Every finding on record at Delaware Veterans Home

Based on record reviews, interviews, and review of the facility's policy, the facility failed to ensure four of nine sampled residents (Resident (R) 4, R46, R8, and R41) reviewed for abuse were free from resident-to-resident physical abuse. On 07/22/25, R8 pushed R4 to the ground. As a result, R4 sustained a closed left radius fracture, a closed, displaced, comminuted right proximal humerus fracture, and a closed, displaced right distal clavicle fracture. Findings include:. 1.Review of the facility's 5-day Follow Up Report dated 07/25/25 provided by the Administrator, revealed that at the time of the incident on 07/22/25 at 5:30 PM, staff heard someone screaming. Upon entering the hallway, staff observed R4 sitting on the floor holding his head. Staff immediately ran down the hallway to investigate. The Nursing Supervisor/Registered Nurse (NS/RN) reviewed the surveillance video and noted R8 walking down the hall into R4's room. After a few seconds, R4 was seen coming out the room with R8 behind him. R8 pushed R4 to the floor. Staff immediately assessed R4, called 911 and transferred R4 to the emergency room (ER) for further evaluation. While at the hospital, R4 was diagnosed with fractures of the right shoulder and left wrist. R8 was placed on hourly safety checks as well as being seen by psych services due to some residual concerns from the incident. Review of R4's admission Record located in the R4's electronic medical record (EMR) located under the Profile tab revealed R4 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, depression, anxiety, and post-traumatic stress disorder (PTSD). Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Further review revealed that R4 did not display any behaviors during the review period. Review of R4's Health Status Note dated 07/22/25 located in the EMR under the Progress Notes tab revealed that at approximately 7:05PM, staff heard loud screaming and observed R4 on the floor. The fall was unwitnessed. The resident c/o [complaint of] right shoulder pain and left wrist pain. Noted active bleeding from laceration on forehead measuring approximately 5cm [centimeter] x 1cm, and a second laceration on the nose measuring approximately 1cm x 1cm. Resident appeared clammy and diaphoretic.Resident was unable to be moved safely; nurse supervisor was notified immediately and 911 was called. EMTs [Emergency Medical Technicians] arrived approximately at 1930 [7:30PM] and transported resident to the ER for further evaluation. Review of R4's Post Fall Evaluation dated 07/22/25 located in R4's EMR under the Assessment tab revealed that on 07/22/25 at approximately 7:10 PM, R4 experienced an unwitnessed fall in the hallway. At the time of the incident, the resident was ambulating in the hallway but was unable to clearly state the specific activity being performed. The cause of the fall was not immediately evident. The resident's pre-fall fall risk score was 10. Post-fall, the resident was assessed for ongoing fall risk. It was later identified that the fall was contributed to by another resident, who reportedly pushed R4, resulting in the fall. Following the incident, the resident reported constant right shoulder pain rated 10/10 [10 out of 10] .order was received to send the resident to the ER for further evaluation. Review of the hospital's After Visit Summary dated 07/24/25 located in R4's EMR under the Miscellaneous tab revealed R4 was admitted to the hospital on [DATE] with a primary diagnosis of a closed, displaced distal clavicle fracture. Further review revealed R4 also sustained a closed left distal radius fracture, and closed, displaced comminuted right proximal humerus fracture. During an interview on 3/09/26 1:43 PM, R4 stated that he was shoved down by one of the residents [R8] who came into his room. R4 stated that he wanted the resident to leave and then he shoved me down. R4 stated that he hurt his right arm and wrist and was transferred to the hospital. R4 stated that the police came into the facility to investigate. R4 stated that when he returned from the hospital, they moved him to another unit and that he has not seen the resident [R8] since. R4 stated that he was not afraid and felt safe in the facility. Review of R8's admission Record located in the R8's EMR located under the Profile tab, revealed R8 was admitted to the facility on [DATE] with diagnoses of dementia with mood disturbances, bipolar disorder, severe with psychotic features, PTSD, insomnia, and depression. Review of R8's admission MDS with an ARD of 05/28/25 revealed R8 had a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. Further review revealed that R8 did not display any behaviors during the review period. Review of R8's comprehensive care plan initiated on 05/23/24 and last revised on 02/02/26, located in R8's EMR under the Care Plan tab revealed that R8 has a behavior problem related to bipolar disorder and dementia. R8 wanders. He refuses care at times. R8 becomes combative and has demonstrated physical aggression toward staff and others, including biting a certified nurse aide (CNA) on the shoulder and swinging his walker at a CNA. The pertinent interventions directed staff to anticipate and meet the resident's needs, divert resident by giving them alternative objects or activities, intervene as necessary to protect the rights and safety of others, and conduct safety checks every shift. On 09/27/25, the facility updated the care plan directing staff to conduct safety checks every hour. On 09/30/25 the facility updated the care plan directing staff to redirect the resident when others are in his personal space or when he is in other resident's space. Review of R8's safety checks dated 07/22/25 – 07/30/25 provided by the Administrator, revealed staff initiated and continued hourly safety checks of R8 to monitor the resident more closely. During an interview on 03/12/26 at 11: 25 PM, CNA11 stated that at the time of the incident, she was doing rounds with another CNA and helping another resident. She then heard R4 scream and noted that he was on the floor. She went to assist R4 and saw R8 coming down the hall, but she did not see what took place. After the incident, R8 was placed on hourly safety checks. During an interview on 03/12/26 at 12:51 PM, Assistant Director of Nursing (ADON) 1 stated that on 07/22/25, she just came on shift, at which time staff notified her that R4 was on the floor. She went to assess R4 and noted an abrasion on his forehead. She called 911. ADON1 stated she reviewed the camera footage to see what happened. She witnessed R8 walking down the hallway into R4's room and a few minutes later, R4 was seen coming out of his room with R8 behind him. R8 then pushed R4, who fell to the floor. After the incident, staff implemented hourly checks and obtained orders for psych to see R8. Additionally, they moved R4 to another unit upon his return from the hospital. During an interview on 03/12/25 at 3:21 PM, NS/RN stated that R8 was dependent upon staff for all ADLs. He is independent with ambulation with a walker and requires some cues with eating and physical assistance. NS/RN stated that R8 does get aggressive at time with care. After the incident, R8 was placed on hourly checks. 2. Review of R41's EMR Face Sheet under the profile tab revealed he was admitted on [DATE] with diagnoses from the Medical Diagnosis tab including dementia, with agitation, Alzheimer's disease with early onset, depression, restlessness and agitation, bipolar disorder, current episode depressed, severe, with psychotic features, mood [affective] disorder, major depressive disorder, recurrent severe without psychotic features, visual hallucinations, PTSD. Review of R41's EMR significant change MDS under the MDS tab with an ARD of 08/13/25 with a BIMS score that could not be determined due to resident is rarely/never understood and was severely cognitively impaired. The MDS indicated R41 had delusions, physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days, other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) behavior occurred one to three days. Review of R41's EMR Care Plan under the Care Plan tab revealed R41 was at risk for ineffective coping related to dementia with psychotic features, had behaviors like aggressiveness towards others, hallucinations, delusions, easily agitated, sitting on another residents' legs, and tends to get into others personal space. Physical Aggression Received note dated 09/27/25 revealed R8 was sitting in a chair in the dayroom when the R41 walked next to his chair and placed his hand on R8's chest. R8 punched R41 in the face with the back of his fist, which R41 responded by punching R8 in his face directly afterwards. The residents were unable to describe what happened. Review of R8's EMR Progress Notes tab revealed a Follow-up visit Psychiatric Periodic Evaluation dated 09/30/25 provided by the facility which indicated, History of Present illness. psychiatric history of Major Depressive Disorder, Post-Traumatic Stress Disorder, insomnia, and dementia, seen today for follow-up psychiatric evaluation and psychotropic medication management. During the visit. the patient was alert and cooperative with the interview. Collateral information from the nursing staff revealed a recent altercation with another resident, during which the patient reportedly placed his hand on the other resident's chest and was subsequently punched in the face. No injury reported. Staff further reported ongoing behavioral concerns, including combativeness with care, intermittent refusal of medications, and episodes of agitation. Despite these behaviors, appetite and sleep patterns have been reported as generally stable. Resident was alert and oriented to person only, had no hallucinations, and no delusions, with poor short term and long term memory, and impaired judgement. There were no other progress notes in the medical record regarding this incident. During an interview on 03/11/26 at 1:56 PM, CNA 6 stated that she has worked with R41 and has seen him be aggressive or violent towards other residents when you enter his space because he doesn't like it. He swings at staff lately but not residents. We redirect, reassure him, tell him what we are doing or trying to accomplish. He hit other people last year. Normally he does not bother unless you touch him or strike at him. R41 wanders and walked up on R8 and R8 usually does not get bothered unless you invade his space. R8 pushed him and R41 pushed back. During an interview on 03/11/26 at 2:16 PM, the Activity Therapist (AT)1 stated R41 likes to be by himself, with not a lot of noise, and likes to be alone. If something is next to him, it belongs to him. If they try to take his things, he has a problem with it depending on the day. Sometimes, he verbally tells him not to touch it. We redirect other residents away from him. R41 does get into altercations with other residents because he tries to see what is going on. If I see a resident-to-resident altercation I redirect them like if I see R41 going towards other residents or touching a walker, I redirect them before things get too involved. R8 does not hit unless he is provoked. During an interview on 03/12/26 at 2:03 PM, NS/RN stated R8 had his monitoring checks increased from 1 hour to 30-minute checks. He was seen and assessed by psych nurse practitioner, and they increased his antipsychotic (Quetiapine) from 100 milligrams to 150 milligrams in the morning. R41 was on 30-minute checks. 3.Review of the facility's Initial Incident Report dated 02/23/26 provided by the Administrator, revealed that on 02/03/26 at 5:53 PM, R56 on the Memory Care unit went into R46's room and removed the blankets from his bed. R46 stated he was hit in the face. The nurse immediately separated and assessed the residents. Staff moved both residents back to their rooms and initiated hourly safety checks for both residents. R46 did not sustain any physical or mental harm. Review of R46's admission Record located in R46's EMR under the Profile tab revealed R46 was admitted to the facility on [DATE] with diagnoses of depression, anxiety, dementia without behavioral disturbances, PTSD, and insomnia. Review of R46's quarterly MDS with an ARD of 01/21/26 located in R46's EMR under the MDS tab revealed R46 was rarely or never understood. R46 required substantial to maximal assistance with activities of daily living. During the review period, R46 was noted to experience hallucinations, verbal behavioral symptoms directed toward others on one to three days, other behavioral symptoms not directed toward others on one to three days and wandering behaviors on one to three days. Review of R46's comprehensive care plan revised on 02/05/26 in the EMR under the Care Plan tab revealed R46 has behavior: cussing and verbally threatening staff, frustration toward staff and others, throws items at staff, refuses medications, aggression with new faces/staff, poor safety awareness. The care plan interventions were updated on 02/05/06 to include hourly safety checks. Review of the Hourly Safety Checks dated 02/05/26 through 03/12/26 provided by the Administrator revealed staff were monitoring R46's whereabouts hourly. Review of the Physical Aggression Received Report dated 02/03/26 revealed CNA10 went to R46's room and overheard the nurse talking and R56 saying that's mine. Upon entry, CNA10 witnessed R56 in R46's room standing by the sink still saying that's mine. CNA10 walked R56 off the unit to cool off. Further review revealed RN3 heard yelling while she was in another resident's room. When she came out into the hallway, she heard R56 yelling at R46 telling him to get out of here this is my house. Upon arrival to room, RN3 noted R46 sitting upright on the side of the bed. R56 was pulling the covers at the foot of the bed, yelling and telling R46 to get out. RN3 intervened letting R56 know that this was R46's room and assisted R56 out of the room. R46 stated get a gun and shoot him. He hit me in my face. Left eye noted slight puffiness, pupils equal, reactive, and round. Review of R56's admission Record located in R56's EMR under the Profile tab revealed R56 was admitted to the facility on [DATE] with diagnoses of anxiety, major depressive disorder, dementia with other behavioral disturbances and agitation. Review of R56's admission MDS with an ARD of 11/06/25 in the EMR under the MDS tab revealed R56 had severe cognitive impairment as evidenced by a BIMS score of three out of 15. R56 did not display any behaviors during the review period. R56 required supervision or touching assistance with ambulation. Review of R56's comprehensive care plan last revised on 02/06/26 located in the EMR under the Care Plan tab revealed R56 exhibits the following behaviors: compulsiveness, repeating words, invading personal space of others, passive aggressiveness, yelling at staff, disruptive at senior center, demanding, false accusations, restlessness, physical aggression, and attempting to assist residents he believes are in need of help. The pertinent interventions directed staff to assist the resident to develop more appropriate methods of coping and interacting. Divert resident by giving them alternative objects or activity i.e., 1 to 1, activity, gave food and fluids. Familiarize resident with own belongings and surroundings. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. One-on-one structured activity or taken out for a walk when getting restless or anxious. The care plan was also updated to include hourly safety checks. Review of the Hourly Safety Checks dated 02/05/26 through 03/12/26, provided by the Administrator revealed staff were monitoring R56's whereabouts hourly. During an interview on 03/10/26 at 9:30 AM, R46 denied any abuse or that anyone came into his room and punched him. Attempts to interview CNA10 on 03/12/26 at 3:00 PM and CNA6 at 3:45 PM were unsuccessful. Messages were left for CNA10 and CNA6 to call back for an interview; however, they did not return the call prior to survey exit. During an interview on 03/12/26 at 3:06 PM, the NS/RN stated that R56 was transferred to the dementia/locked unit because of his cognitive decline. R56 likes to swear and R46 does not like that and gets upset. R56 entered R46's room and R46 stated he was hit in the face. Staff immediately intervened, separated, and assessed the residents. After the incident, staff placed R56 on hourly safety checks. During an interview on 03/12/26 at 4:30 PM, the Administrator stated that they are tracking resident to resident incidents, resident complaints, and all reportable incidents. The facility provides mandatory education when there is an allegation of abuse. For the residents on the dementia/locked unit, we have moved residents, implemented stop signs on resident doors to help prevent residents from wandering into other resident rooms, and initiated safety checks (i.e., hourly, every 30 minutes or every 15 minutes) based on the situation. Currently, the facility is looking into some deescalation training for staff. Additionally, the facility has increased staff on the dementia/locked unit so that a staff member is in the common area and can view both halls, and a staff member in the dining/TV area to monitor residents. Review of the facility's policy titled, Resident Abuse revised on 04/05/23, revealed, The Delaware Veterans Home (DVH) is committed to providing safe and respectful environments that support the health and well-being of all people receiving services. DVH seeks to institute guidelines and resources for staff and enforce zero tolerance for those actions which may jeopardize the health, safety or welfare of any person receiving services.

Based on observation, interview and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans as well as insured one of two can openers had been cleaned. This failure increased the potential risk of foodborne illness and had the potential to affect 61 of 62 residents that received food through dietary services. One resident received nutrition through tube feeding.Findings include:During an observation on 03/09/26 at 10:30 AM, three 6x6x6 stainless steel pans and six 6x24x6 stainless steel pans were stacked together on storage rack were noted to be wet inside with some food debris remaining. During an interview on 03/09/26 at 10:50 AM, the Food Service Director (FSD) stated, The pans are wet and they shouldn't be. They should be dry before they get put away and the pans should be clean and have no food remining on them. During an observation on 03/09/26 at 11:00 AM, one of two can openers bolted to a preparation table had a black substance on the blade. During an interview at this time, the FSD stated The blade is dirty. It should be clean.Review of the facility's policy titled, Food Preparation Area dated 12/13/06 revealed, All machines and equipment that require cleaning shall be cleaned after use. under the heading Washing Pots and Pans. Wash pots and pans thoroughly in the first sink. Use a brush, cloth or nylon scrub pad to loosen the remaining soil. Immerse in second sink, removing all traces of food and detergent. Remove dishes from sanitizer sink to open shelving rack for air drying. Invert glasses, cups and plate covers, pots and pans to allow more thorough drying.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure care plans were revised and updated for one (Resident (R)19) out of 23 resident care plans reviewed. R19 developed two additional wounds and had protective devices added and were not updated to his comprehensive care plan. This had the potential for the resident to have unmet care needs.Findings include: Review of R19's Face Sheet located in the electronic medical record (EMR) and under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset and dementia (severe) with behavioral disturbances.Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R19's Tasks located in the EMR under the Tasks List tab revealed certified nursing assistants (CNAs) would apply derma sleeves to the residents bilateral upper extremities when out of bed (OOB) and to apply biker gloves to the residents hands with a date initiated of 02/03/25. The Tasks List list did not indicate when the biker gloves were to be applied/removed. Review of R19's Skin and Wound Note dated 02/12/26 and located in the EMR under the Assessments tab revealed the resident had incontinence associated dermatitis (IAD) to the right buttock. The note indicated the wound was new and measured 2 centimeters (cm) by 1 cm with no depth. There was a moderate amount of serous exudate (thin, watery fluid) noted. The treatment was noted to be to cleanse the wound with normal saline, apply collagen, zinc oxide paste to the base of the wound, leave open to air, change daily and as needed (PRN). Review of R19's Skin and Wound Note dated 02/26/26 and located in the EMR under the Assessments tab revealed R19's right buttock wound was worsening, the stage/severity was partial thickness. The wound measured 9 cm by 4 cm with no depth. The treatment remained the same. Review of R19's March 2026 Treatment Administration Record (TAR) revealed an order dated 02/06/26 for wound care to cleanse the resident's penis with normal saline, pat dry and apply bacitracin ointment twice a day to the erosion site. Review of R19's comprehensive Care Plan located in the EMR under the Care Plan tab with a date initiated 12/18/24 and revised on 03/04/26 revealed the resident had a focus related to excoriation to his left buttock. Interventions include to provide treatment as ordered and the wound nurse would monitor weekly. Review of another focus area revised on 05/05/25 revealed the resident was at risk for skin impairment related to fragile skin, bowel incontinence, and limited mobility. There was no evidence the resident's Care Plan had been updated/revised to include the wound to his right buttock, the wound to his penis, or for the derma sleeves and biker gloves applied on the resident. During an observation on 03/09/26 at 3:28 PM and 03/10/26 at 11:00 AM revealed R19 was up in his Geri-chair in the common area, He had on derma sleeves and biker gloves (fingers exposed) to his bilateral arms and hands. During an interview on 03/11/26 at 12:50 PM, Registered Nurse (RN)1 stated that R19 always had on derma sleeves and open fingered gloves (biker gloves) to protect the backs of his hands and arms. RN1stated that when providing care, the resident tends to flail his arms around hitting staff or his bed rails, so they are put on for protection. During an interview on 03/12/26 at 1:20 PM, Nursing Supervisor (NS)3 who was the nursing supervisor on the unit where R19 resided confirmed the resident's care plans was not revised to reflect his new wounds to his right buttock, wound to his penis, for the derma sleeves and biker gloves. She revealed the facility had morning meetings to discuss when care plans needed updated. However, confirmed that R19's care plan was not updated and should have been. During an interview on 03/12/26 at 2:00 PM the Administrator confirmed R19's care plan was not updated for his newly developed wounds to his right buttock, penis, for the derma sleeves, and the biker gloves that were applied to the resident while out of bed. Review of the facility's policy titled, Care Plan Development, Implementation and Timing with a revised date of 03/20/23 revealed, Care Plans provide direction for individualized care of the resident . and should be organized by the individuals specific needs . 9. The care plan is a living document that requires ongoing evaluation and revision as the needs of the resident change. 10. Care Plans will be reviewed and/or revised no less than once every three months between comprehensive assessments or with a significant change in resident status.

Based on interview and record review, the facility failed to provide quality for one (Resident (R)47) of one resident reviewed for physician orders in the sample of 23 residents. Specifically, the facility failed to perform R47's daily weights as ordered. Failure to obtain daily weights as ordered for a resident with congestive heart failure can lead to potential worsening of the condition as well as hospitalization and decline in overall condition.Findings include:Review of R47's electronic medical record (EMR) Face Sheet under the admission tab indicated R47 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, heart failure, atrial fibrillation, atherosclerotic heart disease, and edema. Review of R47's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/31/25 in the EMR under the MDS tab documented R47 had heart failure and renal insufficiency.Review of R47's EMR Order Summary Report dated 03/12/26 found under the Orders tab in R47's EMR documented an order for daily weights for congestive heart failure dated 07/02/25. The order specified to call the cardiologist if daily weight gain is greater than three pounds. Review of R47's Care Plan revision date of 07/02/25 in the EMR under the Care Plan tab documented, fluid imbalances and kidney insufficiency due to congestive heart failure. The goal for R47 was to remain free of fluid imbalance as evidenced by decreases in or absence of edema, anxiety, agitation, restlessness, confusion, congestion, and jugular vein distension. The intervention was for daily weights to be obtained. Review of R47's EMR Weights and Vitals Summary under the Wts/Vitals tab revealed that no weights were documented on 08/23/25, 08/24/25, 09/27/25, 10/11/25, 10/23/25, 11/06/25, 11/19/25, 11/24/25, 11/26/25, 12/03/25, 12/17/25, 12/18/25, 02/16/26, 02/26/26, and 02/28/26. Interview on 03/11/26 at 10:07 AM, Registered Nurse (RN)2 stated that R47 is to have daily weights due to his diagnosis of congestive heart failure. Interview on 03/12/26 at 8:45 AM, Nursing Supervisor (NS)1 confirmed that R47 has a physician order for daily weights. NS1 stated the staff are to enter the weights are recorded under the Wts/Vitals tab in the EMR.

Based on observations, record reviews, interviews, and document review, the facility failed to prevent an accidents. Specifically, a resident fell from a Hoyer lift during a transfer for one out of three residents (Resident (R)51) reviewed for Hoyer lifts. This failure to prevent an accident which resulted in R51 experiencing actual harm of a skin tear to the resident's right elbow.Findings include:Review of R51's electronic medical record (EMR) Face sheet under the Admissions tab that R51 was admitted on [DATE]. Under the EMR section titled Medical Diagnosis tab had pertinent diagnosis including spinal stenosis, lumbosacral region, Alzheimer's disease, vascular dementia with other behavioral disturbance, bipolar disorder, pain, spinal stenosis, Review of R51's quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Referent Date (ARD) of 08/13/25 with a Brief Interview for Mental Status (BIMS) score could not be conducted due to resident was rarely/never understood. Review of the MDS indicated that R51 was dependent on staff for transfers from bed to chair.Review of R51's Care Plans under the Care Plan tab in the EMR revealed an ADL self-care performance deficit r/t [related to] Dementia.is totally dependent on one staff to provide shower. and was dependent on Hoyer lift x2 [with two people assist] .Review of R51's Physician Orders dated 08/06/24 in the EMR under the Physician Orders tab revealed, Transfer: Hoyer lift.Review of R51's EMR review under the tab titled Progress Notes revealed a Health Status Note dated 08/12/25 at 5:46 PM revealed, resident s/p [status post] fall, while trying to get him back from the shower bed back to his wheelchair, the Hoyer lift tip [sic] over and he was lower [sic] to the floor by the CNAs [Certified Nursing Assistants] resident [R51] had a skin tear.Review of R51's EMR Progress Notes tab indicated an Incident Note dated 08/12/25 at 7:05 PM revealed, CNA came to me and stated [R51] was on the floor in his sling. The Hoyer lift was being used with the legs widened, to put the resident in his Geri-chair. As the resident was heading to the chair, the Hoyer tipped sideways. The CNAs held the sling on each side of the resident's head, preventing him from hitting anything and resident was lowered to the floor. His L [left] elbow had a 1.0 cm x 0.1cm [centimeter] skin tear Review of R51's EMR under the Progress Notes tab indicated a Post Fall Evaluation Fall dated 08/12/2025 at 4:20 PM, Fall was witnessed. Fall occurred in the bathroom. Activity at the time of fall: transferring via Hoyer with staff assistance of two. Reason for fall: Hoyer tipped sideways. Did an injury occur as a result of the fall: Yes. Injury details: 1.0 cm x 0.1cm skin tear on R [right] elbow. Did fall result in an ER [emergency room] visit/hospitalization: No. Fall Details Note: CNA stated this resident was on the floor in his sling. The Hoyer lift was being used with the legs widened, to put the resident in his Geri-chair. As the resident was heading to the chair, the Hoyer tipped sideways. The CNAs held the sling on each side of the resident's head, preventing him from hitting anything and resident was lowered to the floor. His L [left] elbow had a 1.0cm x 0.1cm skin tear. Review of R51's EMR Physician Order under the Orders tab revealed an order dated 08/13/25 that indicated, 2- view X-RAY to rt [right] humorous, rt hand and rt forearm.The facility's investigation revealed the Hoyer tipped to the side because CNA7 pushed the lift's feet apart instead of using the button. CNA6 and CNA8 lowered him to the ground. Statements from the CNAs involved revealed the same conclusion. Review of R51'sEMR under the Progress Notes tab revealed a note titled Lab Results dated 08/13/25 at 6:05 PM revealed, [R51] lab results hand [2 views] right, no gross fracture or dislocation, humerus [minimum of 2 views] Right no acute fracture or dislocation, Forearm [2 views] Right, no fracture or dislocation. review with team health provider with no new order. During an interview on 03/12/26 at 8:49 AM, Nursing Supervisor/Registered Nurse [NS/RN] stated that R51 was dependent with ADLs, used a Hoyer lift with two people assist to transfer. NS/RN stated that anyone who uses a Hoyer Lift or a sit to stand lift needed to have two people to operate the lift safely. The incident was two CNAs [CNA6 and CNA8] that lowered [R51] in the bathroom, to the floor and he had an elbow injury. The two CNAs who were involved had Hoyer lift reeducation. We evaluated their competencies and those two people had extra reeducation. They were agency staff who are still working with us but not working today. [R51] uses a recliner Geri chair.During an interview with CNA6 on 03/12/26 at 10:35 AM, showed the Joerns Hoyer Advanced 340 and stated it is less steady and the one they had an accident with. This lift the CNA had to manually push a foot pedal to open the legs. It is stored in the shower room and rarely used.During an interview on 03/12/26 at 1:56 PM, NS/RN stated, [R51] was using the manual mechanical lift at the time. We educated the staff as an intervention. There was no change in lift use. It was a witnessed fall. Staff were educated using mechanical lift. The CNAs observed the Hoyer tilting and lowered him to the floor. The straps were maybe more to one side than the other.During an interview on 03/12/26 at 2:11 PM, the Director of Nursing (DON) stated, I was doing my rounds and found out [R51] was having pain in his right arm because he fell out of the lift. He was getting a shower and when they were putting him back into the chair is when he fell. The CNAs were using the electric Hoyer lift. The two CNAs [CNA6 andCNA8] and [CNA7] were operating the machine. [CNA7] was on light duty and was not supposed to be using the Hoyer lift. [CNA7] was trying to get the legs open, and it did not open. She was trying to pull the legs out and it started tipping to the side. The other two CNAs [CNA6 and CNA8] lowered him to the floor so he would not have too much injury. He was grimacing and making a moaning noise for his right elbow movement. The facility did x-rays and they showed no broken bones. [CNA7] was not supposed to be using the lift anyway. Maintenance and the DON looked at it and there were no problems with the Hoyer lift. She [CNA7] no longer works here after this incident. We did competencies with all the staff, and they were able to demonstrate proper use of the Hoyer Lift.Review of the facility's undated document titled, Delaware Veterans Home Hoyer Lift Competency provided by the Administrator revealed that an evaluator would mark either pass or fail with a space for follow up needed. The Administrator stated that the facility had no specific policy and procedure for Hoyer Lifts, just this Competency document. The Procedure indicated, .Ensure two staff members are present when using the lift. 8. Position Hoyer Advance lift with legs open as far under the bed as possible (keep brakes off). Lower cradle to allow sling to be attached. 9. Attach both sides of the sling to their respective side of the cradle. Short straps at top, long straps at bottom to facilitate sitting position. 10. Utilizing the handheld control or the control panel, lift resident up until buttock is above mattress. Grasp residents' legs and turn so legs are off the bed. 11. Roll Hoyer Advance away from the bed. Position resident over desired location (chair, wheelchair). 12. Lower resident into place.

Based on observation, record review, and interview, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and failed to obtain consents for three of eight residents (Resident (R)19, R24, and R37) reviewed for accident hazards out of a total sample of 23 residents. Additionally, R24's first bed rail assessment indicated the resident did not need bed rails; however, bed rails were on the bed. Failure to assess and determine hazards could lead to injury, entrapment, or death. Findings include:1. Review of R19's Face Sheet located in the electronic medical record (EMR) and under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset and dementia (severe) with behavioral disturbances.Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/25 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. During an observation on 03/10/26 at 3:30 PM R19 was observed in bed with 1/4 side rails in the up position on both sides of his bed. There was no evidence in R19's EMR of any assessment of the side rails, any risks or benefits provided, or any consent signed by the resident's representative. During an interview and observation on 03/11/26 at 12:50 PM, Registered Nurse (RN)1 was completing a treatment to the resident's wound. She turned him to his left side, and the resident was unable to grab the side rail. She indicated he was not able to use the side rails that were in the up position for mobility or to hold on to during care. She revealed he has never been able to use the side rails or hold on to them. 2. Review of R24's Face Sheet located in the EMR under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnosis of left femur fracture. Review of R24's admission MDS with an ARD of 06/12/24 located in the EMR under the MDS tab revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Review of the quarterly MDS with and ARD of 12/10/25 located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of the Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab revealed the resident was assessed to not need to have bedrails and the resident signed the assessment stating such. The assessment indicated bed rails were not indicated at this time. Review of the Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab revealed the assessment was blank. During an observation and interview on 03/10/26 at 3:55 PM revealed R24 was in bed and 1/4 side rails in the up position on both sides of the bed. He indicated he used them for positioning. He could not remember being informed of the risks and benefits prior to his use of the side rails or when the side rails were put on his bed.3. Review of R37's Face Sheet located in the EMR under the Admissions tab revealed the resident was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis (paralysis) follow cerebral infarction (stroke) affecting left non-dominant side. Review of R37's quarterly MDS with an ARD of 01/14/26 located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact.Review of the Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab revealed the assessment was blank. During an observation and interview on 03/09/26 at 3:00 PM revealed R37 was in bed with bilateral 1/4 side rails in the up position. R37 stated that he used the side rails for positioning and mobility. He could not remember if anyone had ever went over the risks and benefits with him or when they were put on his bed. During an interview on 03/12/26 at 1:35 PM, the Administrator revealed she thought that 1/4 side rails didn't require a consent or the risks and benefit to be explained to the resident and/or representative. She confirmed there were no consents signed or any evidence R19, R24, or R37 or their representative were provided the risks and benefits for side rails being placed on their beds. She further revealed the facility did not have a policy for bed rails.

Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure two of five residents (Resident (R) 5 and R13) reviewed for pneumococcal vaccines out of a total sample of 23 residents were offered an updated pneumococcal vaccine. The facility further failed to ensure their pneumococcal policy was revised to reflect updated guidance per the CDC for the administration of pneumococcal vaccines. This had the potential for the residents to have an increased risk of contracting pneumonia. Findings include:1.Review of R5's Face Sheet located in the electronic medical record (EMR) under the Admissions tab revealed the resident was admitted to the facility on [DATE] and was over [AGE] years old.Review of R5's Immunization Record located in the EMR under the Immunizations tab revealed R5 received the pneumococcal polysaccharide vaccine (PPSV) 23 on 11/11/21. There was no evidence that the resident was offered the PCV15, PCV20, or PCV21 per recommendations of the CDC in order to be complete for the pneumococcal vaccine.2. Review of R13's Face Sheet located in the EMR under the Admissions tab revealed the resident was admitted to the facility on [DATE] and was over [AGE] years old. Review of R13's Immunization Record located in the EMR under the Immunizations tab revealed R13 received the PPSV 23 on 10/16/23. There was no evidence that the resident was offered the PCV15, PCV20, or PCV21 per recommendations of the CDC in order to be complete for the pneumococcal vaccine.During an interview on 03/12/26 at 10:15 AM, the Infection Preventionist (IP) confirmed R5 and R13 were not offered to receive either a pneumococcal conjugate vaccine (PCV) 15, PCV 20, or PCV21. The IP revealed they were unaware of the update guidance from CDC and confirmed the facility's policy was not updated to reflect the new guidance.Review of the facility policy titled, Pneumococcal Immunizations updated 04/04/24 revealed, Purpose: To reduce the risk of serious respiratory infection to facility residents by offering pneumococcal vaccine . B. A second dose is recommended for anyone over 65 who received the first dose before the age of 65 and at least 5 years have passed . E. The policy will be reviewed annually and revised according to any new recommendations by the CDC. Review of CDC guidelines located at https://cdc.gov/acip-recs/hcp/vaccine-specific/pneumococcal.html and dated 01/08/25 revealed, .Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown. Adults aged 50 years and older if a PPSV23 only was given, give a single dose of PCV21, PCV20, or PCV15 after one year after the last PPSV23 dose.

2. Review of R9's clinical record revealed: 1/16/24 - R9 was admitted to the facility. 12/18/24 6:43 PM - A nursing progress note documented that R9 had contacted 911 services due to having hallucinations. Due to the resident having a history of the behaviors, a note was left in the physician communication log and R9 had continued to be monitored. 12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collected on 12/20/24. 12/20/24 - A urine sample was collected and sent to the lab for analysis and culture. 12/20/24 - A provider note by E13 (NP) documented, . Was asked to see patient [R9] today due to complaints of intermittent hallucinations unit manager reports patient having intermittent visual hallucinations. Today's urinalysis results showed 2+protein and trace of leukocytes . Urinalysis review. Will await urine culture and sensitivity . 12/23/24 12:26 PM - The lab results revealed the urine culture was positive for a urinary tract infection with a positive growth of greater than 100,000 colony forming units of Serratia Marcescens (a type of bacteria). 12/23/24, 12/24/24 and 12/25/24 - The clinical record lacked evidence that R9's UTI was addressed. 12/26/24 1:28 PM - A progress note by E14 (RN) documented, Provider onsite and reviewed UA C&S results. New order for gentamicin 40mg/ml - administer 7 mls BID x 5 days for UTI. Probiotic to be ordered BID for 10 days. 12/26/24 1:35 PM - A physician's order was written for gentamicin sulfate (antibiotic) 40mg/mL, inject 3.5 mL in the muscle two times a day for urinary tract infection for 5 days. There was a delay of two days before the urine results were reviewed and R9 received antibiotics. 3/4/25 2:20 PM - An interview with E15 (RN) stated that if the unit manager is working, they will keep track of results for labs. Otherwise, the supervisor will be available to keep track of lab results. If a lab result is critical, the result can be called to the on-call provider if a provider is not present. 3/4/25 2:29 PM - An interview with E14 stated that lab results automatically populate in the resident's chart. E14 stated that positive results also get faxed to the facility where the fax is monitored each shift for any results. E14 stated, If there was a positive urinary culture result, we try to let the provider know immediately so the medication can be ordered for the resident since the provider does not order anything until the culture results are completed. 3. Review of R35's clinical record revealed: 8/17/22 - R35 was admitted to the facility. 4/30/24 - A physician's order for lisinopril 10 mg give one tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 100 and hold if heart rate is less than 60. 7/10/24 - The July MAR documented R35 had a blood pressure listed 120/77 and heart rate of 56 and a signature indicating lisinopril medication was administered. 7/1/24 - 7/23/24 - A pharmacist's medication regimen review documented that for R35, recommendation to the facility: [R35] is receiving lisinopril 10mg with parameters to hold is systolic blood pressure (SBP) is less than 100 or heart rate (HR) less than 60 and was the medication was given (per MAR). 9/20/24 - A physician's order for lisinopril 10 mg give 0.5 tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 100 and hold if heart rate is less than 60. 12/27/24 - The December MAR documented R35 had a blood pressure listed 114/75 and heart rate of 55 and a signature indicating lisinopril medication was administered. 1/1/25 - 1/13/25 - A pharmacist's medication regimen review documented that for R35, recommendation to the facility: [R35] is receiving lisinopril 10mg with parameters to hold is systolic blood pressure (SBP) is less than 100 or heart rate (HR) less than 60 and was the medication was given (per MAR). 3/6/25 10:30 AM - An interview with E18 (RN) confirmed that if a resident has vitals outside the parameters medication should be held and notification to the provider if an ongoing pattern. E18 confirmed that R35 received the lisinopril on 12/27/24 per the MAR. 4. Review of R41's clinical record revealed: 3/3/22 - R41 was admitted to the facility. 12/4/24 - A physician's order for cozaar 25 mg give 50 mg tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 120. 12/5/24- The December MAR documented R41 had a blood pressure of 119/68 and a signature indicating cozaar medication was administered. 12/9/24 - The December MAR documented R41 had a blood pressure of 110/70 and a signature indicating cozaar medication was administered. 12/14/24 - The December MAR documented R41 had a blood pressure of 112/76 and a signature indicating cozaar medication was administered. 12/15/24 - The December MAR documented R41 had a blood pressure of 116/83 and a signature indicating cozaar medication was administered. 12/1/24 - 12/19/24 - A pharmacist's medication regimen review documented that for R41, the pharmacist recommendation to the facility: [R41] is receiving cozaar with parameters to hold is systolic blood pressure (SBP) is less than 120. On 12/5, 12/9, 12/14, and 12/15 SBP was less than 120 and the medication was given (per MAR). 3/6/25 10:30 AM - An interview with E18 (RN) confirmed that if a resident has vitals outside the parameters medication should be held and notification to the provider if an ongoing pattern. E18 confirmed that R41 received the lisinopril on the aforementioned dates per the MAR. 3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON). Based on record review and interview, it was determined that for four (R422, R9, R35 and R41) out of four residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. For R422 the facility failed to provide treatment for a urinary tract infection for four days causing a change in condition that required a transfer to the hospital. This delay in care resulted in harm to R422. For R9, the facility failed to provide treatment for a urinary tract infection for two days. For R35 and R41, the facility failed to follow a doctor's order. Findings include: Cross Refer F773 1. Review of R422's clinical record revealed: 5/23/24 - R422 was admitted to the facility with a history of a stroke affecting his right dominant side, Parkinson's disease and dementia. 6/13/24 - A nursing progress note documented that E16 (MD) was notified that R422 was getting confused, disoriented and drowsy. 6/13/24 - A physician's order was written by E16 for a urinalysis and urine culture. 6/14/24 - A nursing progress note documented the urine sample was collected and sent to the lab for analysis and culture. 6/16/24 - A review of the lab results revealed a urine culture with a positive growth of enterococcus casseliflavous greater than 100,000 CFU /ml, indicating R422 had a urinary tract infection. 6/16/24 - The clinical record lacked evidence that R422's positive urine culture was treated. 6/17/24 and 6/18/24 - The clinical record lacked evidence that the UTI was being addressed. 6/19/25 3:30 PM - A change in condition evaluation performed by E23 (RN) documented, resident noted with increasing lethargy, altered mental status .increased lethargy. 6/19/24 4:50 PM - A physician progress note documented a change in condition: altered level of copiousness, increased confusion, disorientation, altered mental status .with increased lethargy, send patient to the ER (emergency room) for further evaluation and possible admission. 6/19/24 6:32 PM - Hospital records documented R422 was admitted with altered mental status. A urinalysis was positive for a large number of leucocytes and many bacteria. Awaiting urine culture and sensitivity. R422 was immediately treated with IV antibiotics. 7/13/24 10:18 AM - Hospital records documented that R422 was treated for encephalopathy likely in the setting of a UTI. Upon admission, all tests performed ruled out a stroke and the principal diagnosis was a UTI. 7/8/24 - R422 was discharged from the hospital and chose not to return to the facility. 3/5/25 10:50 AM - During an interview, E2 (DON) stated that lab results are faxed to the nurse supervisor's office. If a lab result is critical and requires immediate attention, the nurse supervisor or the nurse who is assigned to the resident will call the on-call provider, if the provider is not present. 3/6/25 9:25 AM - During an interview, E16 confirmed that she was unaware of the critical lab value for R422 E16 stated that her NP would have been on-call that weekend. In addition, E16 confirmed there were no progress notes and no antibiotic orders for R422. E16 also confirmed she ordered the urine analysis and culture, but did not follow up on the results. 3/6/25 9:48 AM - During an interview via telephone E13 (NP) confirmed that she was not notified of R422's positive urinary tract infection results.

Based on record review and interview, it was determined that for five (R1, R11, R64 and R66) out of nineteen sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include: 1. 2/11/08 - R1 was admitted to the facility. 1/15/25 - A quarterly MDS was completed. 1/28/25 - A quarterly care plan meeting note lacked evidence of input from the physician. 10/16/24 - A quarterly MDS was completed. 10/29/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 7/17/24 - An annual MDS was completed. 7/30/24 - An annual care plan meeting note lacked evidence of input from the physician. 2. 6/11/24 - R11 was admitted to the facility. 6/17/24 - An admission MDS was completed. 7/9/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 9/11/24 - A quarterly MDS was completed. 9/24/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 12/11/24 - A quarterly MDS was completed. 12/26/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 3. 6/6/24 - R64 was admitted to the facility. 6/12/24 - An admission MDS was completed. 9/11/24 - A significant change MDS was completed. 9/24/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 12/11/24 - A quarterly MDS was completed. 12/26/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 4. 8/1/24 - R66 was admitted to the facility. 8/7/24 - An admissions MDS was completed. 11/16/24 - A significant change MDS was completed. 11/19/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 2/5/25 - A significant change MDS was completed. 2/18/25 - A quarterly care plan meeting note lacked evidence of input from the physician. 3/5/25 1:20 PM - In an interview, E2 (DON) stated that while the charting system does not reflect that providers have direct input in the care plan meetings, all residents are seen and assessed by them on a consistent basis. E2 stated that he will ensure that the process is revised to include input from the provider specifically at the time of the care plan meeting. 3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R47) out of two residents reviewed for hospitalization, the facility lacked evidence that R47 was allowed to return timely to the facility. 11/26/24 - R47 was admitted to the facility. 12/6/24 - R47 was admitted to the hospital for altered mental status and for a psychiatric evaluation. The admission history and physical also reflected that R47 had recently been diagnosed with a urinary tract infection. 12/8/24 - A hospital progress note revealed Barriers: Patient is medically cleared for discharge. VA home is not taking patient on weekends . 12/9/24 - A discharge summary revealed that His mental status has improved, he has been pleasantly confused during the hospital stay, which appears to be his baseline. He is medically stable for discharge. 12/10/24 - A daily medical progress report revealed Barriers to discharge: medically cleared. Discharge disposition: placement issues. 12/12/24 - A daily progress report revealed Disposition hospital issue: Patient was already discharged by prior provider, but VA home refused to take him. They think he needs to go to inpatient psych or memory unit . If they think he needs to go to memory unit then he can go back to the same VA then they can start the process. Psych recommended no need for inpatient psych. 12/13/24 - R47's discharge instructions revealed Disposition hospital issue: Patient was already discharged by prior provider, but VA home refused to take him. They think he needs to go to inpatient psych or memory unit . If they think he needs to go to memory unit then he can go back to the same VA then they can start the process. Psych recommended no need for inpatient psych. 12/13/24 - R47 returned to the facility. 3/5/25 1:20 PM - In an interview, E2 stated that the facility wanted to send R47 to a specific behavioral health facility, but R47 was declined due to needing assistance with activities of daily living. E2 stated that the facility would not have refused R47 re-entry back to the facility but acknowledged that there concerns about the safety of the resident and staff due to his behaviors. E2 further stated that residents can return on the weekend although they prefer that they return during the week because leadership is also in the facility. E2 stated they would not refuse a resident to return. 3/6/25 12:33 PM - In an interview, E1 (NHA) and E2 stated they were not aware of any reason that R47 should not have returned to the facility on [DATE], which was a Monday. Both noted that they do not refuse weekend readmissions. 3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.

Based on interviews and record review, it was determined that for one (R4) out of three residents reviewed for accidents, the facility failed to implement the correct assistant device to transfer the resident to prevent accidents. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 12/20/24. Findings include: Review of R4's clinical record revealed: 7/11/23 - R4 was admitted to the facility. 11/20/23 - A new diagnoses for R4 included, but was not limited to, peripheral autonomic neuropathy, lack of coordination, generalized muscle weakness and unsteadiness on the feet. 10/16/24 - A care plan documented that R4 was high risk for falls related to impaired gait/balance. 11/15/24 - A new order documented R4 was a total assist for transfer and to be transferred with two staff using a Hoyer lift. 12/4/24 - R4's annual MDS documented a BIMS score of 15, revealing an intact cognitive state. R4 was documented with impairments on both sides for upper and lower extremities and was dependent on staff for transferring. 12/14/24 12:35 AM - A facility progress note by E6 (RN) documented, Resident in shower room getting ready for a shower. When lowering resident into shower chair resident started to sit himself down, even after staff (CNA and RN) repeatedly told him not to sit yet. Resident started slipping out of sling and he was gradually lowered to the ground. once resident was sitting on the ground, we repositioned the sling and was able to hoyer lift him into the chair. Resident had no c/o pain during or after the entire process. Resident and RN report no injuries . 12/16/24 10:46 AM - A facility incident report revealed that R4 had a witnessed fall while being transferred using a sit-to-stand transfer and the resident was a Hoyer lift for transferring. R4 slipped out of the sling and was lowered to the floor by the staff where no harm occurred to the resident. 3/4/25 9:53 AM - During an interview E6 stated that E7 (CNA) and her, were transferring R4 to a shower chair using the sit-to-stand transfer. E6 stated that R4 was already in a sling for a sit-to-stand transfer when she came to assist and did not stop to check if that was the correct mode of transfer for R4. When R4 was being lifted in the sit-to stand method, R4 was trying to sit and could not get his legs back up. E6 stated that they lowered him to the floor and assessed him and he had no injuries. 3/4/25 10:47 AM - During an interview E7 stated that they used a sit-to stand transfer of R4 to the shower chair. When R4 was lifted, he began to wiggle and then he was lowered to the floor. E7 stated R4 was supposed to be a Hoyer lift transfer and R4 did not have any injuries after the incident. 3/5/25 9:32 AM - During an interview E8 (DOT) stated R4 was changed from a sit-to-stand transfer to a Hoyer lift because R4's participation would not allow him to do the sit-to-stand safely. E8 stated that R4 would not hold on and let go during the sit-to-stand causing him to be a safety risk. 3/6/25 9:05 AM - During an interview E9 (ADON) stated that after the incident re-education was completed that included: lift and transfer competencies, chain of command notification for resident refusals, how to access the transfer status of residents, how to access the Kardex for transfer status of residents, the appropriateness of providing more assistance. The facility audited the evaluations on the Hoyer lift for the residents. In addition, on-going audits are reviewed weekly. The facility created a subcommittee for falls where they are planning to implement additional appropriate signage such as stars for residents at risk. Based on the review of the facility's thorough investigation, documented response, completion of in-service training and audits, staff interviews and no further incidents related to injuries using a Hoyer lift, R4's accident was determined to be past non-compliance. The plan of correction was initiated on 12/14/24 and completed on 12/20/24. 3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

2. Review of R9's clinical record revealed: 1/16/24 - R9 was admitted to the facility. 12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collected on 12/20/24. 12/20/24 - A urine sample was collected and sent to the lab for analysis and culture. 12/23/24 12:26 PM - The lab results revealed the urine culture was positive for a urinary tract infection with a positive growth of greater than 100,000 colony forming units of Serratia Marcescens (a type of bacteria). 12/26/24 1:28 PM - A progress note by E14 (RN) documented, Provider onsite and reviewed UAC&S results. New order for gentamicin (antibiotic) 40mg/ml - administer 7 mls BID x 5 days for UTI. Probiotic to be ordered BID for 10 days. There was a delay of two days before the provider was notified and reviewed the urine results. 3/4/25 2:20 PM - An interview with E15 (RN) stated that if the unit manager is working, they will keep track of results for labs. Otherwise, the supervisor will be available to keep track of lab results. If a lab result is critical, the result can be called to the on-call provider if a provider is not present. 3/4/25 2:29 PM - An interview with E14 stated that lab results automatically populate in the resident's chart. E14 stated that positive results also get faxed to the facility where the fax is monitored each shift for any results. E14 stated, If there was a positive urinary culture result, we try to let the provider know immediately so the medication can be ordered for the resident since the provider does not order anything until the culture results are completed. 3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2. Based on record review and interview, it was determined, for two (R442 and R9) out of three residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results. Findings include: Cross refer F684 1. Review of R422's clinical record revealed: 5/23/24 - R422 was admitted to the facility with diagnoses that included Parkinson's disease, history of a stroke affecting the right dominent side and dementia. 6/13/24 - A physician's order was written for a urinalysis with a culture and sensitivity. 6/16/24 - The results were faxed to the facility supervisor's office which revealed R422's urine culture had a positive growth of enterococcus casseliflavous (a type of bacteria) greater than 100,000 cfu/ml, indicating a urinary tract infection. 3/5/25 - A review of R422's clinical record revealed lacked evidence of the laboratory results and notification of provider. 3/5/25 10:34 AM - During an interview, E2 (DON) stated that all lab results are faxed to the nurse supervisor's office. If a lab result is positive the supervisor or the nurse assigned to the resident notifies the on-call provider if a provider is not present. 3/6/25 9:25 AM - During an interview, E16 (MD) confirmed that there was no evidence of provider notification, progress notes. E16 confirmed the lab results were positive and she was not notified.

35693 36246 39540 Based on interview, record review, and policy review, the facility failed to ensure resident, and resident's representatives were notified at time of discharge of the location and reason for the discharge for a sample of four of four residents (Resident (R)13, R19. R12 and R39) reviewed for hospitalization . As a result of this deficient practice, residents had the potential for location of residents not known to families or resident representatives. Findings include: 1. Review of R13's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] and readmission on 12/21/23 with medical diagnoses that included chronic obstructive pulmonary disease and adult failure to thrive. Review of R13's Significant Change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R13 was severely cognitively impaired. Review of the Misc tab in the EMR revealed a bed hold agreements dated 12/02/23 and 12/17/23 as date of transfer and lacked information about the reason or destination of the transfer of the resident. Review of the Progress Notes tab in the EMR documented Social Services entry on 12/04/23 and 12/18/23 revealed Note Text: Bed hold notice to Ombudsman/MCO/Family/POA [Power of Attorney] and lacked documentation of where the resident was transferred to or why transfer was needed, 2. Review of R19's undated Admission Record, located in the Profile tab of the EMR revealed R19 was initially admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stage 3, diabetes mellitus, essential hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of a quarterly MDS located in the EMR under the MDS tab, with an ARD of 01/21/24 indicated R19 had a BIMS score of 10 out of 15 which indicated R19 was moderately cognitively impaired. Review of a document titled DVH Bed Hold Notice at Time of Transfer dated 03/06/24, located in the EMR under the Misc tab, revealed R19's representative received a bed hold notice upon R19's transfer. The document did not indicate where R19 was transferred too. Review of R19's Social Services progress notes located in the EMR under the Progress Notes tab, dated 03/05/24 indicated social services had sent a bed hold notice to R19's power of attorney (POA). Review of a Social Services progress note dated 03/06/24 indicated the facility had received a signed bed hold notice from R19's POA. Neither note indicated the POA had received written notice of the location of R19's transfer. Review of a document titled DVH Bed Hold Notice at Time of Transfer dated 04/23/24, located in the EMR under the Misc tab, revealed R19's representative received a bed hold notice upon R19's transfer. The document did not reveal where R19 was transferred too. Review of R19's Social Services progress notes located in the EMR under the Progress Notes tab, dated 04/23/24 indicated social services had sent a bed hold notice to R19's POA. The note did not indicate the POA had received written notice of the location of R19's transfer. 3. Review of R12's Admission Record, located in the EMR under the Profile tab revealed R12 was initially admitted on [DATE] and most recently readmitted on [DATE] with diagnoses that included chronic atrial fibrillation, asthma, atherosclerotic heart disease of natural coronary artery without angina pectoris, and retention of urine. Review of the quarterly MDS with an ARD of 02/27/24 revealed a BIMS score of nine out of 15 indicating R12 was moderately cognitively impaired. Review of the Census located in the EMR under the Clinical tab revealed R12 was hospitalized from 11/30/23 to 12/13/23. Review of the Progress Notes located in the EMR under the Clinical tab revealed no written evidence a Bed Hold notification with the location or reason for the transfer/discharge was provided to the resident and resident's representative for the two identified hospitalization s. 4. Review of the Admission Record, found in R39's EMR under the Profile tab indicated R39 was admitted on [DATE]. The Admission Record indicated diagnoses included Alzheimer's disease, depression, restlessness and agitation, and bipolar disorder. Review of the MDS with an ARD of 11/09/23, found in R39's EMR under the MDS tab indicated R39's BIMS score was four out of 15, indicating a severe cognitive deficit. Review of the Health Status Note, found in R39's EMR under the Progress Notes tab, dated 01/23/24 at 4:06 AM indicated R39 was seen physically aggressing another resident while that resident was in bed asleep. The Health Status Note indicated R39 was discovered kneeling on the other resident's bed with one knee while his hands were around the other resident's crossed wrists, pressing against the chest of the other resident. Review of R39's Health Status Note, found in the EMR under the Progress Notes tab, dated 01/26/24 at 3:04 PM indicated R39 left the facility, accompanied by a unit manager, and was transported to Meadowood (an inpatient psychiatric facility). Review of R39'sSocial Service note found in EMR under the Progress Notes tab, dated 01/29/24 at 3:00 PM indicated the Bed-hold Notice at Time of Transfer was sent to the Responsible Party. Review of R39'sBed-Hold Notice at Time of Transfer, found in the EMR, under the Misc tab dated 01/26/24, indicated the Bed-Hold Notice at Time of Transfer, did not include the name of the facility that he was being transferred to and did not include in writing the reason for the transfer/discharge. During an interview on 04/24/24 at 2:26 PM, the Social Work Consultant (SW2) explained the process was to notify family or resident representative within 24 hours with the bed hold information. A note was made in the EMR progress note to indicate the notification was made and the bed hold information was mailed out. During an interview on 04/25/24 at 10:44 AM, the Administrator confirmed the bed hold information sent out to the resident or resident's representatives lacked information about the reason or location where the resident was discharged to and confirmed the information was missing on the form sent to the resident or resident's representative. Review of the facility policy titled Bed Hold Policy dated 01/04/24 revealed, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. When a Transfer/Discharge policy was requested, the Bed Hold Policy was provided and lacked information about the reason or location of the transfer of the resident to be provided to the family or resident representative.

Based on observation, interviews, record review, policy and procedure review, the facility failed to follow infection control procedures during a dressing change for one of three residents (R)4 reviewed. Specifically, the Registered Nurse (RN)1 failed to clean the over the bed table or place a barrier on the table before placing clean wound supplies on the table. Also, RN1 failed to perform hand hygiene when she returned to the room after obtaining a dressing from the treatment cart. The failure created the potential for an infection to develop in R4's wounds. Findings include: Review of the facility's policy titled Skin Integrity/Wound Care dated 03/08/23, revealed .A resident with skin impairment will receive treatment and services, consistent with professional standards of practice, to promote healing . Review of the facility's procedure titled Wound Treatment Competency Audit provided by the Administrator on 04/25/24 revealed the following criteria for all nurses to utilize .7. Assembles necessary equipment &[and] places on clean, accessible surface 8. Places date, time, and initials on dressing. 9. Hand hygiene performed prior to and after the treatment of each wound . 10. Puts on gloves . 12. Soiled dressing gently removed & placed in a small waste bag. 13. Removes gloves and places in trash receptacle 14. Hand hygiene I 5. Prepares dressing, without contamination 16. Hand hygiene, put on clean gloves and cleanse site 17. Applies treatment as ordered .21. Hand hygiene prior to returning equipment to cart .STEPS MUST BE FOLLOWED FOR THE TREATMENT OF EACH WOUND Review of R4's Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R4 was admitted on [DATE] with diagnoses that included chronic atrial fibrillation, unspecified cardiovascular and coagulations; post-traumatic stress disorder, chronic; idiopathic progressive neuropathy, and acute neurologic. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of (ARD) of 04/03/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R4 was unable to participate in the assessment due to severe cognitive impairment. Review of the Progress Notes located in the EMR under the Clinical tab revealed R4 was identified to have two open areas on 04/16/23 which indicated, Nurse notified by aid in reference to two open areas noted behind resident's left knee with measurements of 5.5 centimeters (cm) x 1.3 cm and 1.0 cm x 1.0 cm . Review of the Physician's Orders dated 04/18/24, located under the Clinical tab in the EMR, revealed a treatment order for wound care left posterior knee: cleanse with Normal Saline Solution (NSS), pat dry. Apply calcium alginate and cover with .dry dressing as needed. On 04/24/24 at 9:13 AM, RN1 was observed to perform R4's dressing change to the left posterior knee. RN1 obtained the required materials from the treatment cart and proceeded to R4's room. RN1 placed the items on an overbed table and performed hand hygiene. RN1 did not clean the table or place a clean covering over the table before placing the items on the table. RN1 performed hand hygiene, donned gloves and removed the dressing from the resident's left posterior knee. RN1 doffed the gloves, donned clean gloves and cleaned the wounds with a sterile saline wipe. RN1 dropped the calcium alginate dressing in the trash, left the room to retrieve another calcium alginate from the treatment cart located down the hall from R4's room. RN1 returned to R4's room, without performing hand hygiene donned a new pair of gloves, placed the calcium alginate on the left posterior knee and then a dry dressing. During an interview with RN1 and Unit Manager (UM2) on 04/24/24 at 10:35 AM, RN1 confirmed that she did not perform hand hygiene when she returned to the room after obtaining a calcium alginate from the treatment cart before donning a clean pair of gloves. RN1 confirmed that she did not date the dressing per facility protocol. UM2 stated, the expectation would be to clean the overbed table and wash hands again when returning to the room. In an interview on 04/25/24 at 10:28 AM, the Administrator stated, I retrained everyone on handwashing on 04/24/24 and I personally retrained RN1 on wound care criteria as well.

Based on interview, record review, and policy review, the facility failed to protect two of three residents (Resident (R) 51, R63), reviewed for abuse, when facility nursing staff, a Certified Nurse Aide (CNA)4 used profanity toward R51 during care. In addition, when R39 sat on R63's bed and pushed down on R63's chest with his hands. Failure to protect residents from abuse has the potential to result in injury to residents. Findings include: 1. Review of R51'sAdmission Record located in electronic medical record (EMR) under the Profile tab indicated R51 was admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity with agitation, and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/23, found in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating a severe cognitive deficit. Review of the Investigation File, dated 01/19/24 indicated a written statement by Assistant Director of Nurses (ADON) 1 indicated he was informed that CNA2 witnessed CNA4, during resident care, using profanity toward R51. The statement indicated CNA4 was removed from the unit, asked to write a statement, questioned by ADON1, suspended, and terminated following investigation of the incident. Further review of the Investigation File indicated a Root Cause Analysis indicated the following: at approximately 6:00 AM on 01/19/24, staff (CNA2) witnessed another staff (CNA4) make inappropriate verbal remarks towards a resident (R51) during care. CNA4 stated that she became frustrated with the resident who was not being compliant with care and admitted that her tone was firm, and she may have used profanity words under her breath. CNA2, who came in to assist with care, overheard CNA4 using words of profanity toward R51. Review of CNA2's written statement indicated that while she was helping CNA4 provide care to R51 on 01/19/24, CNA4 was becoming verbally aggressive to him. The statement indicated CNA told R51 he was pissing her off. CNA2 said CNA4 wanted R51 to hold onto the sit to stand device, R51 was not being cooperative, and CNA4 told R51 to hold onto the fucking thing. CNA2 said CNA4 said, within earshot of R51. that he was fucking annoying her. During an interview, by telephone, with CNA2 on 04/24/24 at 7:47 PM, CNA2 said she witnessed CNA4 using foul language with R51. She said they were providing care, and he was not being cooperative, and CNA4 got frustrated with him. CNA2 said CNA4 was using the words fuck and fucking toward R51. During an interview, by telephone, with CNA4 on 04/25/24 at 2:19 PM, she said she was assigned to R51's unit that evening and was already mad because she had been floating and working different units all the time. She said she was providing care to R51 and providing peri care. She said he kept trying to pull up his pants before she was done, and she said she might have gotten loud because he was not hearing her but denied using profanity or being able to recall using profanity. She said she was accused of using profanity towards R51. She said she was removed from the unit and facility and has not been back. Review of CNA4's Personnel File indicated she received training on Abuse, Neglect and Exploitation on 09/12/23, and Dementia Care with the Hand in Hand program on 09/13/23. During an interview, by telephone on 04/25/24 at 10:04 AM, Registered Nurse (RN) 4 said she did not recall anyone reporting this incident of abuse to her because she would have reported it to ADON1. She said CNA2 did tell her that CNA4 was not applying R51's ted stockings so she told her R51 needed to have them, it was ordered so it must be done. RN4 said CNA2 told her that CNA4 told R51 you are making it hard for me to turn you or something, and had exhibited an attitude in general that night. During an interview on 04/25/24 at 9:39 AM, ADON1 said CNA2 reported that CNA4 became frustrated while providing care to R51 and used profanity toward R51. ADON1 said he interviewed staff that were on duty, removed CNA4 from the unit, asked her to write a statement, placed her on administrative leave and had her leave the facility. He said the abuse was substantiated and CNA4 was terminated. He said all staff were re-trained related to abuse. ADON1 said R51 exhibited no behavior changes and did not recall the incident. Review of the Social Worker (SW)3's statement dated 01/19/24 indicated she spoke with R51 and when asked how his day was going, R51 stated it was going great because he had been able to sleep late. The statement indicated that when asked if anything unusual happened, R51 said no, and denied anyone yelling at him or speaking to him in a mean way. The statement indicated R51 did not appear upset. 2. Review of R39's Admission Record in the EMR under the Profile tab indicated R39 was admitted on [DATE] with diagnoses including Alzheimer's early onset, restlessness and agitation, major depressive disorder, and bipolar disorder. Review of R39's quarterly MDS with an ARD of 11/09/23 in the EMR under the MDS tab indicated a BIMS score was four out of 15, indicating a severe cognitive deficit. Review of R39's Care Plans in the EMR under the Care Plan tab indicated care plans in place at the time of the incident included R39's behaviors: aggressiveness, towards others, hallucinations, delusions, easily agitated, tearful episodes, purposeful intentions of sitting self on the floor related to dementia included the following intervention: when resident becomes agitated with staff and other residents encourage resident to go for a walk off the unit. Review of R63'sAdmission Record in R63's EMR under the Profile tab indicated R63 was admitted on [DATE] with diagnoses including anxiety, neurocognitive disorder with Lewy bodies, and post-traumatic stress disorder (PTSD). Review of the admission MDS with an ARD of 11/28/23 in the EMR under the MDS tab indicated the BIMS score was a six out of 15 indicating a severe cognitive deficit. Review of R39's Health Status Note, dated 01/23/2024 at 4:06 AM in the EMR under the Progress Note tab indicated staff heard a commotion and found R39 kneeling on R63's bed with one knee while his hands were around R63's crossed wrists, pressing against R63's chest. The Health Status Note indicated R63 remained lying in bed as if in shock, unable to defend himself. Staff removed R39 from the area and re-directed him. During an interview on 04/24/24 at 4:34 PM, the Unit Manager (UM) 1 stated that R39 has periods when he is up at night, and it was not unusual for him to be in the hallway where R63's room was located. During an interview on 04/25/24 at 9:41 AM, the ADON1 said R39 thought that it was his room and R63 was in his bed. ADON1 said R63 did not realize what was going on and R39 was removed and easily re-directed. ADON1 said R39 was placed on 1:1 supervision and transferred to an inpatient psychiatric facility on 01/26/24. The Investigation File indicated that when R39 was asked what he was doing, he stated that R63 was in his bed. Review of the facility's policy titled Abuse and Neglect dated 12/03/20 and recently revised on 04/04/24 indicated incidents of abuse will be investigated, reported, facility staff will be educated and trained, and incidents could be cause for immediate termination.

Based on observation and record review it was determined that for two residents (R19 and R49) out of two residents reviewed for accommodation of needs, the facility failed to ensure that the residents' call device were within reach. Findings include: 1. Review of R39's clinical record revealed: 3/21/23 - An annual MDS reflected R39 was totally dependent on staff for performance of ADL's, except for bed mobility that required extensive assistance. 4/21/23 8:54 AM - An observation of R39 in their room after returning from breakfast. R39 was seated in the wheelchair and the call device was on the nightstand and not within reach. 47114 2. Review of R19's clinical record revealed: 3/21/23 - R19's Quarterly MDS Assessment documented R19 required extensive assist of two for bed mobility and had an impairment to one side of the upper and lower body. 4/19/23 12:54 PM - During an initial observation and interview, R19 was observed lying in bed and the call device was on the far-right side of the nightstand next to the bed. R19 revealed he had weakness from a stroke and could not reach the call bell. The facility failed to place the call light within reach for a resident who required extensive assist for ADL's (Activities for Daily Living). 4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).

Based on record review and interview, it was determined that for one (R56) out of four residents reviewed for activities of daily living (ADL's), the facility failed to complete a significant change MDS (Minimum Data Set) assessment when R56 had a significant decline in functional and mental status. Findings include: Review of R56's clinical record revealed: 10/26/22 - R56 was admitted to the facility with dementia. 11/1/22 - R56's admission MDS documented that R56 required supervision of one staff member for bed mobility, transfers, eating, ambulation (walking) and required limited assist of two staff members for toileting. R56's BIMS (Brief Interview for Mental Status) assessment documented three out of fifteen correct answers during the interview. 1/31/23 - R56's quarterly MDS documented that R56 required extensive assistance of two staff members for bed mobility, transfers and toileting, supervision of one staff member for eating, and was non-ambulatory (unable to walk). R56's was not able to complete the BIMS interview due to a decline in his cognition. R56 required a significant increase of staff assistance for his ADL's related to a decline in functional and mental status since his 11/1/22 admission assessment. 4/25/23 12:10 PM - During an interview, E7 (RNAC) confirmed that a significant change in status MDS assessment should have been completed 1/31/23 related to R56's decline in functional and mental status. 4/25/23 12:21 PM - During an interview, E1 (Interim DON) confirmed that a significant change MDS assessment should have been completed. 4/25/23 at 1:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (Interim DON).

Based on observation, record review and interview, it was determined that for one (R44) out of one resident reviewed for dental, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R44's missing teeth. Findings include: Review of R44's clinical record revealed: 9/21/22 - R44 admitted to facility. 2/28/23 - A significant change MDS assessment documented that R44 had no broken or loosely fitting full or partial denture. 4/19/23 10:11 AM - During a random observation R44 had missing upper, front teeth. 4/21/23 10:03 AM - During an interview, E5 (RN, unit manager) stated they (the facility) knew about the resident's missing partial denture plate since his admission. In addition, E5 confirmed that the oral assessment section for R44's MDS was a mistake. 4/25/23 at 1:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required trainings on abuse, neglect and exploitation were completed as required for one (E8) out of ten randomly sampled staff members. Findings include: Review of the facility submitted staff training records revealed: 11/8/20 - E8 (CNA) began working at the facility. E8 had no documented date of completion of abuse training. 4/24/23 12:25 PM - During an interview, E1 (NHA) confirmed the findings. 4/25/23 1:15 PM- Findings were reviewed during the Exit Conference with E1 (NHA), and E2 (Interim DON).

Based on interview and record review it was determined that for one (R31) out of five residents reviewed for unnecessary medications the facility failed to provide evidence that the attending physician reviewed irregularities/recommendations documented on the monthly Medication Regimen Review (MRR). Findings include: The facility policy for MRR last updated 1/2023, indicated that, all recommendations shall be acted upon within 30 calendar days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the residents medical record. Review of R31's clinical record revealed: 6/14/22 - The MRR documented the following recommendation in a pharmacy consultant note, to the physician. This resident has been taking an antidepressant at a dosage of 150 milligrams daily. Please evaluate the current dose and consider a dose reduction. The signature line for the attending physician acknowledgement was blank, and the clinical record lacked evidence that R31's attending physician reviewed the recommendation. 4/24/23 11:15 AM - During an interview, E2 (Interim DON) confirmed the facility lacked evidence that R31's attending physician reviewed/responded to the 6/14/22 MRR. E2 did provide an order of a dose reduction for R31's antidepressant medication written by the facility's psychiatric NP dated 6/30/22. 4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).

Based on clinical record review, interviews and review of facility documentation, it was determined that for 1 (R79) out of 32 Stage 2 sampled residents, the facility failed to ensure that R79 received adequate supervision and functional assistive devices to prevent accidents. On 10/24/16 at 10:30 PM, R79 sustained harm when he fell from an unlocked bed, was found on his bedroom floor and sent to the ER for evaluation and treatment of [REDACTED]. On 10/30/16 at 7:50 PM, R79 had an unwitnessed fall from his wheelchair hitting the left side of his head against the centralized nurse's station desk resulting in a headache that was unresolved by pain medication. On 10/31/16 at 8:15 AM, R79 was found on the floor in the centralized nurse's station area, sent to the ER for evaluation and was found to have a bleed inside his brain and 2 skin tears on his left arm. Including and following the 10/24/16 fall the facility failed to implement the current interventions and failed to evaluate for new approaches to ensure adequate supervision and functional assistive devices. Findings include: Review of the facility's policies, R79's clinical record and facility documents revealed: The facility's policy entitled, Fall Prevention/Intervention Program, last reviewed on 3/19/15, stated, .fall prevention program will: 1. Identify (assess) those residents at risk for falls, 2. Generate a plan of action which tries to prevent/reduce falls, 3. Implement preventive measures, and 4. Evaluate/monitor the effectiveness of the plan .A. In the event of a resident fall, the nurse is to document the incident in the following manner: .3. Neurological assessments will be completed per protocol . The facility's policy entitled, Neurological Assessment, last reviewed on 3/19/15, stated, .1. A. If resident has had a fall or suspected fall: .b. Unwitnessed Fall: Any unwitnessed fall will have Neuro checks started immediately. If neuro checks are initiated follow the following guidelines: * Every 15 minutes x 1 hour * Every 30 minutes x 1 hour * Every 1 hour x 4 hours. Notify MD/NP immediately of signs and symptoms of ICP- Change in Level of Consciousness (LOC), Headache or Vomiting. If no changes are noted in resident's condition, discontinue Neuro checks at the end of designated time frame. B. Initiate Neuro checks if ordered by Physician or NP. 2. Neurological assessments are the responsibility of licensed nursing personnel .4. Any change in vital/Neuro signs, in a previously stable resident, should be reported to the physician immediately . 12/3/15 - R79 was admitted to the facility with [DIAGNOSES REDACTED]. 12/3/15 at 10:45 PM - A late entry nurse's note stated that the physician was called regarding R79's multiple attempts to stand and ambulate without assistance. In response, the facility implemented the following safety devices and precautions: low bed with fall mats, wheelchair pad alarm, bed pad alarm and 1:1 staff intervention to maintain his safety. 12/3/15 - Care plan developed for R79 and was care planned for self care deficit with an approach/intervention added on 2/29/16 for the following: .w/c alarm/bed alarm when in bed or a chair, low bed; fall mats when in bed for safety due to unassisted ambulation attempts, clip alarm at all times so earlier movement is caught due to residents continuous movement, unassisted transfer attempts continuous use. 12/4/15 at 11:29 PM - A fall risk assessment stated that R79 had falls within the last six months prior to his admission at this facility; he had periods of restlessness, fluctuating mental status, resisting care, incontinent of bowel and bladder, wheelchair bound and required physical help to balance. Based on the assessment, R79 was identified to be a fall risk. 12/16/15 at 1:44 AM - R79 was found kneeling on the floor mat next to his low bed with no injury and alarms were in place and functioning. In response, the facility implemented 30 minute checks on the 11-7 AM shift. 12/21/15 at 8:20 PM - R79 was found on the bedroom floor with a laceration to the back of his head with minimal bleeding. Safety measures, including alarms, were in place and functioning. R79 was sent to the ER for further evaluation and treatment requiring 4 staples to the head laceration. In response, the facility implemented 30 minute safety checks to include the 3-11 PM shift and to hold R79's aspirin medication. 4/30/16 at 7:50 PM - R79 was found on his bedside fall mat without injury and safety measures were in place and functioning. The facility continued with R79's current plan of care. 8/4/16 at 11:55 PM - R79 was found on the bedroom floor partially on his fall mat and the bed alarm was in place and sounding. However, R79's clip alarm was missing and replaced immediately by the facility. R79 sustained a skin tear to his left elbow. In response, the facility implemented a sleep log to determine his pattern/sleep cycle and requested physical therapy to evaluate. The sleep log was reviewed by the medical team on 9/12/16 which showed that R79 was frequently awake between the hours of 12 AM and 6 AM. Physical therapy recommended to keep wheelchair tilted for improved safety and positioning. 10/22/16 at 8:15 PM - R79 was found sitting on the bedside fall mat without injury and the bed alarm sounding. The facility continued with R79's plan of care. 10/24/16 at 10:30 PM - R79 sustained harm when he fell from an unlocked bed, was found on the floor of his bedroom with a 1.5 inch laceration to his left forehead. R79 was previously identified as a high risk for falls and he was last toileted by facility staff at 10 PM. The incident report/post fall report/witness statements stated that R79's bed alarm was not plugged in nor functioning; the clip alarm was not seen on the bed nor functioning; the bed was at the lowest position and unlocked which allowed the bed to move about easily; and R79 was barefoot. R79 was immediately transferred to the ER for evaluation and treatment and returned to the facility with 7 sutures on his left forehead. According to the ER records, R79 had a CT exam which noted Impression:No acute intracranial findings. In response to the fall, the physician ordered to extend neuro checks upon R79's return from the ER and non-skid socks to be worn at all times when in bed. The facility lacked evidence that staff were re-educated with respect to R79's required safety measures that included ensuring placement and functionality of his bed and clip alarms and maintaining the bed locked in the lowest position. 10/25/16 - Review of the CNA AM Assignment Sheet revealed a safety intervention added on 10/25/16 for R79 which stated, Ensure that Clip for clip alarm is SECURELY fastened onto resident! Ensure that low bed is locked (bed will unlock if positioned at it's lowest setting! set bed just slightly above lowest setting and ensure that it is locked in place!! 10/30/16 at 7:50 PM - R79 was found lying on the floor by his wheelchair with his head against the centralized nurse's station desk. Neuro checks were initiated. The incident report stated that R79 said he hit his head and had a headache. At 8:08 PM, E4 (physician) was notified and ordered to discontinue R79's aspirin. At 8:15 PM, E8 (RN) administered Tylenol medication to R79 for his headache. At approximately 9:16 PM, E8 assessed the Tylenol's effectiveness for R79's headache and documented that R79's headache improved but was still present. At 9:30 PM, E8 administered Ativan medication as R79 was exhibiting restlessness, continued to stand up from the wheelchair and required constant redirection for safety. It was unclear in the record as to what non-pharmacological interventions were attempted prior to administering the Ativan medication. In addition, the clinical record also lacked evidence of physician notification when R79's headache was still present even after receiving Tylenol for hitting his head on the nurse's station desk approximately 1.5 hours earlier and neurological assessments were initiated. 10/31/16 at 8:15 AM - According to E13's witness statement, R79 was sitting in his wheelchair removing his shirt and his shirt was put back on by staff and the clip alarm was on the resident's shirt prior to the fall. The facility's incident report stated that an unidentified resident who was seated in the centralized nurse's station area called out to E9 (CNA), who had her back turned and said, you got a guy on the floor and pointed in the direction. E9 found R79 on the floor on his left side with his left arm wrapped behind his back and he was holding his head up off the floor .saw blood from his left arm. Neuro checks were initiated immediately. E12 (second physician) was notified of the unwitnessed fall and R79's skin tear to left elbow with possible dislocation. At 8:40 AM, R79 was sent to the ER for evaluation and treatment. It was unclear why the facility's incident report failed to identify that R79's chair alarm was not in place, clip alarm was not secure and both alarms were not functioning at the time of the fall. 10/31/16 - According to the ER records, R79 was diagnosed with [REDACTED]. 10/31/16 at 3:20 PM - A facility progress note stated that R79 returned to the facility this afternoon from the ER and fell twice over weekend. had fallen about 1 week prior and required an ER visit with sutures placed. First of two falls this weekend was non-injurious. fell again this AM. Concern about fx of left upper extremity. Sent to ER. had a number of tests completed, including CT of .spine, CT head, xray of left elbow and shoulder. x-rays normal. CT .spine negative. CT of head indicated subacute intraparenchymal hematoma of brain (1.2 cm) left anterior frontal lobe with surrounding edema .small left frontal scalp hematoma .there was no indication for surgery and we agreed to monitor him back here. He is not a surgical candidate and the outcome would not improve his quality of life .severe dementia with safety unawareness .wil (sic) stop aspirin permanently as risks outweigh benefit. 10/31/16 at 4:03 PM - A physician's orders [REDACTED]. Review of R79's clinical record revealed the absence of seven (7) neurological assessments on the following dates and times: - 11/1/16 at 4 PM and 8 PM; and - 11/2/16 at 12 AM, 4 AM, 12 Noon, 4 PM and 8 PM. 11/2/16 at 11:20 PM - A nurse's note stated Held - Neuro System Charting Reason did ot (sic) occur, did not receive notification on report. During an interview on 11/4/16 at 11:17 AM, E14 (CNA) demonstrated using R79's bed how it automatically unlocks when lowered all the way to the floor causing the bed to move back and forth with a slight push with her hand. E14 then showed when she raised the bed just slightly, the bed would lock automatically and she was unable to move the bed by pushing it with her hand. E14 stated that all the beds in the facility unlock at the lowest position. During an interview on 11/4/16 at 11:35 AM, E13 (LPN) stated that on the morning of 10/31/16, R79 was restless, attempting to stand up from his wheelchair and removing his shirt. E13 stated that she put his shirt back on with the clip alarm attached and walked away. E13 stated that the clip alarm was not sounding after R79 fell . E13 stated that she observed the clip was still attached to the alarm but not to the resident. During an interview on 11/4/16 at 11:45 AM, E9 (CNA) stated on the morning of 10/31/16 an unidentified resident told her R79 was on the floor. E9 stated that the alarms were not sounding when R79 was attempting to stand and after he fell . In an interview on 11/4/16 at 1:04 PM, E15 (RN, UM) confirmed the findings. E15 stated that she verbally educated staff on 10/25/16 about safety interventions for R79 but failed to provide evidence by having those employees sign a document stating that education was provided to ensure the staff understood R79's safety measures. Findings were reviewed with E2 (DON) and E3 (ADON) on 11/4/16 at 1:23 PM. The facility failed to ensure that R79 received adequate supervision and functional assistive devices to prevent accidents as evidenced by: - On 10/24/16 at 10:30 PM, the facility failed to plug in R79's bed alarm and failed to ensure it was functioning; failed to apply R79's clip alarm and failed to ensure it was functioning; and failed to ensure his bed was locked at the lowest position. R79 fell from an unlocked bed, sustained harm, and was sent to the ER for a head laceration that required 7 sutures. - On 10/30/16 at 9:16 PM, the facility failed to notify the physician per the facility's Neurological Assessment policy when R79's headache was still present after receiving Tylenol for hitting the left side of his head on the nurse's station desk. - On 10/31/16 at 8:15 AM, the facility failed ensure R79's clip alarm was securely attached to his shirt. Subsequently R79 fell and was sent to the ER where he was found to have a bleed inside the brain and 2 skin tears on his left arm. - On 11/1/16 and 11/2/16, the facility failed to perform seven (7) neurological assessments per a physician's orders [REDACTED]. The facility failed to ensure that R79 received adequate supervision and functional assistive devices to prevent accidents.

Based on record review and interview it was determined that for 1 (R33) out of 48 sampled residents the facility failed to provide adequate supervision to prevent accidents. R 33 was brought to the nurses station for supervision after becoming restless and attempting to get out of bed. R33 experienced an unwitnessed fall from the wheelchair causing her to hit her head on the floor and was transferred to the emergency room with complaints of head pain. R33 sustained significant swelling and bruising to her right cheek and eye. The facility failed to ensure the resident environment was as free of accident hazards as possible for 2 (1255 and 1211) out of 15 rooms observed. Findings include: 1. The following documentation was reviewed in R33's medical record and other facility documentation: 10/15/14 - Care plan for falls, high risk for injury from fall due to poor safety awareness and non compliance with safe transfers and attempts to get out of bed without assistance. The goal was minimal injury from falls. Approaches included; bed alarm when in bed for safety, low bed fall mats when in bed for safety, do not leave unattended, 2 or more assist with mechanical lift transfers, every one hour checks, observe for increased restlessness and anxiety inform nursing (5/19/15), clip alarm in bed at all times (6/12/15), clip alarm in chair at all times (6/16/15). 1/25, 5/18, 5/23, 6/10, 6/11, 8/29/15 - Documented in the care plan evaluation falls from bed to floor mat next to bed without injury. 3/25/15 - Care plan for behaviors did not provide guidance and interventions for staff when the resident becomes agitated and tries to get out of bed at night. 6/12/15 - Quarterly MDS assessment documented severely impaired for decision making, extensive assistance of staff for transfers, does not walk and 2 or more falls with no injury since last review. 9/6/15 - Facility incident report documented a fall at 5:00 AM in the hallway from the wheelchair, resident hit her head with swelling and moderate pain. The fall was documented as not being observed and the alarm was sounding. The resident was transferred to the emergency room . There were no nurses' notes documenting the details of the fall on 9/6/15 and there was no documented assessment of the resident following the fall and prior to R33's return from the hospital. 9/6/15 - Facility witness statement from E11 (LPN) documented I went into the med (medication) room to retrieve something for another resident around 5:00 AM or a little before. (Name of R33) was sitting quietly in her wheelchair in front of the nurses' station. Soon after entering the med room, I heard a personal alarm sound. I immediately left the med room to see the resident lying upon her right side with her leg caught up in her foot rest. The left foot rest had come off her chair .she was expressing 'it hurts' then placed ice on her right cheek which was red and very swollen. She was able to move all her extremities and expressed that her head hurts. 9/6/15 - Facility witness statement from E12 (LPN) documented that she was in another resident's room at the time of the fall. She described seeing another nurse over the resident and the resident with severe swelling noted to the right side of the face. 9/6/15 1:19 PM - nurse's note documented that the resident returned from the emergency room at 7:50 AM with a large bruise to the right eye, small bruise to the right 4th and 5th fingers and a 2 cm bruise to the left forearm. The note also stated the resident continued to try to get out of the wheelchair most of the day requiring frequent to, at times, near constant redirection and near constant supervision resulting in a near one-to-one status. 9/6/15 2:52 PM - nurse's note documented that bruises appeared rapidly as the day went on from the fall. CNA reported when they put her to bed the resident had a bruise on her left hip. Review of the CNA Assignment Sheet active on 9/6/15 lacked instruction on what to do if the resident was agitated and wanted to get out of bed at night. The Assignment sheet provided instruction for staff to report to the nurse if resident was not calm for an afternoon nap and for the resident to attend an afternoon activity if not restful. These instructions failed to include interventions for staff to use at night when R33 was agitated. 9/8/15 - Post fall interventions noted in the facility investigation included: clip alarm to wheelchair, therapy evaluation for wheelchair positioning, medication changes, hipsters and review of medication times. These approaches were not added to the care plan. 9/11/15 8:41 PM - Therapy evaluation documented that the resident's wheelchair back was lowered to make it more difficult for the resident to stand and a new anti-trust (wedged) cushion was placed in the wheelchair. 9/25/15 6:57 AM - nurse's note documented resident was up nearly all night cursing, repetitive speech, grabbing, wanting to leave. Staff took turns doing 1:1 for resident's safety. Medical (sic) made aware by written notification. 9/28/15 - Facility incident report documented that at 5:10 AM R33 had an unwitnessed fall from the wheelchair to the floor with no apparent injury. This fall occurred while the resident was again left at the nurses' station. 9/28/15 - Witness statement from E13 (RN) documented that she was getting a resident's medication out of the med (medication) cart, heard clip alarm sound and turned to see the resident roll to the side on the floor in front of her wheelchair. 10/14/15 8:41 AM - E14 (RN) provided a statement from her security video viewing and from her conversation with E12 the 11 PM -7 AM nurse on 9/6/15. She stated that they (facility staff) did not know the approach to not leave the resident unattended was on the care plan. She further stated that the facility has identified issues with care planning development and would be doing a process improvement plan. E14 also stated that facility staff were removing the approach to not leave the resident unattended from the care plans since that would require a resident to be on 1:1 supervision. Surveyor review of the facility's security video, documenting the events of R33's fall of 9/6/2015, revealed that R33 was left at the nurses' station unattended and fell from her wheel chair. The facility statement from E12 documented that R33 was gotten out of bed and placed at the nurse's station because the resident had been attempting to get out of bed unassisted. E12 stated that R33 frequently attempts to get out of bed unassisted in the early morning and that they placed her at the nurses' station where there were more staff members to keep an eye on her. E12 stated that nursing staff on the unit were aware of R33's fall history and they tried to make a extra effort to watch her. 10/14/15 10:27 AM - E15 (RN, unit manager) stated it would be unrealistic to have an approach to not leave a resident unattended in a facility this size. She was unable to find an approach on the CNA Assignment Sheet for how to handle R33 when she became restless at night. She stated it would be her expectation to get the resident out of bed and try to address whatever concern the resident was having. She stated it would be appropriate to bring the resident to the nurses station since it was a high traffic area and the nurses and aides could keep an eye on her. 10/14/15 10:42 AM - E2, (acting DON) revealed that staff might move the resident closer to the desk at night because there are 5 staff on duty and someone is usually there. E2 confirmed that it would have been safer to leave the resident in bed if she was not in the line of sight of staff. -On 9/6/15 R33 attempted to get out of bed unassisted and was put in her wheelchair and moved to the nurses' station; -The facility failed to follow the resident's care plan that had an approach to not leave the resident unattended; -The resident was left in the wheelchair without constant direct supervision and fell to floor with injury. R33 hit her head on the floor and sustained significant bruising and swelling to the right cheek and eye as well as bruising to the fingers, arm and hip; -Review of the facility's video pertaining to 9/6/15 showed the resident at the nurses' station unattended and without supervision; -On 9/28/15 the resident was again brought to the nurses' station when attempting to get out of bed and fell again when she was unsupervised. These findings were reviewed with E1 (NHA) and E2 on 10/14/15 at 3:30 PM. 2. Observations during the initial tour on 10/16/15 and on the environmental tour on 10/12/15 between 10:00 AM - 11:00 AM revealed: -Room 1255-1 left grab bar next to toilet was loose where grab bar screws into the wall -Room 1211-2 towel bar by shower was loose These findings were reviewed with E17 (Custodial Supervisor) on 10/12/15 at 3:00 PM and with E1 and E2 on 10/14/15 at 3:30 PM.

Based on observation, record review and interview it was determined that the facility failed to ensure that two (R2 and R5) out of 13 residents sampled received adequate supervision to prevent accidents. The facility failed to provide adequate supervision to R2, a cognitively (concerned with the act of knowing or perceiving) impaired resident with coordination issues, when he was eating in the dining room with access to a hot drink. The CNA assigned to his care was not supervising R2 when he picked up hot tea and spilled it in his lap burning his thighs. R5 was not ambulated with the assistance of one person as directed in the restorative ambulation plan. The resident fell while being ambulated improperly without an assistive device which resulted in a broken hip requiring surgical repair. 1. Cross-refer F225 example #1. R2 had diabetes (a disease where blood sugar levels are not maintained in the normal range and which can cause sensory changes to the arms and legs) and dementia (a brain disease causing problems with thinking and decision making). An addition was made to R2's care plan by E12 (RN) on 3/18/14 instructing staff that R2 needed to sit at the table with residents who required feeding assistance to have supervision with meals due to dropping food due to coordination issues. This instruction was added to the CNA Assignment sheet by E12 (also on 3/18/14) and instructed CNAs that R2 had hand to mouth coordination issues requiring that he (R2) be seated at the feeding assistance table during meals for supervision. A quarterly MDS completed on 7/21/14 indicated that R2 had moderately impaired daily decision making skills and required staff supervision (defined as oversight, encouragement, or cueing). On 9/4/14 physical therapy documentation timed 8:52 AM indicated that R2 received physical therapy services related to carrying, moving, and handling objects but no specific instructions related to this for care givers to follow was found in the clinical record. The clinical record and care plan lacked a description of R2's identified hand to mouth coordination issue and failed to describe the level of staff supervision required by R2 during meals. In addition, there were no identified safety precautions or instructions found related to hot foods and beverages despite R2 having coordination issues and requiring supervision with meals. An Incident Report dated 9/24/14 timed 12:15 PM indicated that R2 was in the dining room when he spilled a hot drink (tea) on his lap while eating and sustained burns of both thighs. According to this report, R2's left thigh had a burned area approximately 4 inches by 8 inches with four areas of blisters (fluid filled, raised areas caused by heat damage to the skin). R2's right thigh had an area of redness approximately 4 inches in size with no blisters. The possible cause for the incident was identified as R2 drinking without staff assistance and spilling his hot drink. According to facility investigative documentation, E18, the CNA assigned to R2 on the date of the burn was not at the table where R2 was eating and did not observe R2 attempting to drink hot water for tea. A one-sentence statement by E18 (CNA) indicated that R2 wanted to drink his tea and it fell out of his hands and E18 then went to help sweep (sic) the tea onto the floor. The facility identified that R2 required increased supervision during meals in March, 2014 due to coordination issues, however, a specific, individualized plan for mealtime supervision and safety was not developed and implemented by facility staff. R2 was unsupervised at the time he picked up a cup containing hot tea on 9/24/14 at 12:15 PM and spilled it on his lap and thighs. No staff member witnessed the incident or was positioned near R2 to immediately intervene. Following the spill of hot tea by R2 into his lap during lunch on 9/24/14, immediate nursing assessment of the area did not occur as staff were instructed to apply an ice pack to the wet area of R2's clothing and allow him to continue eating his lunch. The action taken by staff according to Incident Report documentation was to apply an ice pack over R2's clothes. In the section of the Incident Report titled "First Aid", a facility nurse wrote "immediately applied" but it was unclear from the Incident Report documentation what First Aid was actually administered and when it was administered. Interview with E17 (RN) on 1/6/15 at 10:51 AM revealed that the staff in the dining room had called the unit where R2 resided and told E12 about the spill of hot water on R2's thighs. E17 stated that E12 told the staff to put an ice pack over R2's clothes on the area until R2 was finished eating. E17 recalled that when R2 returned to the unit, the staff used a lift in the central bathing room and removed his clothing and realized then how bad the burns were. Surveyor interview with E12 on 1/6/15 at 11:55 AM revealed that R2 remained in the dining room for approximately 10 minutes after the hot water spilled on his lap / thighs. E12 stated to the surveyor that when she (E12) was notified by staff in the dining room that R2 had spilled hot water on his lap / legs, she (E12) was told that R2 had not reacted and was not showing signs of distress so she (E12) told the staff to have R2 finish his lunch and to apply an ice pack to the area. In summary, the facility failed to specify in R2's care plan the level of supervision he required and any safety precautions staff should take to address R2's coordination issues when eating. The facility then failed to supervise R2 during his lunch on 9/24/14 at 12:15 PM while he had access to a cup of hot tea. R2 spilled the tea in his lap while attempting to drink it without assistance or supervision of staff. R2 then sustained burns consisting of blisters and redness of the skin of his thighs. After the burn, the facility failed to move R2 immediately to an area where his skin could be assessed. Staff placed an ice pack on the burned area by placing the ice pack over R2's clothes while he remained in the dining room. R2 was assessed by the nursing staff when he was returned to the unit approximately 15 minutes after the spill had occurred. On 1/12/14 at 7:10 PM, confirmation from E2 (DON) was received that the facility had no policy or procedure related to burn first aid, assessment, or treatment. These findings were reviewed with E1 (NHA), E2, E3 (COO), and E4 (ADON) at the exit conference on January 5, 2015 at approximately 2:15. 2. Cross refer F280 example 2 and F520. Facility Policy: Ambulation: with Assistance and/or Assistive Devices with a most recent implementation date of 12/5/13 stated at all times, staff will use a gait belt when assisting with ambulation of residents. R5's care plan was updated on 11/6/13 for a new functional maintenance program to ambulate the resident 100 ft (feet) daily with supervision of 1, rolling walker and wheelchair to follow. A physician's orders [REDACTED]. R5's annual MDS dated [DATE] documented that ambulation in the corridor required extensive assistance with one person physical assist. The resident was assessed as being moderately impaired for decision making. The care plan was not updated to change the staff assistance from supervision to assistance of one. The instructions on the CNA PM Assignment Sheet for 9/10/14 documented; Restorative walking: Ambulate resident 100 ft with one staff member, rolling walker, and wheelchair follow. On the unit, assist of 1 Assistive Devices: Forward wheeling walker, wheelchair once a day every day. R5 was documented as having a fall on 9/10/14 at 4:30 PM. The facility's incident report documented that after the fall the resident was having severe pain to the right hip and holding the area and grimacing. The resident was transferred to the emergency room . R5 was diagnosed and treated for [REDACTED]. A witness statement provided by the facility from E5, the CNA who was ambulating the resident documented; At approximately 4:30 PM, was ambulating with his rolling walker as part of his care plan restoration. I was directly behind him with his wheelchair following closely. I noticed that his feet were about to get tangled together. Before I could get the wheelchair out of the way, (resident name (R5)) had lost his balance, fell to the floor and landed on his right side. An interview with E5 on 12/30/14 at 3:20 PM revealed that on 9/10/14 when the fall occurred E5 was ambulating with his wheeled walker and she was following behind him pushing the wheelchair. She confirmed that she did not have a gait belt in use with the resident and was not physically assisting the resident with the ambulation but instead was pushing the wheelchair behind the resident as she understood the care plan instructions to read. Interviews on 12/30/14 with E6, CNA, E15, CNA and E7, CNA at 11:35 AM, 3 PM and 3:40 PM respectively revealed that when ambulating R5 they would put a gait belt around the resident's waist, hold onto the gait belt while ambulating and pull the wheelchair behind them with their other hand or have someone else push the wheelchair behind. An interview on 12/31/14 at 8:30 AM with E8, Physical Therapist, revealed that R5's ambulation program was for one person to assist the resident with ambulation and another staff person to push the wheelchair behind the resident in case he needed to sit down. She stated that she is aware that some staff will physically assist the resident with one hand and pull the wheelchair behind with the other but a staff person would have to have a level of comfort to be able to do this. During an interview on 1/5/15 at about 11:30 AM with E9. RN, Investigative Nurse, an investigative statement she provided to the Division of Long Term Care Residents Protection investigator was reviewed and confirmed as accurate. In this statement provided on 10/1/14 E9 revealed that E5 was carrying out the ambulation order incorrectly and stated the resident should have had a gait belt around his waist. E5 should have been walking directly behind him (R5) holding onto the back of the gait belt with one hand and with the other hand holding onto the wheelchair and pulling it along with her. E9 stated the facility has an ambulation policy which requires all CNA staff to use a gait belt at all times when assisting ambulation of residents. E9 stated there is a dress code policy requiring all CNA staff to wear a gait belt while on duty. E9 stated that E5 was interviewed and revealed that she had never received training in the correct (ambulation) method by anyone in the facility. No documentation could be found by the facility that E5 had the proper training by therapy or staff development. After the above incident E5 was provided with training on use of the gait belt and ambulation of residents. R5 was ambulated without proper staff assistance and the proper assistive device, (without the use of a gait belt), and by an aide who had not had the proper training on ambulation of residents with assistive devices. This resulted in the resident losing his balance and falling to the floor. The resident broke his right hip and required surgical intervention to repair the hip. These findings were reviewed with E1, NHA and E2 on 1/5/15 at 2 PM.

Based on record review and interview it was determined that the facility failed to ensure the appropriate treatment and services to restore and/or maintain bladder function were implemented for four (R127, R85, R139, and R100) out of 40 sampled residents. The facility failed to identify and recognize during the three quarterly assessments, that R127 experienced urinary incontinence (UI-the involuntary loss of urine) including a decline in continence. These failures resulted in the lack of a comprehensive assessment including a three day voiding diary, development of a plan of care, and implementation of appropriate interventions to maintain and/or restore bladder function. In addition, R127 experienced multiple urinary tract infections (UTI- an infection that can happen anywhere along the urinary tract). On admission to the facility the facility failed to thoroughly assess R85's, R139's and R100's (UI) resulting in the failure to develop an individualized toileting plan to maintain and/or restore bladder function. When R85, R139 and R100 experienced a decline in urinary continence with the first quarterly review the facility again failed to develop an individualized plan to restore bladder function. Findings include: The draft version of the nursing policy and procedure (P&P) titled incontinence management being utilized by the facility was reviewed which documented that a resident who was incontinent of bladder/bowel will receive appropriate treatment and services to restore as much normal bladder/bowel functions as possible. The P&P indicated that each resident will be assessed for bladder/bowel functioning. Following the assessment, individualized goals will be established to restore or improve bladder/bowel functioning. The facility's procedure included that all admissions/readmissions will have a bowel and bladder training assessment. Based on this assessment, if a resident scores between 1-4, a bowel and bladder retraining assessment must be done and a three day voiding diary will be initiated. In addition, upon completion of the voiding diary, the facility will determine the best toileting plan for that resident. This P&P failed to include a comprehensive assessment of UI including history; physical observation and examination; cognitive, functional, and environmental review; and diagnostic testing ("Bladder and Bowel Rehabilitation Manual", Diane K. Newman, 2006). 1. R127 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented that R127 was independent in daily decision making, was independent in toilet use, used a cane to ambulate, and was always continent of urine. A Continence Assessment was conducted on 12/18/12 that indicated; mental status was independent, usually mentally aware of toileting needs, mobility with assist, continent of urine and predisposing factors of depression (state of mood and adversion to activity that affects feelings and behavior), medications and dementia (a general loss of cognitive abilities), and frequent urinary tract infections (UTI- an infection that can happen anywhere along the urinary tract). Although this assessment documented R127 was continent of urine, the assessment documented that R127 was a good candidate for individual training (re-training). An interview with E2 (Director of Nursing) on 9/25/13 at approximately 2:30 PM revealed that this assessment was completed on all newly admitted residents. E2 verbalized that the staff who completed this assessment failed to complete the entire assessment and in addition, the assessment was inaccurate in assessing R127 was a candidate for individual training. E2 indicated that she would have expected a three voiding diary to have been completed. Review of the certified nurse's aide (CNA) voiding record from 12/18/12 through 12/31/12 revealed that R127 had 42 (87.5%) episodes of urinary continence (UC) and 6 (12.5%) episodes of (UI) during night shifts. Review of the January 2013 CNA voiding record revealed that R127 had one episode of UI on the night shift of 1/27/13, however, incontinence supplies such as pull on brief or brief was provided to the resident during 13 shifts. Record review revealed an urine culture and sensitivity (a lab test to check for bacteria or other germs in a urine sample) result dated 2/1/13 documented a positive urine culture which indicated the presence of a multiple drug resistant bacteria (microscopic organism). R127 was administered Bactrim, a antibiotic for seven days for a "UTI." Review of E9's (attending physician) progress note dated 2/19/13 documented that R127 had a history of [REDACTED]. However, this did not help the dribbling as the resident did not want any medication for this problem. Although R127 was treated for [REDACTED]. In addition, even though the resident had UI as evidenced by urinary dribbling, the facility failed to comprehensively assess the UI (predisposes health problems such as UTI); failed to initiate and complete three day voiding diary; and failed to develop a care plan for UI. The first quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a decline in daily decision making to moderately impaired and R127 continued to be always continent of urine. Review of the CNA voiding record from 3/2/13 through 3/8/13 documented three episodes of incontinence occurred on night shifts on 3/5/13 and 3/6/13, thus, the MDS was coded incorrectly when it stated that the resident was always continent. An interview with E7 (Registered Nurse Assessment Coordinator/RNAC) on 9/25/13 at 10:30 AM confirmed the findings. Further review of the medical teams' progress note revealed that on 3/18/13, E10 (Nurse Practitioner) documented a chronic leaking issue with urine for which the resident did not want treatment (medication). Although the facility had evidence, as documented on the above CNA voiding record, the MDS assessment and the medical team's note, the facility failed to identify the decline in urinary continence; failed to comprehensively assess the UI; failed to complete a three day voiding diary; and failed to implement a care plan for UI. An interview with E2 (Director of Nursing) on 9/25/13 at approximately 2:30 PM revealed she would have expected a three day diary to be completed. Review of the March 2013 CNA voiding record from 3/1/13 through 3/30/13 revealed that R127 had 24 (21.5%) episodes of UI and 88 (78.5%) episodes of UC. There were a total of 16 shifts in which UI occurred with 12 being on night shifts. On 5/21/13, an urine culture was ordered due to R127's complaint of urinary frequency. Urine culture result dated 5/24/13 documented the presence of three types of bacteria and R127 was started on an antibiotic. A care plan was implemented for UTI on 5/28/13 with a goal that the resident would be free from signs of infection, culture negative, urine is clear yellow without odor or sediment in one month. Approaches included that the nurses would use good handwashing technique before and after care; administer medications as ordered; monitor for side effects and effectiveness; notify the attending physician as needed; note characteristics of drainage; and to monitor labs as ordered. The care plan in addition documented that the resident continued with complaints of urinary dribbling and frequency without pain on urination (as documented in the attending physician's note dated 5/16/13) . R127 was treated for [REDACTED]. note. Although the facility implemented a care plan for UTI, the fa facility failed to identify that the resident was experiencing UI and failed to identify that UI predisposes individuals to health problems such as UTI. Review of the subsequent MDS assessment dated [DATE] documented that the resident experienced a decline in UC to occasionally incontinent of urine. Review of the CNA voiding record documented that the resident had ten episodes of UI between 5/25/13 and 5/31/13, thus, the MDS should have been coded as frequently incontinent. An interview with the E7 on 9/25/13 at approximately 10:30 AM confirmed the inaccuracy in the coding. Although the facility had evidence, as documented on the above CNA voiding record and the above MDS assessment, the facility failed to identify the further decline in UC; failed to comprehensively assess the UI; failed to complete a three day voiding diary; and failed to implement a care plan for UI. Review of the May 2013 CNA voiding record from 5/1/13 through 5/31/13 revealed that R127 had 23 (18%) episodes of UI and 106 (82%) episodes of UC. There were total of 14 shifts in which UI occurred with 11 being on night shifts. Review of the urology consultation documentation dated 6/12/13 revealed the reason for referral was "stress incontinence." The stress incontinence was crossed out by the urologist and a [DIAGNOSES REDACTED]. The urologist comments documented that the night time UI occurred once a week and R127 was instructed to wake up during the night to prevent these episodes. The urologist documented lifestyle modifications for the UI at night and a follow-up in six months. This consultation documentation included the initials of the attending physician, E9 which indicated that E9 reviewed the consultation. Record review lacked evidence that interventions to wake up the resident during the night time and/or lifestyle modifications were considered/implemented and not recorded on the above care plan for UTI to prevent the episodes of UI at night. During an interview with E9 on 9/27/13 at approximately 2 PM, E9 verbalized that the reason for consultation of stress incontinence was incorrect since this was written by a clerical staff. E9 verbalized that the reason for the consultation was related to the positive urine cultures. E9, as the facility's medical director acknowledged that the current policy and procedure for UI management required revision. E9 confirmed that when a resident had symptoms of UI, the expectation would be a comprehensive assessment including a completion of a three day voiding diary. During a previous interview with the E9 on 9/24/13 at approximately 1 PM, E9 verbalized that the intervention to wake up the resident did not require a physician's orders [REDACTED]. An interview with E10 (Nurse Practitioner) on 9/24/13 at approximately 2:30 PM revealed that she did not recall reading the above urology consultation's recommendation to wake up the resident at night to prevent the episodes of UI at night and verbalized that this would not require an order. Review of the next quarterly MDS assessment dated [DATE] documented that the resident was occasionally incontinent of urine. Review of the CNA voiding record from 8/17/13 and 8/23/13 documented five episodes of UI and confirmed the accuracy of the coding on the above MDS assessment. Again, although the MDS assessment documented that R127 was experiencing UI occasionally, the facility failed to identify the problem. This failure resulted in lack of assessment; lack of initiation of a three day voiding diary; lack of development of a care plan for UI. Interview with E7 (RNAC) on 9/23/13 at approximately 12:30 PM confirmed that she should have notified R127's unit manager of the UI and documented the notification in the nursing notes. E7 confirmed that there was no evidence that E7 notified the unit manager. Review of the August 2013 CNA voiding record revealed that R127 had 27 (21%) episodes of UI and 99 (79%) episodes of continence. There were total of 18 shifts in which UI occurred with 14 being on night shift. September 2013 CNA voiding record from 9/1/13 through 9/24/13 revealed that R127 had 30 (48%) episodes of UI and 63 (52%) episodes of UC with majority of the episodes of UI occurred on night shifts. Interview with a day shift certified nurse aide (CNA), E13 on 9/23/13 at approximately 3 PM revealed that R127 was independent with toileting and wore adult briefs which the resident changed on her own. E13 verbalized that at times, the bed was wet in the morning when E13 began the shift around 7 AM. An interview with the evening shift CNA, E18 on 9/23/13 at approximately 3:05 PM revealed that the resident was incontinent, however, R127 changed her own adult brief. E18 verbalized that the resident was not on a toileting plan. An interview with a night shift CNA, E16 on 9/25/13 at approximately 8:30 AM revealed that R127 was incontinent of urine and wore pull-ups at night. The aide verbalized that when the resident was in "deep sleep", she had episodes in which the bed was wet from UI. E16 verbalized that when R127 was awake or awakened by staff or other residents, R127 would toilet herself and was not incontinent of urine. In summary, the facility failed to have a policy and procedure on UI which included a comprehensive assessment of UI. The facility failed to identify R127's UI; failed to complete a three day voiding diary; failed to develop a care plan to restore R127's bladder function; failed to implement appropriate treatment and services to restore R127's bladder function. These findings were reviewed with E1, Administrator and E2, Director of Nursing on 9/25/13 at 3:30 PM. 2. R85 was admitted to the facility on [DATE]. The initial nursing assessment in the area of urinary/reproductive condition documented on 5/8/13 that the resident was incontinent, needed help toileting, had potential for retraining with every 2 hour toileting plan and teaching was done on the toileting plan. A Continence Assessment was conducted on 5/8/13 that indicated; mental status was independent, usually mentally aware of toileting needs, mobility with assist, continent of urine and predisposing factors of diabetes (high blood sugar levels), medications and dementia (a general loss of cognitive abilities). The initial nursing assessment dated [DATE] in the area of urinary continence documented that R85 was always continent. The admission Minimum Data Set (MDS) assessment dated 5/13/13 documented the resident's status as; moderately impaired for daily decision making, required limited assistance with toileting with one person physical assistance, occasionally incontinent of urine and not on a trial or toileting program. The care area assessment (CAA) indicated urinary incontinence triggered for review and the facility was proceeding with a care plan. However record review revealed there was no care plan developed for urinary incontinence for R85. A bowel and bladder 3 day voiding diary was conducted 5/31 - 6/2/13. There was no evidence in the medical record that the diary was reviewed and an individualized toileting plan was considered. Review of the certified nurse's aide (CNA) documentation in the electronic medical record (EMR) revealed the following levels of urinary continence; May 7 - 31, 2013 continent 85 out of 141 episodes or 60%. June 2013 continent 57 out of 156 episodes or 40%. July 2013 continent 67 out of 237 episodes or 30%. The quarterly MDS assessment dated [DATE] documented the resident's status as frequently incontinent of urine and not on a trial or toileting program. Record review revealed there was again no care plan initiated for urinary incontinence despite the change from occasionally to frequently incontinent of urine. A bowel and bladder 3 day voiding diary was conducted 8/21 - 8/23/13. There was no evidence in the medical record that the diary was reviewed and an individualized toileting plan was considered. Review of the certified nurse's aide documentation in the EMR revealed the following levels of urinary continence; August 2013 continent 55 out of 223 episodes or 30%. September 1 - 24, 2013 continent 46 out of 171 episodes or 30%. R85 was initially assessed on admission as continent and declined to occasionally incontinent and then to frequently incontinent. Despite the documentation demonstrating this decline the facility failed to implement appropriate interventions to restore and or maintain bladder function. An interview on 9/24/13 at 12:10 PM with E2, Director of Nursing (DON) revealed that R85 was missed for a bowel and bladder review, no care plan was ever initiated and no toileting plan was ever attempted. She stated that it was obvious we (the facility) have a problem and we need to work on it. An interview on 9/24/13 at 1:50 PM with E11 registered nurse revealed the resident is often incontinent at night and doesn't always make it to the toilet on time during the day. He is checked every two hours especially at night. He can go to the toilet but he doesn't always make it, he often urinates before he sits down on the toilet. E11 further stated that it was the unit manager's responsibility to design the toileting plan for the residents. An interview on 9/24/13 at 2 PM with E13, certified nurse's aide (CNA) revealed that it is the facility's practice to rotate resident assignments so staff do not have the same residents very often. She stated that she tries to toilet the resident every two hours. She stated that he says "no" at times and will toilet himself when he knows he has to go. E13 stated that when the resident came in he was using the toilet alone and had declined since admission. E13 confirmed that there was no specific toileting plan in place for this resident. An interview on 9/24/13 at 2:05 PM with E14, CNA confirmed R85 was not on a scheduled toileting plan. E14 stated that he puts R85 on the toilet first thing in the morning and before and after meals. E14 revealed that the resident is still incontinent at times even with the toileting that he does. E14 added that the resident has been worried and depressed since admission. E14 confirmed that direct care staff rotate resident assignments resulting in not caring for the same residents on a routine basis. These findings were reviewed with E1, Administrator and E2, Director Of Nursing on 9/25/13 at 3:30 PM. 3. R139 was admitted to the facility on [DATE]. The initial nursing assessment dated [DATE] in the area of urinary/reproductive condition documented the urine pattern was continent. The Continence assessment dated [DATE] documented the resident was occasionally incontinent, mental status independent, mobility independent, usually mentally aware of toileting needs and had a score of 3 indicating the resident was a good candidate for individual training (retraining). An evaluation note dated 5/22/13 documented the resident had a history of [REDACTED]. R139's care plan dated 5/23/13 included the problem urinary incontinence potential for incontinence related to history of occasional bladder incontinence. The goal was for the resident to have no complications related to incontinence such as infection or skin breakdown through next target review. Approaches included; address underlying causes, identify and continue successful management strategies for established incontinence, assess for toileting program as needed, keep urinal in reach and report changes in voiding pattern. A three day voiding diary was conducted 5/23, 5/24 and 5/25/13 however there was no evidence that this was reviewed and an individualized plan was considered. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was moderately impaired for daily decision making, required extensive assistance with toileting with one person physical assist, was occasionally incontinent of urine (less then 7 episodes of incontinence) and was not on a trial or toileting plan. Review of the nurse aide data for the period of assessment actually documented 7 episodes of incontinence. The facility incorrectly coded the MDS and should have coded frequently incontinent for the 7 or more episodes. The care area assessment (CAA) review dated 6/4/13 documented; the resident had occasional incontinence episodes per documentation during the review, and resident requires extensive assist currently with toileting. He has a history of occasional incontinence related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. During the 3 day bowel and bladder record he was incontinent x(times) 2. Resident is aware and can make his needs known. Will develop care plan. However, no further care plan approaches were put in place as a result of the aforementioned assessments. Review of the certified nurse's aide documentation in the electronic medical record (EMR) revealed the following levels of urinary continence; May 22 - 31, 2013 continent 60 out of 67 episodes or 90%. June 2013 continent 103 out of 191 episodes or 54%. July 2013 continent 122 out of 209 episodes or 58%. The quarterly MDS dated [DATE] documented the resident was frequently incontinent of urine and was not on a toileting trial or program. A three day voiding diary was conducted 8/31, 9/1 and 9/2/13. There was no evidence the results of the diary were assessed and no evidence that an individual toileting program was considered. A nurse's note dated 8/29/13 and timed 11:48 AM by E7, Registered Nurse Assessment Coordinator (RNAC) documented; completion of the quarterly MDS assessment indicated a decline in urinary continence in past three months. Resident declined from occasional to frequent urinary incontinence. He also had one episode of bowel incontinence during the 7 day look back period. Will discuss with unit manager and complete bowel and bladder. Although the facility identified a decline in urinary incontinence they failed to develop a plan for the resident's bladder function. Review of the certified nurse's aide documentation in the electronic medical record (EMR) revealed the following levels of urinary continence; August 2013 continent 121 out of 200 episodes or 60%. September 1 - 23, 2013 continent 76 out of 147 episodes or 52%. R139 was observed on 9/20/13 at 2:50 PM in his personal recliner chair. His urinal was observed to be hanging from the headboard of his bed out of his reach. The resident confirmed he could not reach the urinal and stated that he used to have one to keep next to his chair but that it had disappeared.He stated that he can use the urinal himself when it is in reach. R139's initial continence assessment was identified as occasionally incontinent and declined to frequently incontinent. Despite this decline in continence status the facility failed to develop a plan for the resident's bladder function with appropriate interventions. An interview on 9/20/13 at 9:40 AM with a staff nurse E12, Licensed Practical Nurse revealed that R139 was both continent and incontinent of urine. She stated a 3 day voiding diary was done and should be on the computer. When asked about the change in continence status between assessment periods E12 directed the surveyor to speak to the E7, Registered Nurse Assessment Coordinator/RNAC who was responsible for that. An interview was conducted on 9/20/13 at 1:10 PM E14, CNA about the resident's continence. He stated that it had really not changed since admission in his opinion. He stated he does not have the resident all the time because the facility rotates assignments. He stated the resident can use a urinal independently for the most part and mostly uses it in bed. The resident wears a brief and at times is wet despite the use of the urinal. An interview on 9/20/13 at 2:30 PM with E7 (RNAC) revealed that currently the unit managers are handling the continence changes. She added that with the change in RNAC positions (loss of two full time staff) the decline in R139's continence may have slipped through and been missed and added the bowel and bladder program has been a work in progress. She stated she would usually tell the unit manager if a change is seen and let them follow through. An interview with E6, Registered Nurse Unit Manager on 9/23/13 at 8:55 AM revealed that she had only been in her position three weeks and was not aware of what had happened in the past. She stated a new bowel and bladder assessment had been started for this resident. On 9/24/13 at 8:45 AM during an interview with E2, Director Of Nursing revealed the facility was in transition with the urinary incontinence management policy. The current (old) policy was not being fully used and the RNACs and Unit Managers were starting to implement the (new) draft policy. The draft policy contained the forms that were currently in the electronic medical record. These findings were reviewed with E1, Administrator and E2, DON on 9/25/13 at 3:30 PM. 4. R100 had a bowel and bladder training assessment that was completed on 4/19/13 and indicated he was continent of urine. This assessment inaccurately documented R100's mental status as moderately impaired with a predisposing factor of dementia (a group of symptoms affecting thinking and social abilities, often severe enough to interfere with daily functioning). Based on the incorrect data, this assessment identified R100 as a poor candidate for prompted toileting or a retraining program. A 3 day bowel and bladder diary was completed upon admission and began on 4/20/13 and ended on 4/22/13. On 4/20/13 and 4/21/13, R100 was documented as being always continent of urine. On 4/22/13, there were 3 episodes of urinary incontinence documented on the bowel and bladder diary. Review of the certified nurse's aide (CNA) documentation (daily flow sheet in computer system) documented for the same 3 days, 4/20/13 through 4/22/13, R100 was always continent of urine. The admission Minimum Data Set (MDS) assessment, dated 4/26/13, documented that R100 was independent with daily decision making, needed extensive physical assistance of 2 persons for toileting, was always continent of urine, and that a toileting program was not in place. R100 had a history of [REDACTED]. Review of the 3 day bowel and bladder diary dated 4/20/13 (during the assessment period) actually documented 3 episodes of incontinence. The facility incorrectly coded the MDS and should have coded occasionally incontinent for the 3 episodes. A Care Plan that was initiated on 5/8/13 documented a problem of urinary incontinence with a potential for incontinence related to a history of bowel incontinence. The goal documented for this care plan was that R100 would have no complications related to incontinence such as a urinary tract infection or skin breakdown ...assess for appropriate absorbent product. Interventions included using absorbent product as needed, keeping his urinal in reach ... and reporting changes in urination pattern or appearance of urine. Review of the CNA urinary output documentation revealed: -From admission 4/19/13 to 4/30/13 R100 had 17 (77%) episodes of continence and 5 (23%) episodes of incontinence. -5/1/13 to 5/31/13 had 39 (74%) episodes of continence and 14 (26%) episodes of incontinence. -6/1/13 to 6/30/13 had 39 (72%) episodes of continence and 15 (28%) episodes of incontinence. -7/1/13 to 7/31/13 had 22 (79%) episodes of continence and 6 (21%) episodes of incontinence. -7/19/13 to 7/26/13 (7 day look back period for MDS) had 0 episodes of continence and 3 (100%) episodes of incontinence. -8/1/13 to 8/31/13 had 17 (45%) episodes of continence and 21 (55%) episodes of incontinence. -9/1/13 to 9/23/13 had 2 (12%) episodes of continence and 15 (88%) episodes of incontinence. The quarterly MDS assessment, dated 7/26/13, documented that R100 was always incontinent of urine (decline from admission MDS that documented "always continent"), and that a toileting program was not in place. Record review revealed there was no evidence that the facility reassessed R100's urinary continence or implemented a 3 day bowel and bladder diary when the quarterly 7/26/13 MDS identified the decline in bladder continence. During an interview on 9/20/13 at approximately 10:30 AM, E5, Unit Manager, stated the facility failed to revise the care plan to include actual urinary incontinence and interventions such as a bowel and bladder diary. During an interview on 9/23/13 at approximately 3:30 PM, R100 stated he had episodes of incontinence because he had to wait too long for staff to help him with his toileting needs (usually after breakfast and lunch). The facility failed to identify the decline in bladder continence which resulted in the lack of bladder assessment including the 3 day bowel and bladder voiding diary. Unfortunately, R100's bladder continence declined from 74% continent episodes in April to 12% continence episodes in September. Findings reviewed with E1, Administrator and E2, Director of Nursing at approximately 4:00 PM on 9/25/13.

Based on interview, clinical record review, and review of additional facility documentation, it was determined that the facility failed to ensure that one (R37) out of 37 sampled residents received adequate supervision and assistance devices to prevent accidents. The facility failed to ensure that R37's lower legs were secured (strapped) and that R37 had proper footwear (shoes) during the use of a sit to stand lift device for transfer from bed to the wheelchair. These failures resulted in R37's feet slipping and the resident falling to his knees. Later that evening a Certified Nursing Assistant (CNA) transferred R37 back to bed without another staff person. Subsequently following these improper transfers, during the next shift (11 PM-7 AM), R37's left foot was observed with bruising, swelling, and lacerations of the foot which required further evaluation and treatment in the emergency room . In the emergency room , x-ray verified R37's acute fractures of the left third, fourth, and fifth toes. Findings include: R37 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R37's annual Minimum Data Set (MDS) assessment dated [DATE] documented that R37 was moderately impaired for daily decision making, required extensive assistance of two person physical assistance with bed mobility, total assistance of two for transfer, did not ambulate, had no functional limitation in range of motion, was frequently incontinent of urine, and had history of two or more falls since admission/entry or reentry or prior assessment. Lastly, R37 height and weight was 67 inches and 241 pounds respectively. A care plan for "potential for trauma-fall" dated 12/2/11 included intervention for "sit to stand lift for transfers." Review of nurse's notes dated 3/21/12 and timed 6:29 AM documented "Resident noted this AM with blood on his socks, linen, and left foot. Foot cleansed with nss (normal saline solution) with the following findings: 4th and 5th left toes are bruised/dark colored, cuts/splits on bottom side of toes with bleeding noted, small tear/cut on top of 5th toe; both toes are swollen; 4th toe is crooked; toes are painful, Tylenol administered. (Name of nurse practitioner, E12) notified, resident to remain resting NWB (no weight bearing) until seen by her this morning." Subsequently, R37 had an x-ray of his left foot at approximately 8:41 AM on 3/21/12 at the facility and the results were available at 1:42 PM which initially identified an old fracture of the left fifth toe, however, the final report dated 3/21/12 and timed 3:47 PM included an addendum "exact fracture age is difficult to assess based on plain films that were submitted. Fracture could be compatible with a recent injury." At approximately 2:31 PM on 3/21/12, R37 was sent to the emergency room for further evaluation. Review of the hospital medical records dated 3/21/12 documented that the resident sustained [REDACTED]. Closed reduction of the toes was completed The facility's investigative documentation were reviewed which included three written statements from the three certified nursing assistants (E15, E16, and E17) who were involved in a sit to stand transfer of R37 on 3/20/12 at approximately 4 PM. E15's (assigned aide to R37) statement documented "While raising R37 his feet started going back and we lowered him down to the floor on his knees. We lifted R37 off the floor and placed him back on the bed." E16's (second aide involved with transfer) statement documented that "While putting (R37's name) onto sit to stand, he started moving his feet. Then began getting lowered to floor to reposition him into sit to stand (sic)." The third CNA's (E17) statement documented "I helped lift him up and also helped transfer him to the seat with the sit to stand." Review of interview notes conducted on 3/27/12 by E3 (Director of Nursing) and E18 (Investigative Nurse) revealed that E15 and E16 verbalized that R37 had sock on rather than shoes and that a licensed nurse was not made aware of R37 being on the floor on his knees. Additional interview note conducted by E19 (Director of Human Resources) on 3/30/12 with E16 revealed that R37 did not have shoes or leg straps in place during the above transfer. During the facility's investigation of the above incident, the facility's video footage was reviewed and written summary completed by E9 (Administrative Nurse) on 3/29/12 which documented on 3/20/12 at 10:57 PM, R37 was brought from the nursing station into his room by E15 and E15 exited the room few minutes later with the sit to stand device which was pushed into an alcove area in the hallway. There was no one else seen with E15. Review of the facility's policy titled "Safe Lifting/Transferring of Residents" revealed that the facility was a "No Lift Facility" and that two staff members were required for the use of the "sit to stand" lift device. In addition, "5. Combative and Mentally Impaired Residents. a. In most situations, this type of resident can be lifted using the appropriate mechanical lifting device; however, more care providers may be required to assist." An interview with E27 (Trainer Educator) on 8/24/12 at approximately 12 noon revealed although the above policy failed to include that shoes must be worn and leg straps must be utilized, this was discussed during an in-service on the use of the sit to stand device. An interview with E3 on 8/24/12 at approximately 10 AM confirmed that shoes must be worn and legs must be strapped when using this device. Although R37 was care planned to use the "sit to stand" lift device for transfer, the facility failed to ensure that R37 had proper foot wear to minimize the foot from slipping and failed to secure R37's lower legs during the transfer at approximately 4 PM on 3/21/12. Additionally, when R37 was transferred into the bed on 3/21/12 at 10: 57 PM, the facility failed to ensure that R37 was transferred by two staff members.

Cross-Refer to F279 Based on record review and review of other facility documentation, it was determined that one (1) of seven (7) residents reviewed (R2) failed to receive adequate supervision to prevent accidents. A physician's orders [REDACTED]. the left hand. R2 was transferred to the hospital by ambulance following this fall and remained there until 1/7/11. Findings include: The care plan developed by the facility for R2 failed to describe how staff would provide routine toileting assistance to promote continence and safety for R2, a resident with dementia who was at risk for falls and had recently fallen and fractured her hip in the facility. R2 was readmitted to the facility on [DATE] following surgical repair of a hip fracture sustained in a witnessed fall in the facility. R2 had senile dementia and other chronic medical conditions including diabetes. The January, 2011 monthly physician's orders [REDACTED]. In addition, the Nurse Practitioner (E2) wrote an order effective 12/21/10 for a " bed/chair alarm / Bed alarms while in bed. Chair alarm when in wheelchair " . The need for eyesight supervision and a chair alarm were included in R2 ' s care plan addressing her " Potential for falls " . According to a nursing note dated 1/3/11 and timed 8:57 PM, R2 was found in another resident ' s room (located next to R2 ' s own room) " with her bottoms off. She (R2) had a urine incontinence episode. She has a baseball sized lump on the posterior left head. She had a laceration 3 - 4 cm long in the center of the raised area on her head. She ambulated with no difficulty. She only complained of pain at the site on her head. She had some left hand bruising but no other areas noted " . According to the Incident Report, R2 ' s fall occurred at 7:20 PM on 1/3/11 and she was " sent out to the hospital for evaluation due to hematoma and change in mental status " . Eyesight supervision and a chair alarm were not provided to R2 as ordered on [DATE] when she fell from her wheelchair. Staff statements obtained during the facility ' s investigation of R2 ' s fall indicated that R2 had been propelling herself around the nurse ' s station and she " got out of sight " (e-mail statement of E4 dated 1/7/11). When found in a room next to her own room, the back of R2 ' s wheelchair was " up in the air " and R2 was on the floor on her back " with the foot rests from the wheelchair underneath her thighs. There was no alarm going off or present at that time. Also, her pants were off and were soiled with urine " (e-mail statement of E3 dated 1/10/11). When R2 was discharged from Physical Therapy on 1/3/11, it was documented in the Discharge Summary dated 1/5/11 that R2 ' s " impulsivity " limited her physical therapy sessions and she had " limited carryover due to dementia " . A Weekly Occupational Therapy Progress Note for 12/28/10 through 1/4/11 documented that R2 was " not safe with (wheelchair) brake use " ; was " not safe alone i.e. toilet " ; " continues with impulsive behaviors and is not safe " ; and was " not safe alone " . According to Emergency Department Chart, R2 was " found on the ground after fall " and " now states pain in the back of head and left shoulder " . Multiple areas of local tenderness were identified including " left shoulder, left antecubital fossa and elbow, right hip and ileac crest and posterior scalp " . No fractures or internal head injury was identified and R2 returned to the facility on [DATE] following a 4 day hospitalization . The facility failed to have a system in place to formalize the transfer of responsibility pertaining to eyesight supervision from one care giver to the next care giver.