4:56 AM - Staff member was observed walking past the resident's room, did not enter.4:59 AM - Staff member was observed walking past the resident's room, did not enter.5:10 AM - Staff member was observed walking past the resident's room, did not enter.5:40 AM - Staff member was observed walking past the resident's room, did not enter.5:55 AM - Staff member was observed walking past the resident's room, did not enter.6:04 AM - Staff member was observed walking past the resident's room, did not enter.6:07 AM - New staff on the unit, entered, exited the resident's room and walked back to the nursing station.6:10 AM - Staff members entered the resident's room, other rooms, and checked the back doors.6:11 AM to 6:18 AM staff members were observed outside of the building. The staff failed to follow R1's care plan for visual check for 18 out of 20 opportunities.10/1/25 10:00 AM - During an interview E8 (CNA) stated, The last time I saw the resident in the hallway was around midnight. The Surveyor asked E8 whether R1 had verbalized that he wanted to leave the facility. E8 stated, Yes, all the time.10/1/25 10:10 AM - During an interview E7 (CNA) stated, He [R1] was independent with going to the bathroom so I did not know I have to do anything for him at night. I did not know he was an elopement risk and needed to be checked every hour. I now know that I must see him with my eyes every 30 minutes. The Surveyor asked E7 whether R1 had verbalized that he wanted to leave the facility. E7 stated, Yes, many times.10/1/25 10:30 AM - During an interview E13 (LPN) stated, I check on my residents when I come on shift. I went into the room around 6:10 AM but did not see the resident. I checked the bathroom and the closet but did not see him. I went outside and saw that the window was open. I went to the tell the supervisor right away.10/1/25 4:00 PM - The facility's abatement plan for the immediate jeopardy included:- All staff in the facility and staff reporting for scheduled shifts were in-serviced on the current elopement policy and face-to-face checks for residents at risk for elopement.- The facility reviewed all current residents and identified 8 residents deemed to be at higher risk for elopement. These residents were placed on every one-hour face-to-face checks.- The care plans were updated to reflect specific interventions for high elopement risks.- An alarm was placed on R1's window and all the windows on the units were checked and locked. When windows were found to be damaged, maintenance was called for immediate repair.- R1 was moved to another secure unit with alarm on the window and double locks on both entrances.- All the windows on the secure unit have hard wired alarms and were tested on this same day.- Window limiters were approved by the fire marshal and will be installed upon delivery.10/1/25 1:00 PM - Staff interviews conducted, and in-service education and training verified.10/2/25 2:45 PM - Staff training records reviewed and verified. The IJ was abated at 3:00 PM.10/2/25 3:30 PM - Findings were verified with E1 (NHA) and E2 (DON.) 2. Review of R2's clinical records revealed:4/7/20 - R2 was admitted to the facility with diagnoses including severe intellectual disability, cerebral palsy and morbid obesity12/4/23 - A facility document entitled, Fall Risk Prevention Policy, documented, .The facility will ensure that the resident environment is safe and free of hazards. That each resident receives adequate supervision and assistance to prevent falls or minimize the risk for fall related injuries.3/14/25 - R2's quarterly MDS documented a BIMS score of 00, indicating an inability to conduct a cognitive interview. R2 was non-ambulatory and completely dependent on staff for all activities of daily living.5/11/25 8:57 PM - A facility incident report submitted to the Division documented, Resident fell from the bed to the floor during care and sustained a right eyebrow cut/swollen and Rt [right] knee abrasion. Provider was notified and resident sent to the ER for evaluation.5/13/25 11:00 AM - R2's clinical record documented, Resident seen today for decreased ROM [range of motion] to right knee. Right knee noted with swelling and warm to touch. Resident moaned and grimaced when the right knee was touched. Right knee tender to touch, resident unable to flex knee to 90 degrees. X-ray of right knee ordered.5/13/25 8:40 PM - R2's clinical record documented, .Showed that the resident's right femur is fractured.Send the resident out via 911.5/16/25 11:35 AM - The facility's 5 day follow up report to the Division documented, .admitted for right knee surgery due to a right femur fracture. She [R2] had surgery and returned on 5/16/25.10/1/25 2:00 PM - The facility's post fall investigation documented, [R2] was not care planned for falls because she is unable to move herself. E6 (CNA) interview statement documented, .[R2] does not move at all and cannot scoot because she is heavy. E6 advised that she turned [R2] on her right side as she reached for a washcloth. Resident was being turned towards the window and as she reached for the washcloth R2 rolled off the bed. She fell face down on the floor.The facility failed to provide adequate supervision to prevent R2's fall with injury.10/2/25 1:30 PM - A review of the facility's actions after R2's fall revealed:- R2's care plan was revised and updated for 2 staff members assistance with bed mobility.- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.- The fall was discussed and reviewed at the fall committee meeting on 5/16/25 and at QAPI meetings 6/30/25 and 7/28/25.- A review of all falls since 5/11/25 during the fall committee meeting and QAPI meetings revealed no falls relating to resident's positioning in bed or during care.10/2/25 3:30 PM - During an interview, findings were confirmed with E2 (DON).10/3/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference.

Based on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 received adequate hands-on assistance and supervision to prevent a fall to the extent possible. R1, a cognitively impaired and dependent resident sustained a fall on [DATE] when two staff members improberly used a mechanical lift to perform a transfer. The facility's failure caused R1 to suffer a subdural hematoma and two (2) lacerations to her scalp. R1 was sent emergently to the hospital. Due to this failure, an Immediate Jeopardy (IJ) was called at 10:30 AM on [DATE]. Findings include: The facility's fall policy dated 2023 and titled, Fall Prevention, included, .The facility will ensure that the resident environment is safe and free of hazards. That each resident receives adequate supervision to prevent falls or minimize the risk for fall related injuries . Review of R1's clinical record revealed: [DATE] - R1 was admitted to the facility with diagnoses including dementia, chronic kidney disease and weight loss. [DATE] - R1's fall care plan (revised [DATE]) documented, Transfer with the help of 2 people using a mechanical lift, using the appropriate size sling . [DATE] - R1's quarterly MDS documented a BIMS score of 00, indicating a severe cognitive impairment. R1's MDS also documented, Complete dependence on the staff for all activities of daily living, including eating, dressing and transfers. [DATE] - E5 (CNA) documented in a facility's investigative document titled and timed 12:30 PM, Employee Interview Statement, After I provided care for [R1] Me and the nurse (R4 LPN) were putting her [R1] in the chair, and she slid from her sling to the floor. [DATE] - E4 documented in a facility's investigative document titled and timed 12:30 PM, Employee Interview Statement, .I was in the room .and started (the roommate's) tube feeding. After starting the feeding, I noticed [R1's] CNA come with a lift to get her up for lunch. I told her that since I'm already in the room, I will watch her while she put [R1] in her wheelchair. I watched [E5] connect all 4 hooks to the Hoyer lift. Then she lifted her (R1) up. I saw both of [R1's] legs of out of the sling, and I told [E5] that I will hold both legs so that they don't hit the wheelchair. I was not able to get to them in time. I heard [R1] fall on the floor. I ran immediately and called the unit manager in the dayroom. [DATE] 1:30 PM - E6 (NP) documented in R1's clinical record, Resident fell from the Hoyer lift a few minutes before we were called to the unit staff reports the fall was due to slipping while being transferred. Resident has bleeding of head, left hand, left leg pain .she repeated mumbled in distress .limited exam to her head because of diffuse bleeding and need to apply pressure to the laceration . [DATE] 2:44 PM - E4 (LPN) documented in R1's nursing progress notes, Resident fell at 1244 [12:44 PM] during 2 people transfer from her bed to her chair. She was noted with blood on the back of her head and her right shin. She was alert, treatment was provided. 911 was activated and was sent to the hospital. Of note, both E5 and E6's investigative statements documented that the fall occured at 12:30 PM. [DATE] 12:15 PM - The facility's immediate action plan included training of E4 and E5 on the use of the mechanical lift. [DATE] 1:30 PM - During an interview, E5 (CNA) stated, The fall happened so sudden and fast. I provided her care, and she was ready to get up in the chair. The nurse (E4) was in the room was taking care of the other patient. The nurse said, I am already here, I will help you. The pad was under the resident [R1] and I hooked up the sling to the lift. The nurse was on the other side of bed. I raised the sling to get her [R1] off the bed and tried to straighten myself and it happened suddenly. I was behind the lift and tried to open the legs of the lift to put the resident above the chair. The nurse was around the side of the bed, but the resident slid out of the bed before she could reach her. The Surveyor asked E5 if the nurse Had hands on the resident while she was being lifted from the bed. E5 stated, The nurse was coming around the bed to reach the resident. It all happened so fast. [DATE] 12:30 PM - During an interview R4 (LPN) stated, I was putting the feeding up for the roommate and the aide [E5] was helping [R1] to get up for lunch. She finished getting her ready to get up and I told her that I would help her with the lift. I was on one side of the bed, and the aide was on the other side. She started to bring her around to the chair, and I saw her [R1's] legs hanging out of the sling. I said, Hold on, let me secure her legs so they don't hit the wheelchair. The resident was in the air already by the time I got around from the other side of the bed. And [E5] was backing up with the lift to put her in the chair. I came around to help put the resident in the chair, but she started to slide and fell before I could reach her. I did not get to reach her legs before she hit the floor. [DATE] 10:30 AM - An Immediate Jeopardy was called due to the seriousness of this incident. [DATE] 1:30 PM - A review of R1's hospital records revealed that she sustained the following: - An intra cranial traumatic hemorrhage, - A 9 cm. laceration to the mid- scalp, - A 5 cm. laceration to the back of her scalp. R1 was placed on comfort care and expired at the hospital. The facility failed to provide the recommended use of two persons hands on assistance for R1 during the transfer from the bed to the wheelchair with the use of a mechanical lift. R1 sustained a traumatic fall which resulted in head injuries and expired at the hospital. [DATE] 3:30 PM - The facility's abatement plan was accepted. The facility's action plan included: - All nursing staff will complete a mandatory in-service training on the proper use of mechanical lifts and the requirement for two-person assistance with hands on the resident while in the air when transferring residents. - A review of the facility protocols for safe transfers, including the use of mechanical lifts, a detailed explanation of the risks and potential injuries caused by improper transfers, emphasis on the importance of following the care plan for each resident and using the required number of staff for transfers; and hands-on resident training while in the air, on proper techniques and safety protocols for lifting and transferring residents while using mechanical lifts. - A full review of all residents' care plans requiring two-persons assistance for transfers. [DATE] 1:00 PM - Based on the Surveyor's review of the facility's investigation, documented response, completion of audits from [DATE] to [DATE], staff interviews and no further mechanical lift fall or injuries, the IJ was considered abated on [DATE] at 7:00 AM. [DATE] 3:00 PM - Findings were reviewed at the exit conference with E1 (NHA), and E2 (ADON.)

Based on observations and interviews, it was determined that the facility failed to ensure that food was stored, prepared, and served in a sanitary manner. Findings include: 2/14/22 8:30 - 9:15 AM - During the initial kitchen tour with E25 (Food Service Supervisor), the following were observed: - an upright refrigerator in the food preparation area contained: - 3 unlabeled insulated lunch bags belonging to staff. - an unlabeled zip lock baggie containing fresh broccoli. - an unlabeled plastic container with a lid containing a staff members soup. - 2 opened unlabeled jars of chicken and beef base and a bottle of hot sauce. - an approximately 3 inch by 3 inch piece of butter wrapped in plastic and unlabeled. - a hand sink in the food preparation area did not have a garbage can close by. 2/14/22 9:15 AM - During an interview, the above findings were confirmed with E25. 2/15/22 9:20 AM - During the kitchen inspection an unlabeled open bag of frozen french fries was observed in a freezer. 2/15/22 1:30 PM - During an interview, the above findings were confirmed with E24 (Food Service Director). 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review, it was determined that the facility failed to provide two (R18 and R78) out of four residents reviewed for personal funds with quarterly statements of resident funds. Findings include: September 2013 - The facility policy provided by E9 (Financial Determination Administrator) included that quarterly personal funds statements Will be sent to a client or their legal or responsible representative. 1. Review of R78's clinical record revealed: 11/17/98 - R78 was originally admitted to the facility. 1/7/22 - An Annual MDS (Minimum Data Set) assessment documented that R78 was moderately cognitively impaired with poor decision-making skills. 2/14/22 3:45 PM - During an interview, R78 stated No. I don't get statements. They [the facility] robbed me! I went from $3,000 to nothing! 2/22/22 1:55 PM - During an interview with E9, it was revealed that the facility does not send quarterly personal funds statements to FM2 (resident representative for R78) because the facility is R78's representative payee. E9 stated that she was not aware that a resident representative / guardian needs to receive quarterly statements if the facility was the resident's representative payee. 2. Review of R18's record revealed: 12/3/21 - A quarterly MDS assessment documented that R18 was severely cognitively impaired. 2/14/22 1:30 PM - In an interview, FM1 (POA and resident representative for R18) reported that no financial statements had ever been mailed to her by the facility. 2/17/22 12:07 PM - During an interview, E9 (Financial Determination Administrator) said that FM1(R18's POA) had not been mailed R18's account statement because FM1 was not listed as the financial contact for R18. 2/17/22 2:00 PM - A facility policy provided by E9 stated that R18's financial account statements will be provided to the resident or the resident's representative quarterly. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interview and other facility documentation, it was determined that for two (R31 and R78) out of two residents reviewed for abuse, the facility failed to immediately report allegations of abuse. Findings include: A facility policy entitled Protection from Abuse and Responding to Reportable Incidents (last revised 4/1/21) included: c. Immediately shall mean as soon as the situation is stabilized (e.g., actions have been taken to provide treatment, comfort and safety of residents involved. 1. Not later than 2 hours if the alleged violation involves abuse. Cross refer F610 1. Review of R31's clinical record revealed: 2/22/05 - R31 was admitted to the facility with a [CONDITION(S)]. 1/30/22 11:15 AM - An incident report submitted to the State Agency documented that on this date and time R31 reported to the facility, Resident stated that his CNA 'verbally abuses me.' She calls me stupid and that I am full blown [CONDITION(S)] and that is in my file. She told me I did this to myself. She was talking about the kidney disease. 1/31/22 1:13 PM - The 1/30/22 incident was reported to the State Agency approximately twenty-six hours later. 2/17/22 11:45 AM - During an interview, E11 (Charge Nurse) confirmed the incident occurred on a weekend and it was reported to the Supervisor. The facility incident report was then prepared by E12 (RN Supervisor) on 1/31/22 at 11:30 AM. E12 reported the incident to the State agency on 1/31/22 at 1:13 PM. 2. Review of R78's clinical record revealed: 11/17/98 - R78 was admitted to the facility with a stroke and dementia. 2/14/22 3:45 PM - During an initial interview, a State Surveyor asked R78 if he has ever been abused and he said two CNAs hit him a couple of weeks ago. 2/14/22 approximately 4:10 PM - A facility internal incident report included: Per survey team member, the resident reported he was abused two weeks ago when she asked him Have you been abused? The Surveyor immediately reported the allegation of abuse. 2/16/22 1:39 PM - An email to SS1 (DHCQ - Division of Healthcare Quality Investigator) composed by E13 (Quality Assurance Administrator) included that on 2/14/22 a State Surveyor completed an interview with R78 as part of the annual licensing survey. During the interview, R78 shared that he had been abused. After the interview, the State Surveyor shared the allegation of abuse with the facility Nursing Supervisor. 2/16/22 2:35 PM - An email reply to the facility from SS1 (DHCQ Investigator) included: I have checked our IRC complaint system and there is no recent facility reported incident for abuse regarding R78 . However, our office will still need an Incident Report from your facility regarding the initial allegation (of abuse) made on 02/14/22. 2/21/22 1:30 PM - During an interview, E10 (Hospital Administrator) and E1 (Nursing Home Administrator) confirmed that the incident had not yet been formally reported to the State Agency. E1 stated that SS1 (DHCQ Investigator) was emailed regarding the incident. E1 and E10 reported they thought that after the Surveyor reported the incident to the facility, the Surveyor would formally report the allegation of abuse by R78 to the State Agency. 2/22/22 12:01 PM - The facility to immediately report an allegation of abuse. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interview and review of other facility documentation, it was determined that for one (R31) out of two residents reviewed for abuse, the facility failed to immediately put measures in place to ensure further potential abuse. In addition, the facility failed to thoroughly investigate R31's allegation of abuse. Findings include: A facility policy entitled Protection from Abuse and Responding to Reportable Incidents (approved 4/1/21) included: Prevention: Prevent further potential abuse .while an investigation is in progress. Cross refer F609 1. 2/22/05 - R31 was admitted to the facility with a [CONDITION(S)]. a. 1/30/22 11:15 AM - An incident report submitted to the State Agency documented that on this date and time R31 reported to the facility, Resident stated that his CNA (E21) 'verbally abuses me.' She calls me stupid and that I am full blown [CONDITION(S)] and that is in my file. She told me I did this to myself. She was talking about the kidney disease. 1/30/22 - Review of the facility CNA resident assignment sheet confirmed that E21 (CNA) worked on the 7:00 AM to 3:00 PM shift and was assigned to R31. Review of the electronic employee time stamps for time worked on 1/30/22 revealed that E21 clocked in at 7:00 AM and clocked out at 3:00 PM. The allegation of abuse occurred at 11:15 AM and E21 remained at the facility until 3:00 PM. E21 was removed from R31's care assignment, but remained in the facility caring for other residents. 2/4/22 - A 5 day follow up submitted to the State Agency by the facility included in the root cause analysis that the CNA was immediately reassigned and removed from the resident's care. 2/17/22 10:37 AM - During an interview, E11 (Charge Nurse) confirmed that E21 (CNA) was reassigned and removed from R31's care after the allegation of abuse, but worked the rest of the shift providing resident care. E11 added that two CNA's just swapped their assignment to have someone else care for R31. The facility failed to protect R31 and/or other residents from further potential abuse. b. A facility policy entitled Protection from Abuse and Responding to Reportable Incidents (last approved 4/1/21) included: Investigation - Interview all potential witnesses. Review of the facility investigation related to R31's allegation of abuse on 1/30/22 revealed that only E21 (CNA) and E11 (Charge Nurse) provided written statements. No other staff working on R31's unit provided statements. The facility failed to thoroughly investigate R31's allegation of abuse. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on clinical record review and interview, it was determined that for one (R4) out of one resident reviewed for PASARR (Preadmission Screening and Resident Review), the facility failed to refer R4 with newly evident or possible serious mental disorder(s) for a PASARR level II resident review. Findings include: Review of R4's clinical record revealed: 11/6/00 - A PASARR Level I analysis was completed prior to R4's admission to the facility and determined that a nursing home admission was necessary. R4 had [CONDITION(S)] (post-traumatic stress disorder), chronic adjustment disorder and depression. R4 was prescribed medication to treat depression. 6/13/02 - R4 was admitted to the facility. 2/21/22 9:40 AM - During an interview, E26 (SW) confirmed that no PASARR's had been submitted to the State since R4 was admitted to the facility in 2002. 2/21/22 10:00 AM - During an interview, E8 (Pharmacist) confirmed that R4 had three antipsychotic medications since 2016 for [CONDITION(S)] mood disorder and borderline personality disorder, including [MEDICATION(S)] originally ordered 2/21/19, [MEDICATION(S)] from 2016 - 2019 and [MEDICATION(S)] from January - September 2016. 2/22/22 10:29 AM - SS2 (State PASARR Supervisor) confirmed that the facility should have referred R4 for a PASARR level II resident review when he had new psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interview and review of other facility documentation, it was determined that for one (R31) out of 20 sampled residents investigated for comprehensive care plans, the facility failed to initiate a comprehensive care plan to monitor R31's [CONDITION(S)] catheter. Findings include: Cross refer F698 1. Review of R31's clinical record revealed: 2/22/05 - R31 was admitted to the facility with a [CONDITION(S)] and [CONDITION(S)] was initiated related to kidney disease. 8/28/21 - A doctor's order included: I attend [CONDITION(S)] with (said [CONDITION(S)] Center) on Mondays, Wednesdays and Fridays at 9:40 AM. 2/4/22 - Although R31's care plan included that R31 had a [CONDITION(S)] catheter in his right upper chest, there were no interventions in place to monitor it for an intact dressing or complications. 2/16/22 12:45 PM - During an interview, E14 (Unit Manager) confirmed there was not a comprehensive care plan to monitor R31's [CONDITION(S)] catheter. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interview and review of other facility documentation, it was determined that for one (R31) out of one sampled residents reviewed for [CONDITION(S)], the facility failed to monitor R31's [CONDITION(S)] catheter and failed to consistently monitor R31's before (pre) and after (post) [CONDITION(S)] weights. Findings include: Review of R31's clinical record revealed: 2/22/05 - R31 was admitted to the facility with a [CONDITION(S)] and [CONDITION(S)] was initiated related to kidney disease which required a [CONDITION(S)] catheter. 11/20/20 - A physician's order included: Weights three times per week Monday, Wednesday and Friday morning. Review of R31's [CONDITION(S)] Communication forms revealed: -12/6/21; 1/7/22; 1/19/22; and 1/26/22 - no post [CONDITION(S)] weights. -12/27/21 - no pre or post [CONDITION(S)] weights. -2/9/22 - no pre [CONDITION(S)] weight. 02/16/22 12:45 PM - During an interview, E14 (Unit Manager) confirmed there was no physician's order to monitor R31's [CONDITION(S)] catheter. 2/17/22 10:05 AM - During an interview, E14 confirmed there were missing [CONDITION(S)] weights on the aforementioned dates. E14 stated that the facility was responsible for pre [CONDITION(S)] weights and the [CONDITION(S)] center was responsible to record post [CONDITION(S)] weights in R31's [CONDITION(S)] communication book. 2/17/22 10:26 AM - During an interview, E11 (Charge nurse) confirmed that the facility does not weigh R31 after [CONDITION(S)] or contact the [CONDITION(S)] center to follow up on post [CONDITION(S)] weights. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review, it was determined that for two (R47 and R62) out of five residents reviewed for unnecessary medications, for R62, the facility failed to complete a Gradual Dose Reduction (GDR) and for R47, the facility failed to monitor side effects of psychoactive medication. Additionally, for R47, the facility failed to ensure that PRN [CONDITION(S)] medication had a specific duration for continued use. Findings include: The facility policy Psychoactive Medications, dated 11/15/17, documented that an AIM's assessment should be completed quarterly for residents taking [CONDITION(S)] medication. 1. Review of R62's clinical record revealed: 6/1/04 - R62 was admitted to the facility with major depressive disorder, recurrent, severe with psych symptoms. 10/31/17 (revision date) - The Policy and Procedure for psychoactive medication documented that the Pharmacy Consultant Will recommend GDR to the primary care physician/NP when appropriate, after each quarterly review. GDR must be attempted quarterly, unless clinically contraindicated. 5/14/21 - An annual MDS assessment documented the use of an antidepressant and a GDR was clinically contraindicated per the Physician, dated 8/29/17. There were no mood symptoms or behaviors. 6/3/21 - Physicians orders revealed an order for [MEDICATION(S)] 12.5 mg to be given by injection into the muscle for one day, then hold 13 days for major depressive disorder and antipsychotic features, then give the next dose. 6/14/21 - A Psychiatric consult signed by E16 (MD) documented R62's mood as Not too bad and was cooperative, pleasant. 1/14/22 - A quarterly MDS assessment documented use of an antipsychotic and no mood symptoms or behaviors. 1/20/22 - Review of the Pharmacist Medication Regimen Review revealed [MEDICATION(S)] consider GDR due on 1/1/22. The facility lacked evidence that the recommendation was considered by the Physician. 2/18/22 12:27 PM - During an interview, E6 (RNAC) confirmed that GDR information for a resident taking an antipsychotic medication was obtained from Behavioral Health Services. 2/21/22 - An email communication with E22 (MD) provided no additional information about a GDR for [MEDICATION(S)]. There was no evidence of a GDR or rationale not to conduct one in the clinical record. 2a. The following was reviewed in R47's clinical record: 6/22/21 - A physician order was written for [MEDICATION(S)] 5 mg/ml - 5 mg into the muscle PRN (as needed for [CONDITION(S)] activity times 6 doses, 5 mg every 5 minutes and may repeat up to 30 mg total dose. The order lacked an end date or rationale for continued use beyond 14 days. 2/21/22 3:00 PM - During an interview, E8 (Pharmacist) said that the prescription for [MEDICATION(S)] was renewed by the Physician on 12/28/21. E8 confirmed that the order was extended beyond 14 days and did not include a specific duration for use. b. 2/10/20 - A physician order for [MEDICATION(S)] twice daily was written for R47. 3/23/21 - A review of documentation revealed an AIM's test was completed. 10/26/21 - The pharmacy medication review revealed the last AIM'S test was competed on 3/23/21 (7 months ago). 1/25/22 - A pharmacy medication review incorrectly documented that medication monitoring was adequate, no changes recommended. 2/21/22 9:00 AM - Review of the clinical record lacked evidence of an AIM's assessment after 3/28/21. 2/21/21 1:30 PM - During an interview, E18 (RN) confirmed that AIM's testing was not completed since 3/23/21 for R47. E18 immediately confirmed with E3 (Blossom Unit Manager) that AIM's assessments should be completed every three months for residents on [CONDITION(S)] medications. Findings were reviewed with E1 (NHA) and E2 (DON) during exit conference on 2/22/22 at 2:22 PM.

Based on observation, interview, and record review, it was determined that for one (R22) out of two residents reviewed for pressure wounds, the facility failed to complete accurate MDS assessments. Findings include: A review of MDS assessments 4/23/21 (annual), 9/17/21 and 12/3/21 (quarterly) documented that R22 had a stage 3 wound and an unstageable wound. 2/14/22 11:12 AM - During an interview, R22 stated she had a wound on her bottom that the facility was treating. 2/16/22 10:30 AM - During a wound care observation performed by E5 (WCN), R22 had a wound on the left hip area with depth down to the bone. 2/16/22 11:29 AM - During an interview, E5 (WCN) stated that R22 had the stage 4 left hip wound for over a year. E5 said that a wound care company had also been treating the resident for this chronic Stage 4 wound. 2/16/22 11:56 AM - During an interview, E6 (RNAC) confirmed that she had made an error when coding R22's pressure wound and confirmed the three MDS assessments were coded inaccurately. 2/22/22 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interviews, and review of facility's policy as indicated, it was determined that the facility failed to develop a plan of care ([DATE] to [DATE]) and failed to implement measures to prevent the development of a new pressure ulcers (PUs) of the bilateral heels for one (R54) out of 81 sampled residents. R54 was admitted to the facility with one, stage I and three, stage II PU. Although R54 was assessed at "very high risk" for development of new PU, the facility failed to implement measures which resulted in R54 acquiring bilateral heel Suspected Deep Tissue Injury (SDTI, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The National Pressure Ulcer Advisory Panel 2007). Findings include: R54 was originally admitted to the facility on [DATE] from the resident's home with hospice services. R54's [DIAGNOSES REDACTED]. Past medical history included [MEDICAL CONDITION], obstructive sleep apnea, and [MEDICAL CONDITION]. Past surgical history included right [MEDICAL CONDITION] and repair. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R54 was severely impaired for daily decision making, had short term and long term memory problem, required extensive assistance of one staff for bed mobility, extensive assistance of two staff person for transfer, had an indwelling Foley urinary catheter, was always incontinent of bowel, had one, stage I PU of left lower buttock, and two, stage II PUs of left buttock, and one, stage I PU of right buttock. The admission weight and height were 187 pounds and 56 inches respectively. Review of the "Admission Nursing Assessment" dated [DATE] documented that R54 had multiple areas of PUs of bilateral buttocks. On [DATE], the "initial assessment" wound care forms were initiated for these four PUs. Review of the [DATE] admission physician's orders [REDACTED]. An interview with E2 (Director of Nursing) on [DATE] at approximately 10 AM revealed that the low air loss mattress was implemented upon R54's admission to the facility. The facility's policy entitled "Wound Care" indicated that all residents will be assessed for potential loss of skin integrity by utilizing the Braden Scale for predicting PU on admission. Review of R54's admission Braden Scale evaluation completed on [DATE] did not include a score for "Moisture" and "Nutrition" since the resident was a new admission, however, the total score was documented as "7" which placed R54 at a "very high risk" for the development of PU. Further review of the above "Wound Care" policy revealed: "Policy: "4. A resident may be deemed at risk if there is a previous history of skin breakdown, a significant undesired weight loss or if the resident is on Hospice. Also consider any [DIAGNOSES REDACTED]." "6. For residents identified at risk, interventions will implemented per attachment #2, "Guide to Interventions for At Risk Residents." These interventions will be reflected in the Care Plan." "7. Any resident unable to move or change position will be repositioned by staff (see P/P 511 Turning and Positioning) and UOC (Unit of Care) G6135 will be added to the care plan. Review of "Attachment #2 (Guide to Interventions for At Risk Resident)" of the above policy revealed for a score of "9" or lower or "Very High Risk", the following interventions would be implemented: - Add UOC 6477 "Potential for Impairment of Skin Integrity" to Care Plan. - Turn and reposition. Use lift sheet if needed. - Toileting program or incontinence care. - Moisture barrier. - Float heels (Ensure heels are free from the surface of the bed) . - Manage nutrition and hydration. - HOB (head of bed) no higher than 30 degrees except for meals. - Consult wound nurse. - Pressure relieving support surface (bed, chair). Review of the "Basic Care Plan and Assignment Record"(communication utilized to direct care delivery for newly admitted resident) dated [DATE] documented under "Problem:" - "G-6132: General Care Needs" with interventions including assess resident's self care ability, nurse will monitor BM's and follow facility protocol, weight will be monitored and changes reported per facility protocol, and call bells will be within reach." For this problem, the form indicated "On Assignment Record (Certified Nursing Assistant's Assignment Record). - "Skin Risk Factors of incontinent and unable to turn independently with a goal that the skin will remain clean, dry, and intact." The intervention included assess for potential or actual impairment of skin integrity and monitor position changes." For this problem, the form indicated "add to Assignment Record, if applicable." Review of the CNA "Approach/Intervention" section revealed an intervention to "observe skin and report any problem to nurse", however, the facility failed to incorporate the additional interventions per the above policy. Lastly, the facility failed to incorporate interventions for the actual PUs. An interview with E17 (Unit Manager) on [DATE] at approximately 10:30 AM revealed that R54 was an emergent admission on a Friday evening at approximately 7 PM and upon assessment of R54's heels, there were no skin impairments including boggyness. E17 instructed the ,[DATE] shift staff to roll the blanket to float R54's heels until the "Float pillow" was obtained from the wound care nurse on the following Monday, [DATE] since there were no extra pillows in the unit to float the resident's heels. E17 confirmed that she was not aware that the interventions in the policy and verbalized that since the facility's business office was closed until Monday, [DATE], there was not an opportunity to initiate the care plan in facility's computerized system (UOC 6477). E17 confirmed that the "Basic Care Plan and Assignment Record" did not include the interventions to float the heels. Although E17 verbalized that she instructed the staff to roll a blanket to float R54's heels during the 3 PM-11 PM shift on [DATE], interviews with four CNAs who provided care to R54 from [DATE] through [DATE] revealed the following. Interviews with two CNAs, E39 and E40 on [DATE] at approximately 3 PM revealed that they did not remember R54 or the care provided to R54. E39 and E40 verbalized that if a resident required floating of the heels, they would know based on the "Resident Profile", a CNA care plan and would have documented on the CNA record. Another interview with E37 (CNA) on [DATE] at approximately 2:50 PM revealed that if the intervention was on the CNA record, E37 would ensure that the intervention was completed and would have documented on this record. An interview with E38 (CNA) on [DATE] at approximately 2:55 PM revealed that she remembered R54 and that R54 was turned, repositioned every two hours, the heels were elevated and that R54 was not resistant to care. Surveyor reviewed the CNA record with E38 during this interview and the CNA record lacked evidence of these interventions were implemented. Despite the fact R54 was admitted with multiple PUs and was assessed as "Very High Risk" on the Braden Scale, record review and interviews lacked evidence that facility's system ensured that the preventative measures for additional PU development were implemented. Interviews with two staff nurses, E8 and E35 on [DATE] at approximately 11:20 AM and 11:25 AM respectively revealed if a resident was assessed as "Very High Risk" using the Braden Scale, E8 and E35 were uncertain as to what interventions to implement or that the facility's "Wound Care" policy included "the "Guide to Interventions for At Risk Residents." Additional interview with E41 (Registered Nurse Supervisor) on [DATE] at approximately 5 PM revealed that if a resident was assessed as "Very High Risk" using the Braden Scale, E41 was not aware that the facility's "Wound Care" policy included the "Guide to Interventions for At Risk Residents." E41 verbalized that it would be helpful if these guidelines, based on the level of risk be on the backside of the "Braden Scale" to assist the staff to determine which interventions to implement. Review of Nurse's Note dated [DATE] and timed 12 noon by E33 (Facility's Wound Care Nurse) documented the presence of new PUs of bilateral heels, SDTI which were not noted on admission and heel float pillows were provided. Upon this assessment, two, new "initial assessment" wound care forms were initiated. 1) Right heel acquired on [DATE] and staged as SDTI measuring 3.6 cm. (centimeter) in length (L) and 3.4 cm.W (width) with no drainage, with healthy surrounding skin, and pain present. This documentation contained the signature of the attending physician (E80) and the date of [DATE]. - Left heel acquired on [DATE] and staged as SDTI measuring 3.5 cm. L and 3.2 cm. W with no drainage, with healthy surrounding skin, and pain present. This documentation contained the signature of E80and the date of [DATE]. An interview with E80 on [DATE] at approximately 10 AM revealed although he signed and dated the above documentation, E80 did not observe the PU on [DATE]. Although the facility implemented the above wound sheets for the SDTI, the assessment failed to include the wound appearance. An interview with E33 on [DATE] at approximately 10 AM revealed that she worked Monday through Friday and she was aware that R54 was being admitted on [DATE] with PU of the sacrum and support surface mattress was to be implemented. E33 verbalized when she assessed R54 on [DATE], R54's were not floated and the wound appearance was dark purple and was not a fluid filled blister. E33 indicated that based on the results of the Braden Scale, the interventions on the facility's algorithm should have been implemented which included suspending or floating the heels which were not completed. E33 indicated that M6478 should have been implemented since this would have included the intervention to float or suspend the heels. Review of the [DATE] physician's orders [REDACTED]. - [MEDICATION NAME]/[MEDICATION NAME] mix q shift and as needed. - Float heels at all times. - "No Sting" daily to bilateral heels. Review of "Resident Profile" a, CNA care plan for R54 dated [DATE] included interventions of low air loss mattress and float heels. Review of the CNA use of heel pillows provided by the wound nurse. A care plan was implemented on [DATE] for "M6477-Potential for impairment of skin integrity" with intervention to suspend heels and "M6478-Impairment of skin integrity: right pressure ulcer, stage II of bilateral buttocks with an intervention including suspending heels. Although the facility implemented an actual care plan for pressure ulcers, the care plan lacked evidence of a care plan for the bilateral SDTI of the heels. Subsequent review of the right heel SDTI assessments on [DATE], [DATE], and [DATE] revealed that the wound appearance remained as dark purple with size of the wound increasing to 5.1 cm., 4.6 cm., and 4.6 cm. in L respectively. In addition, the width measurements of 4.2 cm., 3.8 cm., and 4.0 cm. respectively with pain present and with slight inflamed/indurated. On the [DATE], [DATE], and [DATE], surrounding skin was assessed as healthy and no pain present. Subsequent review of the left heel SDTI assessments on [DATE] and [DATE] revealed that the wound appearance remained dark purple, however, the PU was improving with size of the wound decreasing to 1.8 cm. and 1.2 cm in L as well as width from 1.6 cm and 1.0 cm with no pain and healthy surrounding skin. On [DATE], the left heel SDTI was documented as absorbed (resolved). The right heel SDTI remained stable through the last documented assessment on [DATE]. On [DATE], R54 expired with final [DIAGNOSES REDACTED]. Findings reviewed with E1 (Director), E2 (Director of Nursing/DON), E3 (Assistant DON), E4 (Assistant Director), E5 (Medical Director), and E7 (Quality Assurance Administrator) on [DATE] at 10 AM.

Based on record review, interviews, and review of facility's policy as indicated, it was determined that the facility failed to develop a plan of care and failed to consistently implement interventions for two (R134 and R63) out of 29 sampled residents to ensure that they received the necessary treatment and prevention for pressure ulcers. Findings include: 1. R134 was readmitted from the hospital on [DATE]. The resident's Braden assessment for pressure ulcer risk dated 1/15/13 scored 14, a moderate risk for pressure ulcer development. R134's care plan initiated on 1/15/13 for potential for impairment of skin integrity included the approaches of reposition resident in bed or chair every two hours, on back for meals only, float heels on pillows, and suspend heels off mattress/surface by placing pillow under lower legs. A care plan for impairment of skin integrity related to pressure ulcer stage IV to sacrum included the approaches reposition side to side in bed or chair every two hours, on back for meals only. Observations on 2/8/13 at 9:15 AM, 9:50 AM 10:52 AM, 1:30 PM, and 3:18 PM in bed with her right heel on the pillow and her left heel on the mattress and at times partially on the pillow. There was no suspension of the heels to provide pressure relief. On all observations except 3:18 PM the resident was on her back. Review of the nurse aide documentation sheets (NADS) for February 2013 revealed staff were documenting that the heels were being suspended. An interview on 2/11/13 around 11 AM with nurse E3 revealed that the resident does refuse care often. E3 stated that the refusal of care would be documented in the behavior monitoring sheets and the nurses notes. Review of these documents revealed the resident had not refused care during the above observation period. These findings were reviewed with E2 Director of Nursing on 2/11/13 at 12:15 PM. 2. R63 was readmitted to the facility on [DATE] from the hospital for treatment of [REDACTED]. The most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R63 was severely impaired for daily decision making, required total assistance of one staff for bed mobility, extensive assistance of two staff person for transfer, did not ambulate, was frequently incontinent of urine, and did not have any unhealed pressure ulcer. Review of the "Readmission Nursing Assessment" dated 1/25/13 documented that both the right and left heel were boggy (or spongy feel of the heel can indicate the start of a pressure ulcer/PU). The facility's policy entitled "Wound Care" indicated that all residents will be assessed for potential loss of skin integrity by utilizing the Braden Scale for predicting PU on admission. Review of R63's readmission Braden Scale evaluation completed on 1/25/13 scored the resident at "14" or "moderate risk" for the development of a PU. Further review of the above policy included: "6. For residents identified as "at risk", interventions will be implemented per attachment #2, "Guide to Interventions for At Risk Resident. These interventions will be reflected in the Care Plan.." For "Moderate Risk" resident's the following interventions would be implemented: - Add UOC (Unit of Care) 6477 "Potential for Impairment of Skin Integrity" to Care Plan or incorporate proactive interventions into existing Care Plan. - Turn and reposition. Use lift sheet if needed. - Toileting program or incontinence care. - Moisture barrier. - Float heels. - Manage nutrition and hydration. - HOB (head of bed) no higher than 30 degrees except for meals. - Consult wound nurse. - Pressure relieving support surface (bed, chair). Although R63 was readmitted to the facility with bilateral boggy heels and was assessed as being at "Moderate Risk" for development of new PU, review of the "Basic Care Plan" implemented on 1/25/13 failed to include the intervention to relieve pressure of the heel such as floating the heel. An interview with E2 (Director of Nursing) on 2/8/13 at approximately 3 PM confirmed the above finding on the care plan. On 1/26/13 at 10 AM, the following physician's orders [REDACTED]. - "CAM boots (Control ankle movement boot -a boot that provides support, protection and immobilization of the ankle after injury or surgery; www.nationalbraceandsplint.com) on while in bed. - No sting (liquid film forming skin protectant which can be used on intact or damaged skin to help prevent irritation) to bilateral heels daily. The "Basic Assignment Record"(communication utilized to direct care delivery for admission and readmitted resident) dated 1/25/13 documented "Skin Integrity Impairment: Potential or Actual" an intervention to "Float heels using pillows" which the certified nursing assistants (CNAs) documented their initials indicating that this intervention was implemented beginning on 1/26/13 through 1/29/13. In addition, a hand-written intervention of "CAM boots on while in bed" which the CNAs consistently initialed as being completed. An interview with E10 (a CNA who provided care to R63 during this period of time) on 2/11/13 at approximately 3 PM revealed that the CAM boot was in the resident's room and proceeded to show the surveyor the device. The device observed by the surveyor was not a CAM boot but rather a heel lift device to float the heel when a resident was in the bed. On 1/27/13, a physician's orders [REDACTED]. Review of the readmission computerized Care Plan dated 1/30/13 included for "UOC 6477 Potential for impairment of skin integrity", interventions to "utilize devices: resident uses heel protectors while in bed. No sting skin prep. to heels three times a week" although these were discontinued on 1/27/13. This care plan failed to include care and services to relieve pressure to R63's heels including the heel lift device that was in use. Review of the NAD from 1/30/13 through 2/7/13 included "utilize devices: residents uses heel protectors while in bed. No sting skin prep. to heels three times a week." CNAs consistently documented their initials indicating that these interventions were in place. This documentation failed to include intervention to relieve pressure to R63's heels. An interview with E16 (Operation Support Specialist) on 2/11/13 at approximately 1:15 PM revealed that on Monday, 1/28/13, R63's previous care plan including UOC 6477 was printed for the licensed nurse to review and revise. This care plan did not include intervention to relieve pressure to the heels. Upon receipt of the revised care plan, E16 printed the care plan and the NADS documentation on 1/29/13. Observations of R63 during the survey on 2/8/13 at approximately 3 PM and on 2/11/13 at approximately 1 PM revealed the resident sitting in a wheelchair with diabetic shoes on. Repeat observation of R63 on 2/11/13 at approximately 2 PM revealed R63 in bed with heel suspension boots. . On 2/8/13 at approximately 3 PM, an interview with E2 (Director of Nursing) revealed that when the computerized care plan was revised on 1/30/13, the care plan incorrectly included the interventions for the heel protectors and the No sting skin preparation. In addition, that the care and services to relieve pressure to R63's heels were not on the care plan or on the NADS for the staff providing care to R63. In addition, when the order for the CAM boot was written, the facility failed to clarify this order. Subsequent to this conversation with the surveyor, the facility obtained an order to discontinue the CAM boot while in bed and to use heel suspension boot while in bed. These new orders were incorporated into the care plan and the NADS during the survey on 2/8/13. Findings reviewed with E1 (Administrator) and E2 on 2/11/13 at approximately 4:15 PM.

Based on record review and interview it was determined that for one (R32) out of 47 sampled residents the facility failed to ensure that a resident whose plan of care was tube feedings was not provided with any food by mouth. R32 was fed a dinner meal on the second day back from a hospitalization for aspiration pneumonia. This resulted in R32 requiring a second hospitalization for aspiration pneumonia. Findings include: R32 was readmitted to the facility on [DATE] after a hospitalization for ventilator dependent [MEDICAL CONDITION], pneumonia and [MEDICAL CONDITION]. The hospital discharge sheet stated that the diet was to be [DEVICE] feeding with Glucerna. The computer generated Physician order [REDACTED]. The changes included crossing out all diet orders and medications by mouth orders. Additionally, the physician ordered a speech therapy consult and an around the clock tube feeding formula. While the physician did not write a NPO (nothing by mouth) order he intentionally crossed off all diet and medication orders that were to be administered by mouth. Review of the Admission Nursing assessment dated [DATE] at 2:15 PM documented the diet as enteral feeding (tube feeding). A nurse ' s note on 7/21/11 at 10:50 PM stated the resident was fed dinner because the aide did not know the resident was not supposed to get anything by mouth (NPO). The resident's vital signs were noted to be stable and the resident was not short of breath. This resulted in the resident being fed dinner while receiving a continuous tube feeding. An interview on 8/23/11 with E21, the aide who fed the resident dinner, revealed that she was not usually assigned to this unit and was not on the unit at the time of the start of shift report. E21 further stated that she was not told the resident was NPO (nothing by mouth) and that a dinner tray came to the floor for the resident. E21 revealed that her assignment sheet noted that she was to feed R32 so she did. The resident tolerated the meal without any problems noted. Review on 8/22/11 of the current assignment sheet for Assignment #3 for the 3-11 PM shift still included the task of feeding R32. A Diet Communication form was initiated by nursing on 7/21/11 at 8:25 AM. The head nurse E19, called the dietary department on 8/22/11 where it was revealed that they did not enter the change into the system until 7/22/11. It was unclear when the dietary department actually received the communication form. Review of the care plan dated 3/26/10 and last reviewed on 6/22/11 revealed that a pureed diet with nectar liquids had been crossed out in pen with no discontinuation date. The approach of a pureed snack at lunch time and pudding in the evening remained on the care plan as of 8/22/11. Review of the Nursing Aide Documentation Sheet (NADS) for July 2011 included the pureed diet with nectar thick liquids for snacks and pudding. The letters NPO were noted on 7/21/11 but 7/20 and 7/22/11 were blank. An interview with E24, a CNA working the 3-11 shift on 7/21/11 revealed that R32 ' s meal consumption for dinner was documented on the unit ' s meal sheet that night and she was aware the E21 had fed R32. The daily meal sheet was not retained by the facility. A nurse ' s note on 7/21/11 at 12 midnight documented that R32 ' s lungs were noted with expiratory wheeze, frequent non productive cough and [MEDICATION NAME] was given with little relief and Tylenol was given for discomfort. Nurses ' notes on 7/22/11 documented that on day shift R32 continued to have coughing, expiratory wheezing and was sluggish. At 3 PM the resident had decreased oxygen saturation to 81% and was started on oxygen. At 4 PM the resident was in respiratory distress with decreased breath sounds in all lung fields, no air exchange in right lower lobe and inspiratory wheeze in right upper lobe. There was expiratory wheezing bilaterally and a nebulizer treatment was administered with no improvement. The resident was sent to the emergency room . The hospital history and physical dated 7/22/11 documented under assessment aspiration pneumonia and acute [MEDICAL CONDITION]. The chest x-ray from the hospital dated 7/22/11 documented worsening left basilar infiltrate (as compared to 4 days earlier) and aspiration pneumonia should be considered. The discharge [DIAGNOSES REDACTED]. An interview on 8/19/11 at 11 AM with E2, DON and E3, RN Supervisor revealed that they were unaware that R32 was fed a dinner tray when he was NPO and went to the hospital less then 24 hours later in [MEDICAL CONDITION]. An interview on 8/24/11 with the QA Administrator, E4 revealed that although nurses in her department review the records of all residents who go to the emergency room or hospital there was no report or investigation of the resident being fed a dinner tray while NPO.

Based on observation, record review and interview it was determined that for one (E4) out of eight residents the facility failed to ensure that a resident who was NPO (nothing by mouth) did not have a plan of care that included taking food and liquid by mouth. Findings include: R4 was originally admitted to the facility on [DATE] from the state psychiatric facility. On 7/19/11 the resident was transferred to another state long term care facility to be closer to family. On 8/8/11 R4 was admitted to an acute care hospital and discharged back to the facility for skilled care on 9/7/11 with a newly placed gastrostomy tube ([DEVICE]). R4's admission orders [REDACTED]. Review of R4's current care plan printed 10/14/11 and originating on 8/26/10 for potential for injury related to dysphagia (difficulty swallowing) with a goal of "Resident will be free from aspiration during and after feeding" included the approaches; - Elevate head of bed 90 degrees during meal/snacks and for 30 minutes after eating. - Encourage resident to keep head tilted slightly forward, support head with pillows as needed. - Clear residents mouth of any remaining food particles following the meal. - Feed slowly, one bite at a time. Offer liquids every 3-4 bites to reduce residual in oral cavity. These above approaches populated onto the Nursing Assistant Data Sheet (NADS) used by the facility to guide and document care. The aides documented these approaches on the 33 days reviewed for October and November 2011 all three shifts until identified by the surveyor on 11/2/11. Observation of R4 on 11/1/11 and 11/2/11 revealed a water pitcher full of liquid on the bedside table with a stack of clear plastic cups. An interview with the head nurse, E9 on 11/2/11 revealed that the water is kept at the bedside for the nurses to use when administering medication into the [DEVICE]. Review of facility records revealed R4 was treated as a new admission with the exception of his care plan and the NADS. These records were carried over in the computer system from the June 2010 admission. An interview with E9 on 11/2/11 confirmed that she failed to ensure the by mouth approaches were removed from the care plan and the NADS. She further stated she did not know why the computer pulled the June 2010 data into the current clinical record. An interview with the E4, QA administrator on 11/2/11 and auditing tools provided by the QA department on 11/3/11 revealed that reviewing the care plan was not a measure being used for new admissions only re-admissions. An interview with a QA nurse, E8 on 11/3/11 at 3:30 PM revealed the admission audit tool was being revised to include the same areas as the new-readmission tool including review of the care plan but was not in place at the present time.

Based on record review and interview it was determined that for one (R4) out of eight sampled residents the facility failed to ensure that therapeutic drug monitoring was part of the plan of care. Findings include: R4 was admitted to the facility on [DATE] with physician's orders [REDACTED]. (milligram) twice a day for [MEDICAL CONDITION] disorder. No laboratory monitoring orders were included in the admission October 2011 physician order [REDACTED]. An interview with the attending physician (E7) on 11/2/11 revealed that a resident stable on VPA should be monitored every 6 months. Those residents less stable would be monitored every 2-3 months. After reviewing the record, E7 confirmed the VPA monitoring blood work had not been ordered for R4. Review of records from the previous long term care facility noted that the resident had been on 1250 mg. of VPA daily. Review of hospital records revealed a psychiatrist's consultation dated 8/12/11 that documented "I recommend very gradually increasing his psychiatric medications to therapeutic levels although he was at relatively high doses of the medications prior to being in the hospital. Because of the fact that he is suffering from infection and lethargy, I am going to restart him on extremely small doses. I understand that he does have a history of aggression and violence and will need to be placed back on his medications. At this point; however, he is exhibiting no form of agitation, so I think increasing his medications gradually is an ideal plan for him." He started R4 on 250 mg. twice a day, his current dose at the facility. Hospital laboratory results for VPA on 8/16/11 were low at 15 (50 - 120 mg/L). The pharmacist reviewed R4's medications on 9/27/11 and 10/18/11 without inquiring about the VPA level. The pharmacist did write on top of the review form that the resident was on VPA for [MEDICAL CONDITION] disorder. There was no evidence that the facility ensured monitoring was in place for R4's VPA level.