Every finding on record at Encore at West Meadow L.L.C.

Based on observation, interview, and record review, it was determined that one (R1) of three residents sampled did not receive adequate supervision and assistive devices to prevent elopement, as R1 is a newly admitted resident identified as an elopement risk. This failure resulted in R1 eloping from the facility to a busy road between approximately 5:00 PM and 5:20 PM without supervision or intervention. An Immediate Jeopardy was identified to the facility on 6/25/26 at 10:00 AM and was determined to be past noncompliance as of 6/16/26.Findings include:Review of R1's clinical record revealed:6/12/26- R1 was admitted to the facility for short-term rehab with diagnoses that included, but were not limited to, traumatic subarachnoid hemorrhage (a bump or blow to the head that caused bleeding near the brain). 6/12/26- The admission elopement evaluation documented that R1 was a risk for elopement.6/12/26 10:22 PM- A progress note documented Resident noted independently ambulatory with baseline confusion. Wander risk. Reported to NP (nurse practitioner), via Team Health. Order for Wanderguard (requested).6/12/26 11:23 PM- An order note documented Wanderguard (ordered). Check placement and function q (every) shift. 6/13/26 10:36 AM- A progress note documented that the Wanderguard was placed on the resident's left ankle. 6/15/26 approximately 5:00 PM- Video surveillance revealed that R1 eloped from the healthcare facility through a set of double doors and that the Wanderguard alarm was not activated, and R1 was able to walk out the doors unattended, 6/15/26 5:56 PM- A progress note documented Resident (R1) was found outside the building by the road by (E3 [COTA-L]) without supervision around 1500 (should be 5 PM) on 6/15/26. Resident has baseline confusion, poor safety awareness. BIMS score of 6. Wanderguard had been placed around the Resident's left ankle. Wanderguard failed. Resident brought back into the building.6/15/26- R1, who was assessed as independent but at increased risk for elopement, was observed leaving the facility through the exit double doors without staff knowledge. Despite being seen exiting the building, the wander management system did not activate or alert staff. R1 continued ambulating along a main traffic roadway with a posted speed limit of 45 miles per hour for approximately 0.5 to 1 mile. At approximately 5:20 PM, E3 identified R1 walking along the roadway and returned the resident to the facility. Facility staff was unaware that R1 had exited the building.6/24/26 12:00 PM- During an interview, E3 stated, I was driving home from work when I noticed (R1) walking on the side of the road towards Wendy's. I recognized him as a resident because I worked with him earlier that same day. I pulled over and asked (R1) where he was going, and he said he was going to see his son at college. I was able to get him into my vehicle and brought him back to the facility and back to the unit, where nobody realized he was gone.6/24/26 12:30 PM- During an interview, E1 (ADON) stated, We realized that (R1) eloped from the facility when (E3) brought him back into the building and let the unit manager know. (R1) was fully assessed and no injuries occurred during the elopement. His Wanderguard was immediately replaced, and we moved him to the second floor of the facility.Following the elopement incident, the facility took the following immediate actions:A head-to-toe assessment was completed upon the resident's return, and vital signs were obtained and monitored. The malfunctioning Wanderguard was removed and replaced with a functioning device.The incident was reported to the State in accordance with reporting requirementsThe resident's attending physician and responsible party were notified of the incident.The resident was relocated to the second floor to provide an additional layer of protection, as the Wanderguard system deactivates elevator access when functioning properly.The resident was placed on increased monitoring for elopement risk and related behaviors.The resident was placed in the facility's At Risk for Elopement binder, including a current photograph for staff identification.The resident's elopement assessment was reviewed and updated.The resident's care plan was revised to reflect the elopement incident and include individualized interventions to address elopement risk.An audit was conducted of all residents identified as being at risk for elopement who were wearing wanderguards. Placement and functionality of each device were verified, and any malfunctioning devices were immediately replaced. The wanderguard system, including door alarms and elevator controls, was evaluated to ensure proper operation. Staff education and systemic corrective actions include (completed on 6/16/26):Education was provided to all staff regardingIdentification of residents at risk for elopement;Daily monitoring and verification of Wanderguard placement and functionality;Immediate intervention when a resident identified as being at risk for elopement is observed approaching or exiting a secured area; The requirement for nursing staff to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) immediately if Wanderguard placement or functionality cannot be confirmed.Staff competency regarding elopement prevention procedures and Wanderguard monitoring will be validated through observation and follow-up education as needed6/25/26 10:00 AM- An immediate jeopardy was called in the presence of E1 (ADON), and E2 (MDS Coordinator) regarding the 6/12/26 elopement of R1. Based on the immediate actions taken by the facility, no further elopements occurred, and interventions were verified by the surveyor onsite during the survey; this incident was past non-compliance. 6/25/26 - Findings were reviewed during exit conference with E1 and E2.

Based on observation, interview and record review, the facility failed to provide adequate supervision for R22, an independent resident who told multiple staff prior to the incident that he wanted to go home. On 11/10/25, R22 self-ambulated his wheelchair from the healthcare area to the independent living front lobby entrance and exited the building without staff knowledge. R22 continued down a main traffic road where the speed limit was 45 miles per hour for 0.3 of a mile and then called 911 where police officers responded. As a result of the inadequate supervision, R22's elopement from 4:50 AM to 5:21 AM had the potential to have a serious outcome, injury or death. An immediate jeopardy past non-compliance was called on 1/8/26 at 9:57 AM. Based on review and confirmation of the actions taken by the facility in response to this incident and no further elopements had occurred, the facility was back in substantial compliance as of 11/15/25. Findings include: Review of R22's clinical record revealed: 7/10/25 - R22 was admitted to the facility for short term rehab with diagnoses that included, but were not limited to orthostatic hypotension, repeated falls and dementia. 7/10/25 10:03 PM - The elopement evaluation by E23 (LPN) documented that R22 was not at risk for elopement. 7/16/25 - The admission MDS assessment revealed that R22 had a BIMS score of 13, which revealed that R22 was cognitively intact, and had no wandering behaviors. 7/17/25 - A follow-up note by E6 (Medical Doctor) documented that R22 . carries a history of recurrent falls. [R22] was actually asking when he would be able to be discharged . discussed with staff. Will review disposition with case management social services. 7/17/25 9:38 PM - The elopement evaluation by E23 (LPN) documented that R22 was not at risk for elopement. 7/31/25 10:56 PM - The elopement evaluation by E23 (LPN) documented that R22 was not at risk for elopement. 8/14/25 - A follow-up progress note by E6 (MD) documented that . Staff reports ongoing issues with impaired daily care and mobility. There was concern regarding his discharge plan. I was contacted by his primary care physician [D4's name] regarding his plan of care. She had concerns regarding his cognitive decline and his capacity for medical decision making. There were concerns regarding his safety at home and discharge planning issues. The patient denied any issues in this regard. At this time he indicates his goal would be to return home where he lives independently. We did discuss concerns regarding his underlying medical conditions and risks of failure. 8/28/25 - An acute progress note by E6 (MD) documented that . Staff reports that patient has completed his course of subacute rehabilitation. There was concern regarding his safety and appropriateness for discharge to home to live alone. Patient with desire to return home to live alone. Some concern regarding patient's ability to fully participate in the medical decision-making process as he may be unaware and fully understanding of the risks associated with his underlying medical conditions. 9/30/25 3:57 PM - A social services note by E4 (SSD) documented Spoke to resident today about discharging home tomorrow. Resident has been requesting to return home every day and states he is able to make his own decisions. 10/1/25 8:24 AM - A discharge note by E4 (SSD) documented Resident is discharging home where he lives alone. Resident has been requesting to return home. 10/1/25 9:18 AM - A social services note by E4 (SSD) documented SW [Social Work] had a meeting. Discussed the safety concerns with resident going home alone. Resident is adamant about going home. It should be noted that R22 was not discharged from the facility on 10/1/25. 10/15/25 - A follow-up psych evaluation by E24 (NP) documented, .has a past psychiatric history of anxiety, depression, dementia, cognitive deficit. alert and oriented x 3. Patient reports that he wants to go home, reports that he is sad to be (sic) because it is not where he belongs. has some mild forgetfulness due to dementia. 10/16/25 9:42 PM - The elopement evaluation by E25 (MDS Coordinator) documented that R22 was not at risk for elopement. 10/22/25 3:12 PM - An activity note by E26 (AD) documented that R22 sits near the lobby or in the hall from time to time. He states his interest is to go home. 10/23/25 - A progress note by E6 (MD) documented . It has been 60 days since patient transition into long-term nursing care. He [R22] continues to focus on his discharge to home. We again had a lengthy discussion regarding safety issues in this regard. The patient carries a history of neurocognitive disorder and is unable to provide daily care to himself. 11/3/25 11:15 AM - A social services note by E4 (SSD) documented that . Today, resident [R22] asked for his checkbook and told me he would like to hold it in his room. 11/10/25 5:02 AM - The police report documented . I was dispatched to 201 Possum Park Road, [NAME] DE in reference to check on the welfare (sic). Upon arrival, I made contact with [R22] who advised he does not want to be at Millcroft Living anymore and walked out the door. [R22] stated he did not want to go back because he felt trapped. I responded to 255 Possum Park Road (Millcroft Living) and made contact with nurse [E27] who advised he received a phone call from RECOM advising that a patient has left the facility. I advised [E27] that we have [R22] and another Trooper will be transporting him over. [E27] is unsure how he escaped and I advised him that they should be more careful. [R22] refused any medical treatment. 11/10/25 8:00 AM - A nurse's note by E27 (LPN) documented, At approximately 0425 [4:25 AM] hours, I entered resident room to check on resident in B bed and observed resident leaving his room toward the area near the nurses station; he typically sits on a sofa near there. By 0500 [5:00 AM] hours, the resident was not in his usual location near the nurses station. I proceeded to search the building and then reported to the night supervisor, who informed me that he had just received a call indicating the resident exited the building and was in someone's custody. I went outside the building with the supervisor to locate the resident. The resident was brought back to the facility by two police officers and handed over after an interview. Resident (sic) when asked where he was going, he stated, 'I was going home in New Castle Delaware (sic) to come get me'. 11/10/25 9:21 AM - The elopement evaluation by E28 (RN/UM) documented that R22 was at risk for elopement. Following the elopement incident, the facility took the following immediate actions:-11/10/25 - Evening shift and night shift employees were educated on residents remaining within eyesight during shift if not in their rooms.-11/10/25 8:00 AM - Signs were posted to identify risk of elopement. 30-minute checks for 72 hours and check in and out log was created for R22.-11/10/25 9:57 AM - Physician's order obtained for wanderguard bracelet, applied to left ankle and monitored every shift for placement.-11/10/25 10:00 AM - R22 moved to second floor.-11/10/25 all day - Elopement protocol training.-11/13/25 - Elopement drills on evening and night shifts.-11/14/25 - Elopement drill on day shift.-11/14/25 - Elopement protocol training completed.-11/17/25 - Quality assurance meeting held. Reviewed identified time/location of incident; implemented visual site of all resident out of bed between 11 PM - 7 AM outside of 2-hour bed checks; all residents elopement risk have been updated; elopement evaluations to be completed every 4-weeks post admission; communicate any risk; education completed for all staff on risk identification; and elopement drills completed. 1/7/26 at 1:57 PM - During an interview, E29 (Receptionist) stated that the front entrance of independent living has coverage from 8:30 AM to 8:00 PM. E29 stated that the doors are on a timer and lock at 8:00 PM and the main phone transfers to the healthcare nursing station. E29 stated that no doors lock between the healthcare area and the independent living front entrance lobby. 1/7/26 2:05 PM - During an interview, E30 (Maintenance Director) stated that the front entrance door of independent living locks from the outside, not the inside. E30 stated that nobody can get in, but anybody can get out. 1/7/26 2:15 PM - During an interview, E2 (DON) confirmed that he and E30 watched the facility video of the 11/10/25 elopement and E2 documented the timeline that was provided to the surveyor. The 11/10/25 timeline was: 4:45 AM - [R22] Exited room & [and] goes past the nursing station.4:48 AM - Goes into IL [independent living] hallway.4:50 AM - [R22] Left the building.5:21 AM - Police enter building.5:28 AM - Nurse met them.5:42 AM - Escorted [R22] back to his room. 1/7/26 2:55 PM - During a combined interview, E2 and E3 (ADON) confirmed that there have not been any elopements since the 11/10/25 incident involving R22. 1/7/26 2:28 PM - Observation of the front entrance door of independent living revealed that it is a fire exit door and has a sign in emergency push to open. 1/8/26 9:57 AM - An immediate jeopardy was called in the presence of E1 (Interim NHA), E2 and E3 regarding the 11/10/25 elopement of R22. Based on the immediate actions taken by the facility, no further elopements occurred, and interventions verified by the surveyor onsite during this survey, this incident was past non-compliance. 1/12/25 3:30 PM - Finding was reviewed during the exit conference with E1 and E2.

Based on interview and facility record review, it was determined that the facility failed to ensure that it had a documented and updated facility assessment that included the conditions in the addendum. Findings include:Review of facility documents revealed:1/5/26 - A Significant Organizational Change facility assessment tool was completed by E1 (Interim NHA). 1/9/26 3:00 PM - A review of the facility assessment tool lacked evidence that the following addendums were included and attached in the assessment:- Facility - Payroll Based Journal Report- Staff Certification Requirements - Education Schedule Summary- Infection Control Risk Assessment - Inventory Listing- All Hazards Risk Assessment/Emergency Preparedness Plan- HIPAA Security Compliance Information- Authorization for Disclosure Policy & Procedure 1/12/26 9:00 AM - A request for the attachments to the addendum was made to E1 (Interim NHA). 1/12/26 2:46 PM - E1 confirmed that the facility did not have the attachments to the facility assessment addendum. 1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on observation and interview, it was determined that the facility failed to handle, store, process, and transport laundry in a manner that prevents cross contamination.Findings include:1/7/26, 10:30 AM - During a laundry tour with E32 (Housekeeping Staff), the surveyor observed that a smaller auxiliary laundry room was located adjacent to the main washer/dirty room, with its only entrance/exit door opening directly into the dirty laundry area. The smaller room contained a household type washers and dryers. The door to this room was open at the time of the observation.E32 stated that personal clothing for residents is washed and dried in this smaller room, and that clean laundry is then transported out through the main washer/dirty room. E32 reported that this practice has been in place for years. A designated clean laundry room exists on the opposite side of the main washer room; however, it was not being used for the processing or transport of these personal clothing items.1/7/26 4:15 PM - The findings were reviewed with E1 (Interim NHA).

Based on interview and review of facility documentation, it was determined that for seven (E14, E15, E16, E17, E18, E20 and E21) out of seven facility staff reviewed, the facility failed to ensure that the required Behavioral Health Care Needs training was completed. Findings include:1/12/26 1:30 PM - Review of the facility training records revealed a lack of evidence of Behavioral Health Care Needs training for the following facility staff:2/4/25 - E14's first day in the facility as RN (Registered Nurse).4/1/25 - E15's first day in the facility as RN.3/18/25 - E16's first day in the facility as CNA (Certified Nurse Aide).9/16/25 - E17's first day in the facility as CNA.6/10/25 - E18's first day in the facility as CNA.9/30/25 - E20's first day in the facility as Maintenance Tech.11/18/25 - E21's first day in the facility as Restorative Aide/CNA.1/12/26 2:00 PM - Findings were discussed with E1 (Interim NHA).1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on observation and interview, it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness to the residents, in reference to the FDA Food Code. Findings include:1/7/26 9:40 AM - During a kitchen tour with E31 (Director of Food and Beverages), the surveyor observed multiple open food items in the walk in freezer that were not dated. The undated items included one bag of potato French fries, one bag of uncooked sweet potato fries, three bags of dinner rolls, three bags of bagels (one of which contained a moldy bagel), three bags of English muffins, and seven bags of sliced wheat bread.1/7/26 4:15 PM - The findings were reviewed with E1 (Interim NHA).

Based on record review and interview, it was determined that for four (R3, R4, R39, R87) out of six reviewed for infection control, the facility failed to maintain an infection control program that obtained and documented on the monthly line listing the organism being treated by antibiotics. Findings include: 1. Review of R3's clinical record revealed:9/7/23 - R3 was admitted to the facility with diagnoses including but not limited to multiple sclerosis and neurogenic bladder with an indwelling suprapubic catheter.12/31/25- R3's EMR Follow Up note documented, .Patient seen for follow-up status post recent emergency room visit.She [R3] was recently seen in the emergency room for UTI (urinary tract infection) and continues on antibiotics at this time.1/8/26 11:41 AM - A review of the December 2025 infection control line listing revealed documentation of R3 receiving Cefpodoxime (an antibiotic) from 12/30/25 to 1/4/26. There was no documentation of the organism being treated on the line listing.1/8/26 1:15 PM - During an interview, E10 (Infection Preventionist) confirmed that the facility had not followed up with the emergency room to ascertain the urinary tract organism that R3 was being treated for.The facility failed to obtain and document the organism being treated with antibiotics as required for their infection surveillance program.2. Review of R4's clinical record revealed:9/25/25 - R4 was admitted to the facility with diagnoses including but not limited to dementia.1/8/26 11:45 AM - A review of the October 2025 infection control line listing revealed documentation of R4 receiving ciprofloxacin (an antibiotic) from 10/6/25 to 10/13/25. There was no documentation of the organism being treated in the line listing.The facility failed to obtain and document the organism being treated with antibiotics as required for their infection surveillance program.3. Review of R39's clinical record revealed:11/10/22 - R39 was admitted to the facility with diagnoses including, but not limited to, non-Hodgkin lymphoma.11/27/25 - E11 (NP) documented in R39's EMR progress notes, .He [R39] follows with Urology and had a urinalysis done and positive for UTI with recommendations for amoxicillin x 7 days.1/8/26 11:48 AM - A review of the November 2025 infection control line listing revealed documentation of R39 receiving amoxicillin from 11/25/25 to 12/2/25. There was no documentation of the organism being treated on the line listing.1/8/26 1:15 PM - During an interview, E10 (Infection Preventionist) stated that the facility uses McGeer's criteria for antibiotic stewardship.1/8/25 2:10 PM - A review of R39's EMR lacked documentation of symptoms that support prescribing an antibiotic according to the McGeer Criteria for Infection Surveillance. R39's documented vital signs showed no evidence of a fever at any time during the month of November 2025. R39 had not documented lab work since August 2025, so there were no documented leukocytosis or microbiologic urine specimen results.1/8/26 1:15 PM - During an interview, E10 confirmed that the facility had not followed up with the urology practice to ascertain the urinary tract organism that R39 was being treated for.The facility failed to obtain and document the organism being treated with antibiotics as required for their infection surveillance program.4. A review of R87's clinical record revealed:6/2/24 - R87 was admitted to the facility with diagnoses including, but not limited to, pancreatic cancer.1/8/26/12:01 PM - A review of the November 2025 infection control line listing revealed documentation of R87 receiving doxycycline from 11/25/25 to 11/29/25. There was no documentation of the organism being treated on the line listing.The facility failed to obtain and document the organism being treated with antibiotics as required for their infection surveillance program.1/8/26 11:30 AM - A review of the October, November, and December 2025 infection control line listing revealed multiple urinary tract infections documented as being treated with antibiotics without documentation of the pathogen/organism.-October 2025 Infection control line listing had four UTIs that were treated with antibiotics; only one listing named the organism.-November 2025 infection control line listing documented seven UTIs that were treated with antibiotics; only two listings named the pathogen.-December 2025 infection control line listing documented three UTIs treated with antibiotics; only one of the listings named the organism.1/12/25 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on interview and review of facility documentation, it was determined that for seven (E14, E15, E16, E17, E18, E20 and E21) out of seven facility staff reviewed, the facility failed to ensure that the required QAPI (Quality Assurance and Performance Improvement) training was completed. Findings include:1/12/26 1:30 PM - Review of the facility training records revealed a lack of evidence of QAPI training for the following facility staff:2/4/25 - E14's first day in the facility as RN (Registered Nurse).4/1/25 - E15's first day in the facility as RN.3/18/25 - E16's first day in the facility as CNA (Certified Nurse Aide).9/16/25 - E17's first day in the facility as CNA.6/10/25 - E18's first day in the facility as CNA.9/30/25 - E20's first day in the facility as Maintenance Tech.11/18/25 - E21's first day in the facility as Restorative Aide/CNA.1/12/26 2:00 PM - Findings were discussed with E1 (Interim NHA).1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for four (R3, R22, R28 and R94) out of four residents reviewed for care planning, the facility failed to ensure the care planning process facilitated the inclusion of the resident and/or resident representative in the development and implementation of each residents' person-centered care plan. Findings include: 1. Review of R22's clinical record revealed: 7/10/25 – R22 was admitted to the facility. 7/16/25 – The admission MDS assessment was completed. There was no evidence that a care plan conference was held with the resident/resident representative. 10/16/25 – The quarterly MDS assessment was completed. There was no evidence that a care plan conference was held with the resident/resident representative. 2. Review of R94's clinical record revealed: 12/13/25 – R94 was admitted to the facility. 12/19/25 – The admission MDS assessment was completed. R94 was discharged to hospital and returned on 12/24/25. 12/30/25 – The 5-day MDS assessment was completed. There was no evidence that a care plan conference was held with the resident/resident representative. 1/5/26 11:58 AM – During an interview, R94 and R94's family member stated that they don't recall participating in a care plan conference since admission. 1/8/26 3:50 PM – During an interview, E4 (SSD) stated that new admissions have an interdisciplinary meeting within 7 days of admission and short-term rehabilitation residents have care plan meetings based on each resident's progression in therapy. E4 stated that residents in long-term care have a care plan conference every 3 months within the month of the MDS assessment. E4 stated that she either sends an email to the interdisciplinary team members or announces care plan conferences during the morning meeting. E4 stated that she emails an invitation letter to the resident/resident representative. When asked by the surveyor where the care plan conferences are documented to show who participated and the resident's status addressed, E4 stated the care plan information was documented in the electronic health record under progress notes. The surveyor asked E4 to provide copies of the invitation letters to residents/resident representatives and the care plan conference progress notes. 1/9/26 8:55 AM – During a combined interview with E2 (DON), E28 (RN/UM) and E26 (AD), the surveyor was handed a document with handwritten note No care plan info. Surveyor confirmed that the facility had no evidence of documented care plan conferences and invitations to residents/resident representatives to participate. 2. Review of R3's clinical record revealed: 9/7/23 – R3's initial admission to the facility with diagnoses including anxiety disorder. 2/26/24 – R3 was readmitted to the facility from the hospital with diagnoses including pulmonary embolism (sudden blockage in a lung artery by a blood clot) and multiple sclerosis (nervous system disease that affects the brain and spinal cord). 1/5/26 1:30 PM – In an interview, R3 stated that she cannot recall attending a care plan meeting. 1/9/26 11:00 AM – A review of R3's progress notes lacked evidence of care plan meeting notes for the year 2025. 1/9/26 11:19 AM - In a telephone interview, F3 (Family Member) stated that she was not invited to any care plan meetings in years. 1/9/26 11:35 AM - During an interview, E3 (ADON) stated that she does not take down notes during care plan meetings, but she would check with the Social Worker, (E4 SSD) who was off that day (1/9/25). 1/9/25 2:00 PM – In a follow up interview, E3 confirmed that the facility lacked evidence of R3's care plan conferences. 3. A review of R28's clinical record revealed: 10/21/23 – R28 was admitted to the facility with diagnoses including hypertension and acute respiratory failure. 10/28/25 – R28's annual MDS assessment documented a BIMS score of 13, indicating intact cognition. 12/3/25 – A facility document entitled, Care Plan Report stated, .Last Care Plan Review Completed: 12/03/2025. 1/5/26 4:08 PM – During an interview, R28 stated, I don't know about anything regarding my care. The Surveyor asked R28, Are you informed of when care plan meetings will be held and invited to come? R28 stated, No. I haven't been to any care plan meetings. 1/8/26 3:45 PM – During an interview, E2 (DON) stated, [R28] does not come to care plan meetings and [R28]'s son doesn't return phone calls to come to care plan meetings. The Surveyor asked E2, Is there any documentation of when R28 or R28's son was informed of or invited to care plan meetings? E2 (DON) stated, [E4, Social Services Director] handles the documentation of care plan meetings. 1/8/26 4:15 PM – The Surveyor submitted a written request to E4 for documentation of R28's care plan meetings, attendees of the meetings and any correspondence to R28 or R28's son informing them of when care plan meetings were scheduled. During an interview E4 stated, I will look for [R28]'s care plan documents. 1/9/26 10:15 AM – During an interview, E2 stated, [E4] left a note about [R28]'s care plans. No care plan documentation for [R28] was found. 1/9/26 2:49 PM – Finding was confirmed with E2 and E3 (ADON). 1/12/26 3:30 PM – Findings were reviewed with E1(Interim NHA) and E2 during the Exit Conference.

Based on interview and review of facility documentation, it was determined that for four (E16, E18, E20, and E21) out of four facility staff reviewed, the facility failed to ensure that the required Corporate Compliance and Ethics training was completed. Findings include:1/12/26 1:30 PM - Review of the facility training records revealed a lack of evidence of Corporate Compliance and Ethics training for the following facility staff:3/18/25 - E16's first day in the facility as CNA (Certified Nurse Aide).6/10/25 - E18's first day in the facility as CNA.9/30/25 - E20's first day in the facility as Maintenance Tech.11/18/25 - E21's first day in the facility as Restorative Aide/CNA.1/12/26 2:00 PM - Findings were discussed with E1 (Interim NHA).1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for one (R6) out of one resident reviewed for discharge, the facility failed to ensure that R6 had home health services arranged per the discharge plan from the facility to home on [DATE] (Friday). Findings include: Review of R6's clinical record revealed:9/26/25 - R6 was care planned for discharge with the goal to be discharged to home. Approaches included:-home health services per physician order;-physician to review discharge and admission orders, care plan and prior level of function;-therapy services per physician order.12/5/25 - An insurance appeal determination letter documented, A review of the medical records received shows that the patient [R6] was admitted to a SNF [skilled nursing facility]. Self-care tasks such as bathing, dressing, and toileting require moderate to maximum assistance. Bed mobility tasks require supervision assistance. Transfer tasks require moderate assistance. The patient can walk up to 50 feet with a wheeled walker and moderate assistance. The patient can be transferred to Home with support from Home Health services.12/11/25 10:01 AM - A BIMS evaluation by E4 (SSD) revealed that R6 was cognitively intact with a score of 15.12/11/25 10:03 AM - R6's discharge information was printed and included R6's facesheet, medication review report, 9/29/25 history and physical note by E6 (MD), 12/8/25 acute progress note by E6, 9/26/25 physician's orders to flush nephrostomy (tube) and change dressing, 12/9/25 physical therapy and occupational discharge summaries, and a handwritten prescription for home health care for PT/OT, RN and HHA by E6. (30 pages)12/11/25 - A discharge progress note by E6 (Medical Doctor) documented, . Suprapubic catheter and left percutaneous nephrostomy tube were maintained. Ultimately he met his therapy goals. Consequently he was felt stable for discharge to home with close ongoing care as an outpatient . Discharge Instructions: Reviewed with patient and staff Home Health: Per social services Physical and Occupational Therapy Skilled nursing Home health aide. Certification Period: 60 days I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. Impaired mobility leaving home requires a considerable and taxing effort a normal inability to leave the home Reason for Home Health Services: The patient requires home health services because of the below listed diagnosis. Chronic kidney disease. Hypertension. Hydronephrosis with renal and ureteral calculous obstruction. Bladder outlet obstruction. Physical deconditioning Plan: Patient appears medically stable for discharge to home in the morning with close ongoing care as an outpatient. Social services will arrange for home health care. This was all reviewed at length with the patient and the staff prior to discharge.12/12/25 11:00 AM - The Transition of Care and Discharge Summary, started on 12/4/25 at 9:32 PM, documented R6's discharge date of 12/12/25. Under the Social Services section, R6 was being discharged to home/community and had the following services checked that were recommended upon discharge: home health nursing services [B1's company name] and home health therapy services [B1's company name]. Under the nursing section, the summary included that R6 had a suprapubic catheter and a left nephrostomy tube. Under the therapy section, the summary documented that R6 required partial/moderate assistance with bed mobility, dressing, bathroom activity; required substantial/maximal assistance for transfers, bathing and the ability to move from one location to another.12/12/25 (untimed) - A facility fax cover sheet documented that E4 (SSD) handwrote to B1 (home health company name) [R6's name] D/C [discharge] 12/12/25 Needs PT, OT, HHA, RN.12/12/25 1:34 PM - An email transmittal from B1 (home health care company name) confirmed referral information of 31 pages received.12/12/25 2:06 PM - A discharge summary by E33 (RN) documented, Resident discharged home alert and in stable condition. discharged with facility transport with personal belongings, paperwork, remaining medications.1/5/26 - A typed statement by E4 (SSD) and provided to the surveyor documented, I have spoken to [R6's name] on several occasions as well as his [R6's family member] on one occasion to discuss the challenges of obtaining home health (PT, OT, HHA and RN) due to his [B8's name] insurance plan. Referrals were sent to [company names of B1, B2, B3, B4, B5, B6 and B7]. [B1]- Could not accept due to no staffing in his area. I also was told that [B1] was having a contracting issue with [B8, name of insurance company] therefore were not taking any of their members. [B2, B3 and B4]- Do not accept his insurance. [B7]- Does not service [NAME]/Bear area. [B5 and B6]- Had no staff during referral period.When speaking to [R6], I encouraged him that as the new year approaches, he should consider looking into other insurance options that may have better home health availability for any future needs he may have. This conversation took place via phone on 12/19/25. This was the last time I spoke to [R6]. I also let [R6] know that he should contact his PCP [primary care physician] to get an outpatient PT, OT script for continued therapy.The facility failed to ensure R6 had home health services arranged per the discharge plan.1/12/26 3:30 PM - Findings were reviewed during the exit conference with E1 (Interim NHA) and E2 (DON).

Based on observation, interview and record review, it was determined that for one (R94) out of two residents reviewed for catheters and one (R91) out of three residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure that a person-centered care plan was developed to address each residents' identified needs. Findings include:1. Review of R94's clinical record revealed: 12/13/25 – R94 was admitted to the facility with a diagnosis of a stroke. 12/15/25 – A physician's order stated to bladder scan q6 [every 6 hours]. Straight cath if PVR [post void residual] is greater than 400 ml [milli-liters]. Document output every 6 hours. Review of the R94's care plan lacked evidence of the development to address R94's urinary retention and the approaches on how the facility would meet R94's needs. 1/9/26 3:08 PM – During a combined interview with E2 (DON) and E3 (ADON), finding was reviewed and confirmed. 2. Review of R91's clinical record revealed: 12/16/25 – R91 was admitted to the facility with diagnoses including severe dementia with agitation. 12/17/25 – R91 had a care plan developed for impaired ability to perform or complete activities of daily living for oneself such as dressing, bathing or toileting. Interventions included to provide assistance as needed. 12/22/25 – R91's admission MDS (Minimum Data Set) revealed that R91's cognition was severely impaired with no mood nor behavioral issues. R91 required substantial to maximal assistance of one staff person for upper body dressing including the ability to dress and undress above the waist using fasteners if applicable. 1/5/26 12:49 PM – In an interview, F2 (Family Member) stated, Every time I come to visit my mom, she does not have her bra on. They [staff] are not putting my mother's bra on her! 1/7/26 2:30 PM – An observation of R91 in her room sitting in her wheelchair revealed that R91 did not wear a bra. 1/7/26 2:32 PM - In an interview, E13 (CNA) stated, I did not put her bra on because she refuses and fights back a lot when you put it on her. [R91] would say 'No, I don't want it'. When asked if she notified the nurse, E13 replied, No, I did not notify the nurse. 1/7/26 2:45 PM – A further review of R91's record lacked evidence that a person-centered care plan was developed to address R91's refusal to wear a bra when wearing day clothes. 1/9/26 3:00 PM – Findings were discussed with E2 (DON) and E3 (ADON). 1/12/263:30 PM – Findings were reviewed with E1 (Interim NHA) and E2 during the Exit Conference.

Based on observation and interview, it was determined that for one (R92) out of 32 sampled residents, the facility failed to ensure that R92 was treated with dignity and respect. Findings include: Review of R92's clinical record revealed:10/27/25 - R92 was admitted to the facility.10/30/23 - R92's admission MDS (Minimum Data Set) revealed that R92's cognition was moderately impaired. 1/7/26 1:50 PM - During an observation, R92, whose bed was near the open door, was seen from the hallway with her legs and thighs uncovered, exposing her skin and incontinence pad. R92 had a roommate with a male visitor (unidentified) at that time of observation. 1/7/26 - Subsequent observations from 1:53 PM through 2:01 PM revealed that R92's uncovered legs, thighs and incontinence pads were visible from the hallway. R92's roommate still had the male visitor with her in the same room. 1/7/26 2:05 PM - In an interview, E12 (LPN) confirmed the finding and stated that R2 had the tendency to kick her blanket off her. E12 further stated that she will attend to R92 and will put on her pants. 1/9/26 3:00 PM - Findings were discussed with E2 (DON) and E3 (ADON).1/12/26 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2.

Based on record review and interview, it was determined that for one (R106) out of eighteen residents reviewed for quality of care, the facility failed to notify family representative of the resident's 8/1/25 lab work. Findings include:Facility Consent for Treatment form stated, We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and service we provide you. Last reviewed 7/9/20247/24/25 - E6 (MD) ordered in R106's EMR, Labs - CMP (complete metabolic panel), CBC (complete blood count) in one week from date of admission. 7/25/25 - R106 was admitted to the facility with diagnoses including but not limited to pancreatic cancer.7/31/25 - R106's admission MDS (Minimum Data Set) revealed R106's BIMS (Basic Inventory of Mental Status) as 13, which was reflective of normal cognition.8/1/25 8:12 AM - R106 had labs (CMP, CBC) drawn at the facility.8/1/25 10:00 AM - F7 (R106's wife) signed R106's discharge paperwork and R106 was discharged from the facility.8/1/25 11:29 AM - R106's lab results were reported to the facility. There were several abnormalities within the lab results, including hyponatremia (low sodium) and anemia (low hemoglobin).1/7/26 2:42 PM - During a telephone interview, F7 (R106's wife) stated, They [the facility] never called me with the lab results.Had I known this on Friday, August 1st, I would have taken [R106] to the ED (emergency room) immediately and perhaps we would have had a different outcome.1/9/26 10:09 AM - During an interview, E28 (RN/UM) stated, I remember telling his wife [F7] that he [R106] had labs that morning. I did not call her with the results. We don't have a protocol for that because we rarely get labs on the day of discharge. I guess she got the lab results from the portal.1/12/25 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for one (R46) out of one resident reviewed for PASARR (Preadmission Screening and Resident Review), the facility failed to complete MDS assessments to accurately reflect changes in R46's behavior and medication status. Findings include:Review of R46's clinical record revealed:11/15/2024 - R46 was admitted to the facility with diagnoses including hypertension and osteoarthritis.4/29/2025 - A Behavior Note entered in R46's clinical record documented, [R46] noted agitated sitting around nurse's station.asking roommate to get off his property.[R46] yelling at everyone to vacate his property.5/26/2025 9:30 PM - A Behavior Note entered in R46's clinical record documented, [R46] continues to yell at the nursing station.5/29/25 - A quarterly MDS assessment completed for R46 indicated no behaviors of delusions or yelling at others.8/22/25 9:04 AM - A Behavior Note entered in R46's clinical record documented, Staff reported that [R46] was aggressive verbally and physically hitting his CNA in the face.aggression started when [R46] was verbally aggressive to another resident, yelling and cursing at her with family present.8/25/25 5:34 PM - An Alert Charting Note entered in R46's clinical record stated, .[R46] is telling other residents to shut up or yells profanity at them. [R46] swatted his hand in front of another resident's face.9/2/25- R46's quarterly MDS assessment indicated R46 had not exhibited any behaviors consisting of delusions, hitting, threatening or cursing at others.8/27/25 7:24 PM - A Behavior Note entered in R46's clinical record documented, [R46] agitated [sic].talking about someone stealing his truck, cussing at staff members.11/3/25 9:02 PM - A Behavior Note entered in R46's clinical record documented, [R46] extremely agitated and hostile. [R46] asked this nurse if she had a gun so he could shoot another resident. [R46] yelled profanity towards other residents.11/4/25 4:05 PM - A Behavior Note entered in R46's clinical record documented, [R46] is agitated at this time and yelling profanity at staff and residents.redirection ineffective.11/5/25 5:00 PM - Review of R46's Medication Administration Record documented that Depakote Oral Tablet 125 MG, an anticonvulsant medication, was ordered for R46 to be given three times a day.11/22/25 - R46's annual MDS assessment indicated R46 had not exhibited any verbal behaviors of threatening, screaming, or cursing at others. The assessment also documented that R46 was not taking an anticonvulsant medication.1/9/26 2:45 PM - During an interview, E5 (MDS Coordinator) stated, The MDS assessments should have documented [R46]'s hitting, yelling, and cursing behaviors. The Depakote medication should have been documented as an anticonvulsant on the MDS.1/9/26 2:49 PM - Finding was confirmed with E2 (DON) and E3 (ADON).1/12/26 3:30 PM - Findings were reviewed with E1(Interim NHA) and E2 during the Exit Conference.

Based on record review and interview, it was determined that for one (R80) out of four residents reviewed for respiratory care, the facility failed to review and revise the resident's care plan. Findings include: 8/28/23 - R80 was admitted to the facility.9/25/25 - R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia (low oxygen saturation).9/25/25- E6 (MD) ordered in R80's EMR, Change mask/cannula and tubing and clean oxygen concentrator filter every night shift every Thursday.10/1/25 - R80's admission MDS (Minimum Data Set) assessment documented that R80 was using supplemental oxygen.1/8/26 12:30 PM - A review of R80's care plan lacked evidence of the addition of R80's supplemental oxygen intervention, goals and tasks.1/8/26 1:11 PM - During an interview, E7 (RNAC) stated, I don't see any mention of oxygen therapy in [R80]'s care plan. I will add it.The facility failed to revise R80's care plan to include his supplemental oxygen requirement after the 10/1/25 MDS assessment.1/12/25 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on record review, observation and interview, it was determined that for one (R80) out of four residents reviewed for respiratory care, the facility failed to provide care consistent with professional standards as the supplemental oxygen tubing was out-of-date. Findings include:8/28/23 - R80 was admitted to the facility.9/25/25 - R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia (low oxygen saturation).9/25/25- E6 (MD) ordered in R80's EMR, Change mask/cannula and tubing and clean oxygen concentrator filter every night shift every Thursday.9/25/25 10:51 PM - R80's alert charting note documented, Resident arrived at facility via stretcher on oxygen 2L (liters) via nasal cannula.1/5/26 (Monday) 2:15 PM - An observation of R80's supplemental oxygen tubing revealed that it was marked as having been changed on 12/26/25 (11 days prior).1/8/26 (Thursday) 1:11 PM - An observation of R80's supplemental oxygen tubing revealed that it was marked as having been changed on 12/26/25 (14 days prior).1/9/26 1:37 PM - An observation of R80's supplemental oxygen tubing revealed that it was marked as having been changed on 12/26/25 (15 days prior).The facility failed to provide care consistent with professional standards by failing to replace R80's supplemental oxygen tubing after seven days.1/12/25 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for one (R22) out of four residents reviewed for accidents, the facility failed to ensure that R22 received medically-related social services, when it was determined that the resident lacked capacity for medical decision making in F6's (MD) progress note dated 11/10/25. Findings include: The facility's job description of Social Worker, updated July 2015, included, but were not limited to the following job duties:- . 2. Assists with the coordination of Health Center admissions. 9. Maintains regular and on-going relationship with family to discuss needs or concerns, mediates issues that may arise between resident/family/staff. Cross refer to F553 example #1 and F561 example #1 Review of R22's record revealed: 9/21/25 - A typewritten letter from F5 (R22's POA/friend) to R22 stated, September 21, 2025. [R22's name] As you have informed me, in a few days you'll be returning to your home. You've asked me for keys and I am enclosing the set you gave me some time ago . I am reminding you I will no longer be available for assistance effective date of this letter. I am officially retiring. I wish you the best in your journey ahead and hope you can find another assistant that gives as much as I have tried to do. 9/30/25 3:57 PM - A social services note by E4 (SSD) documented, . Resident states his POA [F5's name] is trying to keep him from returning home and it's his right to return home if he wants. POA [F5] had provided a letter to resident stating that she is handling over his keys to him and does not want to be involved in his care as she is retired. Called and left a message for POA [F5's name] to inform her of the discharge as well. No return phone call. It should be noted that R22 was not discharged from the facility. 10/20/25 - R22's printed facesheet revealed that F5 continued to be listed as R22's POA despite the 9/21/25 letter that F5 would no longer be available for assistance. There was no evidence of follow-up by social services in response to F5's 9/21/25 letter. 11/10/25 - An acute progress note by E6 (Medical Director) documented, . He [R22] remains frustrated and angry about being in this facility. We have had multiple discussions in the past regarding his disposition and the discharge planning process. We have discussed multiple times that he is unsafe to live at home alone. Unfortunately, he does not have any options in regards to help at home. He became somewhat agitated during our meeting and refused to answer additional questions regarding his condition. Encounter for assessment of decision-making capacity. Patient does not possess medical capacity to fully partake in medical decision making process. Patient with poor insight and unaware of safety risks. Patient unable to live at home alone without 24-hour supervision. Patient with recent elopement earlier this morning and was found off facility grounds down the street. Patient unable to provide details in regards to this elopement. Social services will continue to work with patient and any family members regarding disposition and ultimate discharge planning process. The facility lacked evidence of social services follow-up to the 11/10/25 determination of R22's incapacity for medical decision making. 1/5/26 1:07 PM - A copy of R22's current facesheet revealed that F5 continued to be listed as R22's POA-Care despite the 9/21/25 letter provided to R22 and given to the facility stating that she would not be available going forward. The facesheet also listed F8 (R22's family member), but it did not identify F8 as a POA contact. 1/9/25 1:00 PM - During an interview, surveyor asked E2 (DON) for a copy of R22's POA document as it was not in his electronic clinical record. In response, the facility handed the surveyor a copy of an attorney's office cover letter only, dated 8/17/18, that stated the following, . I am enclosing a copy of a durable power of attorney [DPOA] which give (sic) [F8's first name only, F6's first name only, F5's first name only, and F9's first name only] the power to act for you, individually or jointly, effective immediately. This document gives [F8's first name, F6's first name, F5's first name, and F9's first name] the power to make health care decisions for you. It was confirmed that the facility failed to obtain a copy of the actual legal document to confirm the resident's four DPOAs with full names listed, which included F8 (R22's only family member). 1/12/26 3:30 PM - Finding was reviewed during the exit conference with E1 (Interim NHA) and E2.

Based on interview and record review, it was determined that for one (R3) out of two residents reviewed for dental services, the facility failed to provide or obtain from an outside resource, R3's routine dental services. Findings include:Cross refer F553 and F656Review of R3's clinical record revealed:12/15/25 - R3's quarterly MDS assessment revealed that R3 had a BIMS score of 15 and an intact cognition.1/5/26 1:35 PM - In an interview, R3 stated that it has been a long time since she was last seen by the dentist. R3 stated, I did not know that I can be seen by a dentist here in the facility.1/9/26 11:10 AM - Further review of R3's clinical records lacked evidence of dental consults and appointments for 2025.1/9/26 11:30 AM - In a telephone interview, F3 (Family Member and POA) stated that she and R3 prefer to set up the appointments and transportation services for R3's outside facility consultations and that included an unsuccessful dental clinic visit. When asked if R3 was seen by the dentist lately, F3 stated that R3 was all set up for the dental visit one time but the dentist (not identified) did not see R3. F3 stated, The dental clinic was very tight, the place for her to sit could not accommodate [R3's] motorized chair. [R3] was not seen at all. I am wondering if the facility has a dentist that visits the place so [R3] will not have the same accommodation issue again. 1/9/26 11:50 AM - During an interview, E3 (ADON) stated she was aware that R3 canceled her dental appointment in the past. E3 also stated that she was aware of the accessibility issue of R3's motorized chair when R3 went out to the dental clinic. E3 stated, I was just talking to [F3] on the phone now, and I told her we have a dentist [D3] who comes to the facility and he can see [R3]. 1/9/25 2:30 PM - In a follow up interview, E3 reported to the surveyor that D3 will see R3 for dental consultation on Sunday, 1/17/26. 1/12/26 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for three (R22, R80 and R106) out of four residents reviewed for accidents, the facility failed to allow these residents to exercise their right to self-determination by having their family contact representatives sign consents. Findings include: 1. Review of R22's clinical record revealed: 7/7/25 – The facility's Consent for Treatment, as part of the Resident Agreement was electronically signed by R22 that stated, You authorize Millcroft Living to provide care and treatment consistent with the terms of your Health Center admission Agreement, dated 7/10/25. You also authorize Millcroft Living to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which you may be transferring. You have the right to request, refuse and/or discontinue treatment. If you are, or become, incapable of making your own medical decisions, we will follow the direction of the Delaware Consent Act. Under the Consent Act, persons shall have legal authority to make medical treatment decisions on your behalf in the following order of priority: -A court appointed guardian, if the health care decision is within the scope of the guardianship; -An attorney-in-fact appointed by you in a Durable Power of Attorney, if the health care decision is within the scope of authority; -A person giving priority by you based on another statutory provision;. This consent for treatment is executed this 7 day of July, 2025. 7/10/25 7:01 PM – An admission note by E15 (RN) documented that R22 was admitted to the facility. The note documented, . Resident A&O [alert and oriented] x [times] 2-3 and confused. DMOST and all admission paperwork was signed by one of the patients (sic) POA [F5]. The following consents were signed by F5 (R22's POA) and not R22, the resident: -Consent to scheduling/setting up transportation for appointments and requirement that a family member attend the appointment. F5 signed, dated 7/10/25 and wrote decline. -Authorization to use and/or disclose health information. F5 signed and dated 7/10/25. -Acknowledgement of receipt of resident rights. F5 signed and dated 7/10/25. -Consent to treatment and medication. F5 signed and dated 7/10/25. -Dental care authorization and assignment of benefits. F5 signed, dated 7/10/25 and wrote decline. -Immunization informed consent for influenza, pneumococcal and Covid-19 vaccinations. F5 signed, dated 7/10/25 and checked decline for all three vaccinations. -Pain management consent form. F5 signed, dated 7/10/25 and checked the consent for Tylenol medication. -Foot care authorization and assignment of benefits. F5 signed, dated 7/10/25 and wrote cut toe nails & [and] fingernails. -Patient portal access consent and authorization form. F5 signed, dated 7/10/25 and checked to voluntarily participate in and obtain access to the Patient Portal. -Bed rails informed consent and release. F5 signed, dated 7/10/25 and checked consent to the use of bed rails as recommended. -Delaware Medical Orders for Scope of Treatment (DMOST) was signed by F5 on 7/10/25 and signed by E11 (contracted NP) on 7/11/25. It should be noted that F5 signed the DMOST document in the signature section above the following statement: .If [aA]uthorized [rR]epresentative signs, the medical record must document that a physician has determined the patient's incapacity & the [aA]uthorized [rR]epresentative's authority, in accordance with DE [Delaware] law. 7/11/25 – An initial consult note by E11 (contracted NP) documented, . past medical history of. dementia, major neurocognitive disorder. alert and oriented x 2-3. Discussed with resident [R22] and POA [F5's name] overall goals of care. They wish to be a DNR with treatment of symptoms only. Consent: POA [F5] agreed to discuss advance directives. This note did not document R22's determination of incapacity. 7/12/25 3:53 PM – The speech therapy evaluation and plan of care documented R22's BIMS as a 13, cognitively intact. 7/13/25 – The social services initial evaluation documented that R22 had a BIMS score of 13, which revealed that R22 was cognitively intact. 1/9/26 8:25 AM – During an interview, E22 (Admissions Coordinator) stated that the facility's practice was that the admitting nurse obtain all of the signed consents and the resident's POA document, if applicable. E22 stated that she completed the resident admission agreement during business hours and that she was not involved with R22's consents or the POA document. The facility failed to promote and facilitate R22's right to self determination with respect to signing his own consents and DMOST. 2. Review of R106's clinical record revealed: 7/25/25 – R106 was admitted to the facility with diagnoses including but not limited to pancreatic cancer. 7/25/25 11:41 AM –R106's [Hospital] Interagency Discharge Orders documented, . Discharge Diagnoses: Acute hyperactive delirium due to another medical condition. Additional Instructions from the Care Team.You were admitted to the hospital with altered mental status, unable to exactly fond out the cause, but probably medication induced, but now mentation has improved. 7/25/25 – F7 (R106's wife) signed R106's consents for Acknowledgement of receipt of Resident Rights, Consent to treatment and Medication, Pain Management Consent form and Bed Rails Informed Consent and release form. 7/25/25 8:32 PM – R106's EMR (electronic medical record) admission Summary documented, . Patient awake, alert, oriented X3-4. Patient's wife signed all his admission consents and paperwork. 7/26/25 - F7 declined and signed R106's Dental Care authorization and assignment of benefits. 7/28/25 – E6 (MD) completed R106's DMOST (Delaware Medical Orders for Scope of Treatment) form and had F7 sign it. 7/30/25 – E24 (psych NP) documented in R106's Psychiatric evaluation, .Mental status Examination: Appearance/Behaviors: calm/cooperative, Sensorium: alert, Orientation: person, place, time, Speech: coherent, Affect: appropriate . Concentrations: fair, insight: poor, Judgment: fair. 7/31/25 – R106's admission MDS (Minimum Data Set) revealed R106's BIMS (Basic Inventory of Mental Status) as 13, which was reflective of normal cognition. 8/1/25 10:00 AM – F7 signed R106's [facility] Transfer/Discharge Report prior to discharge from the facility to home. 3. Review of R80's clinical record revealed: 8/28/23 – R80 was admitted to the facility. 8/4/25 - R80's quarterly MDS (Minimum Data Set) assessment documented that R80's BIMS (Basic Inventory of Mental Status) as 14, which is reflective of normal mentation. 9/25/25 – R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia (low oxygen saturation). 9/25/25 11:21 PM – R80's clinical admission nursing progress note documented, . mental Status: resident is alert & oriented X 3. Oriented to time. Oriented to person, Oriented to place. Level of cognitive impairment: alert. Resident is coherent. Speech is clear. Resident makes self understood (sic). Resident understands others. Mental Status note: alert and oriented X 3. 9/26/25 - E8 (RN/Unit manager) obtained consent via the telephone from F1 (R80's daughter) for the bedrails informed consent and release form. 9/27/25 – E8 obtained consent via the telephone from F1 (R80's daughter) for the appointment scheduling consent, the consent to treatment and medication, the pain management consent form, and the psychopharmacologic medication informed consent forms. The facility failed to allow R80 to exercise his right to self-determination by having his daughter sign consents when R80 was capable of understanding and signing his own consent forms. 10/1/25 – R80's admission MDS assessment documented that R80's BIMS (Basic Inventory of Mental Status) as 13, which is reflective of normal mentation. 10/14/25 – R80 signed his immunization informed consent form. 1/8/26 10:58 AM – During a combined interview, E8 (RN) stated, [R80} was his own person. He can make his own decisions. E9 (LPN) stated, Oh, he makes his own decisions. He is able to sign his name. He has MS (multiple sclerosis) so he cannot move his lower extremities but his upper extremities are good. 1/8/26 11AM – During an interview, R80 confirmed that he is able to sign his signature with his right arm. 1/12/25 3:30 PM - Findings were reviewed with E1 (Interim NHA) and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for one (R1) out of four residents reviewed for pharmacy services, the facility failed to ensure R1 was free of a significant medication error. This failure resulted in a harm in which R1 seized and was transferred to the hospital on 8/7/25 with benzodiazepine withdrawal from missing four doses of lorazepam. Based on a review of the facility's corrective actions taken and completed on 8/8/25 at 11:20 PM, it was determined that this incident was past non-compliance. Findings include:8/5/25 11:59 AM - R1's [Hospital] Discharge summary documented, . Medications at discharge. lorazepam 2 mg (milligrams) oral tablet, 1 tablet by mouth 2 times a day. Please contact PCP (primary care provider) for refill. 2 weeks sent to [pharmacy].8/5/25 - R1 was readmitted to the facility with diagnoses including, but were not limited to, diabetes and anxiety disorder.8/5/25 - C1 (DO) ordered lorazepam tablet 2 mg by mouth two times a day for anxiety for 14 days. 8/5/25 10:20 PM - E6 (LPN) documented in R1's EMR, eMAR- Administration note- Lorazepam tablet 2 mg- give 1 tablet by mouth two times a day for anxiety x 14 days. Medication not available.8/6/25 9:39 AM - E7 (LPN) documented in R1's EMR, eMAR- Administration note- Lorazepam tablet 2 mg- give 1 tablet by mouth two times a day for anxiety x 14 days. Resident new admit, waiting for pharmacy to deliver.8/7/25 - C1 (DO) documented in R1's admission History and Physical note- . History of Present Illness-. She [R1] was focused on her lorazepam therapy that she apparently takes chronically for anxiety. Apparently, a prescription was not sent from the hospital at the time of admission, no documentation in her discharge summary indicates that it was sent.Diagnosis and Assessment: .Anxiety disorder -.concern regarding lorazepam therapy as patient previously hospitalized with encephalopathy (a condition that causes brain disfunction) secondary to benzodiazepine use.8/7/25 2:56 PM - E8 (LPN) documented in R1's EMR, eMAR- Administration note- Lorazepam tablet 2 mg- give 1 tablet by mouth two times a day for anxiety x 14 days. Unit manager called pharmacy, meds (medication) will be delivered in (sic) the next shift.8/7/25 11:08 PM - E9 (RN) documented in R1's EMR, Health Status note- resident seized and was sent to the hospital.8/7/25 11:09 PM - E6 (LPN) documented in R1's EMR, eMAR- Administration note- Lorazepam tablet 2 mg- give 1 tablet by mouth two times a day for anxiety x 14 days. Medications was (sic) delivered at the time the patient was having a medical emergency and she could not swallow.8/8/25 11:57 AM - C2 (hospital NP) documented in R1's hospital EMR, .Chief complaint- seizure -like activity without history. History of present Illness: .Upon chart review, it is noted that it was recommended that the patient be weaned off lorazepam. Patient [R1] states that she has not received any lorazepam since returning to the facility as they have been 'out of it'. Patient presents to the ED (emergency department) from a skilled nursing facility with witnessed seizure-like activity. Patient has no history of prior seizures. Patient states that she has been taking lorazepam for 20 years, her physician recently retired and the practice has been taken over by another physician. She states that there had been a discussion about weaning off of her lorazepam, but she wants to fire the doctor because she does not feel she should be weaned off.8/8/25 1:54 PM - C3 (hospital MD) documented in R1's EMR neurology consult, .Assessment/Plan: .New onset seizure- suspected secondary to holding Ativan (lorazepam) (has been on ativan for many years and missed several days of dose). The facility self-identified this issue and took the following corrective actions: - Educated staff members on the rights of medication administration- Enacted daily audits of all new admission patients for medication supply at the Monday to Friday morning clinical meetings- Educated staff members on the process to follow if medication is not available- Tasked admission staff with confirming all new admission patients come from the discharging facility with necessary prescriptions, that the prescription was sent to their facility pharmacy and confirm with the facility pharmacy that he prescription was received- Tasked [facility pharmacy] with notifying the facility for any new admission medication that requires a prescription and the prescription was not sent directly from the discharging facility- Educated staff members that the providers are to be informed immediately for a recognized failure in obtaining necessary medication- Educated the providers that prescriptions for medications from the Emergency supply box(E Box) must be written in the exact formulation of the drug supplied in the emergency supply box. The facility alleged that all these corrective actions were completed by 8/8/25 at 11:20 PM. The surveyor confirmed education with staff during interviews. 8/9/25 - R1 was re-admitted to the facility after hospitalization. 8/11/25 - C1 (DO) documented in R1's EMR re-admission History and Physical note- . History of Present Illness- . The patient was readmitted there [hospital] with reported seizure-like activity. There appeared to be some issues obtaining patient's chronic benzodiazepine therapy from the pharmacy in a timely fashion at the time of admission. She apparently went 48 hours without a dose of her lorazepam therapy. Workup at the hospital was largely unremarkable and included EEG monitoring and MRI imaging. She was evaluated by the neurology team who recommended ongoing benzodiazepine therapy without changes at this time.Diagnosis and Assessment: Seizure- appears to be related to benzodiazepine withdrawal.8/14/25 - C1 (DO) documented in R1's EMR progress note, .Diagnosis and Assessment: Benzodiazepine dependence- secondary to prolonged use of high-dose lorazepam therapy, resulting in withdrawal seizure requiring hospitalization.10/29/25 9:45 AM - A review of R1's MAR revealed the 8/5/25 8PM, 8/6/25 9 AM and 8/7/25 9 AM lorazepam doses were documented as not given/ see nurses notes. The 8/6/25 8 PM lorazepam dose did not have any documentation in the MAR or progress notes regarding this medication.10/29/25 10:39 AM - During an interview, E2 (DON) confirmed that R1 did not receive any doses of lorazepam from 8/5/25 to 8/7/25. 10/29/25 1:45 PM- The findings were reviewed during the exit conference with E1(NHA), E2 (DON), E3 (RDOCS), E4 (RN/UM) and E5 (RN/UM).

Based on interview, record review and review of other facility documentation it was determined that for three (R1, R2 and R3) out of three residents reviewed for wandering and elopement the facility failed to provide adequate supervision to prevent elopements. R1 eloped on two occasions 8/16/24 and 8/18/24. On 8/16/24, R1 was seen in the parking lot. On 8/18/24, R1 was seen outside of the building, near the fire lane of the facility turn-in and a busy roadway. Additionally, R2 eloped from the facility on 8/17/24 and was found outside of the building at the edge of the curb on the rounded driveway. On 7/11/24, R3 was seen exiting the facility unattended by a facility visitor who immediately reported R3's elopement to staff. The facility was made aware on 8/23/27 at 4:47 PM of immediate jeopardy. All three residents were at risk for serious adverse outcome. The immediate jeopardy was abated on 8/24/24. Findings include: The facility policy entitled Wandering and Elopements indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident care plan will include strategies and intervention to maintain the resident's safety. 1. Review of R3's clinical record revealed: 5/9/24 - R3 was admitted to the facility with a history of multiple diagnoses including dementia and unsteadiness on his feet. 5/9/24 - R3's admission elopement evaluation scored a 3 and assessed that the resident was at risk for wandering. The evaluation assessed that R3 wandered, and the wandering was likely to affect the safety of the resident or others. 5/15/24 - An admission MDS assessment documented R3 as having active diagnoses of anxiety, dementia, and severe cognitive impairment. R3 was assessed as using a walker and able to walk ten feet with moderate partial assistance and supervision. 5/27/24 - R3's care plan for wandering was created with interventions of distract resident from wandering by offering pleasant diversions, structured activities, food conversation, television, books. Staff is aware of elopement risk. 7/11/24 2:40 PM - A progress note in R3's clinical record written by E22 (RN,UM) documented, Resident was found on outside driveway loop by another resident's family. Resident retrieved and had no apparent injuries and no complaints of pain. Elopement evaluation completed, resident at high risk for elopement. Family contacted and made aware. MD made aware and ordered wander guard. orders placed, wander guard placed on left ankle without incident. Resident to continue to be at nurses station during the day for observation. 7/11/24 - R3's elopement evaluation scored a 6 and assessed that in addition to the prior evaluations assessment, R3 now had a history of elopement, expressed a desire to go home, and that wandering was likely to affect the privacy of others. 7/11/24 - A physician's order was written for R3 to wear a wander-guard and for placement of the wander-guard to be checked every shift. During an interview on 8/26/24 1:14 PM, E22 (RN, UM) confirmed that R3 was found outside the facility on 7/11/24. E22 stated, [R3] was at an activity and he was upstairs and a residents family member [FM2] said [R3] is outside in the circle. He was last seen in an activity we assume he went out on the elevator alone then outside. E22 confirmed the facility was unaware R3 was outside prior to notification from FM2. During an interview on 8/26/24 at 1:24 PM, FM2 stated, There was one time mid July a resident [R3] got out. I was outside and [R3] came walking out said he was going home. So I went in and told the first person I saw but by the time we got there someone was already coming in with him. He only had about one minute of freedom. During an interview on 8/27/24 at 11:44 AM, E18 (CNA) who was assigned to R3 on 7/11/24 during the day shift stated, I don't remember much because I just heard about it, but I didn't see it. I am pretty sure I was with another resident. E18 was unable to recall when she had last seen E18. 2. Review of R1's clinical record revealed: 7/17/24 - R1 was admitted to the facility with multiple diagnoses including unspecified dementia with agitation, anxiety disorder, unspecified psychosis, unsteadiness on the feet and difficulty walking. 7/17/24 - A baseline care plan was created for R1's risk for elopement with the goal that R1 would not elope from the community. Interventions included complete admission elopement evaluation and initiate placement of a wandering device. 7/17/24 - The comprehensive care plan for R1 for risk of wandering/elopement with a goal for safety to be maintained included interventions to complete frequent checks every shift, identify if there is a certain time of day wandering elopements attempts occur and schedule time for regular walks/appropriate activity. There were no updates/revisions to this care plan. 7/17/24 - R1's admission elopement evaluation scored R1 as a 3 and assessed that R1 was at risk for elopement related to a history of attempted elopement while at home, history of elopement or attempted leaving the facility without informing staff and wandering. 7/23/24 - An admission MDS assessment documented that R1 had a BIMS score of six indicating severe cognitive impairment. The wandering section of the assessment was left blank, indicating it was incomplete. R1's functional ability was documented as able to walk ten feet with supervision and use of a walker. 8/13/24 - A second elopement evaluation scored R1 as a 6 and assessed that R1 continued as at risk for elopement related to a history of attempted elopement while at home, history of elopement or attempted leaving the facility without informing staff and wandering. Additionally, R1 was assessed as wandering aimlessly or non-goal directed and wandering behavior likely to affect the safety or well-being of R1 and privacy others. 8/13/24 - A physician's order was written for R1 to wear a wander-guard and for placement of the wander-guard to be checked every shift. a. 8/16/24 4:22 PM - A progress note in R1's clinical record written by E14 (RN) documented, Resident noted to be an elopement risk with wandering behavior. Resident has wander-guard in place. It was proposed to the family to move the resident to the second floor as a safety precaution. Family refused at this time. 8/16/24 - An un-timed statement in the investigation documents written by E22 (RN-UM) documented that R1 was found in the parking lot by housekeeping and bought back to the floor by two CNA's . 8/16/24 - An un-timed statement in the investigation documents written by E16 (CNA) documented, [E21 (H)] was on her way outside and said someone was outside with a handbag and seemed lost could we see if she was a resident? So, I went outside only to see [R1] by the cars in the parking lot. 8/16/24 - A third elopement evaluation scored R1 as an 8 and assessed that R1 continued as at risk for elopement related to a history of attempted elopement while at home, history of elopement or attempted leaving the facility without informing staff, wandering aimlessly and wandering behavior likely to affect the safe or well-being of R1 and privacy others. Additionally, R1 was assessed as verbally expressing a desire to go home. 8/22/24 - R1's existing wander-guard order was expanded to include checking the function of the wander-guard daily. During an interview on 8/23/24 at 2:20 PM, E21 (H), stated that on 8/16/24, Maybe at 2:00 PM or 2:30 PM I was at the time clock to punch out, I heard the alarm and I look out the window and see [R1] outside and went and got [E16 (CNA)]. During the interview E21 accompanied the surveyor to the time clock and confirmed seeing [R1] through the window outside on 8/16/24. During an interview on 8/26/23 at 2:26 PM, E12 (RN) confirmed that she was assigned to [R1] on 8/16/24 during the time of the elopement. E12 stated, I was in another patient's room and didn't know [R1] got out. During an interview on 8/23/24 at 2:28 PM, E18 (CNA) stated that on 8/16/24, I believe I was heading to the kitchen and [E21 (H)] was standing there. [E16 (CNA)] was standing there. Me and [E16] go out there. We didn't notice [R1] left because someone must have disarmed the alarm. E18 then confirmed other incidents of elopement regarding R1 and stated, I just heard about Sunday (8/18) where she was found across the street but I wasn't here that day. During an interview on 8/23/24 at 2:32 PM, E22 (RN) stated that on 8/16/24, I just remember I was off the floor and when I had come back they said she made it out to the cars and a housekeeper found her. We came up with putting her on the second floor and [FM1] said he didn't want to do that because she had a friend on the first floor and I explained it was a safety measure and he refused. We did make signs and we put those on the glass doors and above the key pad. E22 confirmed that the it was unknown how long R1 had been outside of the facility and stated, I'm not sure how long but it couldn't have been more than five or ten minutes at the most. She had been sitting on the couch. E22 denied that R1 had prior elopements and stated, [R1] did voice the desire to leave. We saw her walking off the unit but she had not made it beyond that. With difficulty to redirect, we did do a wander-guard. E22 was asked to show the surveyor the sign and when visualizing the Healthcare entrance door key pad there was no sign posted. E22 stated, Housekeeping must have taken them down. E22 then provided the surveyor with a copy of the signs she created and posted on 8/16/24. The sign indicated the following HIGH ELOPEMENT RISK ON FIRST FLOOR. ONLY NURSING STAFF TO DISARM THE ALARM! Thank you. During an interview on 8/23/24 at 2:37 PM, E16 (CNA) stated, That day we were getting our last changes done. I can't remember what time it was. I do know that housekeeping leaves around 2:30 so it had to be around that time frame. I was charting and [E7 (H)] ran to the desk and she said I think a resident is out. I got up immediately and darted towards the door. When I went out, I saw it was [R1]. When I ran out to the parking lot two housekeepers was trying to get her to come in. E16 stated that R1 was observed outside in the parking lot by the spot that says visitor where the doctors park at. b. 8/18/2024 10:40 AM - A progress note in R1's clinical record written by E22 (RN-UM) documented, Resident wandered out of facility; Charge nurse was made aware by [E10 (AD)] while on break. Resident was encouraged to returned to facility from the front main entrance, Resident had some combative behaviors. Resident returned to first floor unit. ADON and CEO were made aware. Resident's son was called and made aware and notified of patient transfer to second floor unit. Patient was transfer to second floor. 8/18/24 - An un-timed statement in the investigation documents written by E3 (ADON) documented, [E10 (AD)] notified me Sunday morning that an attempted elopement occurred with [R1]. I notified [E2 (DON)] and [E1 (ED)]. I was informed that resident made it to the edge of the premises, but no one knew whether she left the actual premises. 8/18/24 - R1 was relocated from a room on the first floor to a room on the second floor of the facility. 8/23/24 9:23 AM - During random observation and tour of the facility, two sets of double doors with a service area between them that connected the Healthcare facility and Independently Living facility were observed to be open. The doors remained open throughout the day. During an interview on 8/23/24 at 11:35 AM, FM1, responsible party for R1, confirmed R1's 8/18/24 elopement and stated, I was under the impression it was during the day on Sunday around ten. My mom has dementia, and she does this sometimes, as her situation has worsened. They have worked with us, taking as much control as they can. They moved her to a more secure floor and put an alarm on her. From what somebody told me, she went for a walk. I think from what I gather, she may have gone past the entry way of [the facility] and off the grounds proper. From what I was told, she wasn't far away, and I don't think she knew she was off the grounds. FM1 stated he was unaware of other elopements at the facility. During an interview on 8/23/24 at 12:21 PM, E10 (AD) confirmed that R1 eloped on Sunday 8/18/24. E10 stated, I was in the hallway downstairs in the Independent Living and the receptionist [E8] was calling my name and she said she thought there was a Healthcare resident in the parking lot. If you're coming into the facility [R1] was right at the corner with her walker and a gentleman. E10 confirmed the gentleman was a person unknown to the facility and referred to him as a good Samaritan and reported she obtained his contact information and gave it to E1 (ED). E10 then stated, Me and one of my staff [E14 RN] escorted [R1] in. E10 stated, I think there is one other episode [of elopement] I'm not sure. R1 did have her wander-guard on when I bought her back through the door it did go off. During an interview on 8/23/24 at 12:50 PM, E1 (ED) stated, I wasn't in the building, so I didn't know anything about the elopement on the sixteenth. On the eighteenth, [E10 (AD)] called me and said a resident was out on the sidewalk and looked confused. She went and got her back. [R1] did have a wander-guard. Depending on the door she goes through, it goes off. I don't know which door she came out of. During an interview on 8/23/24 at 1:11 PM, E7 (DES) confirmed that the Independent Living main entrance doors do not sound an alarm and do not automatically close or lock when a wander-guard passes through. The last alarmed door triggered by wander-guards is the first set of double doors that lead to the service hallway where the kitchen and employee break room is located that then lead to the Independent Living main hallway to its main entrance door. When a wander-guard passes through the first set of double doors, an alarm sounds until disarmed by a pin number entry on the keypad. The doors do not lock. The doors were observed as open at the time. During an observation on 8/23/24 at 1:14 PM E7, (DES) demonstrated with the use of a wander-guard that the facility's Healthcare main entrance doors alarm until disabled and lock temporarily when triggered by a wander-guard. During an observation on 8/23/24 at 1:21 PM, at the Independent Living main entrance, E7 (DES) had triggered the double door wander guard alarm. However, it could not be heard at that distance. During an interview on 8/23/24 at 1:22 PM, E7 (DES) confirmed that the set of two double doors connecting the Healthcare Facility to the Independent Living facility were typically open during the day. During an interview on 8/23/24 at 1:29 PM, E8 (receptionist) stated that on 8/18/24, Another Independent Living resident told me [R1] was in the middle of the street. I called [E10 (AD)], she was the manager on duty, and I got up to see if I could see [R1], but I couldn't see her. I did see someone bring her back towards the building. When the lady, a visitor, told me someone looked like they belong here was in the road. I got up because I couldn't see, but by the time I got up, she was near the flagpole where the cars come in. During an interview on 8/23/24 at 3:36 PM, E14 (RN) stated that on 8/18/24, I was the nurse that day. I went on break and while I went on break an employee [E10 (AD)], came and told me that a resident [R1] is outside. E14 confirmed that R1 was seen at the nurse's station before E14 went on break and that it was an estimated twenty minutes later when E14 was notified that R1 had exited the facility. E14 then confirmed that the facility was not aware that R1 had exited the facility unbeknownst to staff. During an interview on 8/23/24 at 4:03 PM, E3 (ADON) confirmed that during both the 8/16 and 8/18 elopements, staff had no knowledge R1 would be exiting the building. c. 8/23/24 11:52 AM - A progress note in R1's clinical record documented, Resident was found without her wander-guard on the second floor. 8/23/24 7-3 shift. Small pair of manicure scissors found in her room. Resident cut the strap off herself. New wander-guard placed around the resident's right ankle. Scissors removed from the residents room and placed in the medication room behind the nurses station. Resident's POA [FM1] notified of incident. Resident remains a high elopement risk. During an interview on 8/23/24 at 4:26 PM, E13 (RN) stated that R1 was standing in the hall and we noticed she did not have it [wander-guard] on. Her nurse went in the room and saw the strap cut. So we confiscated the scissors. Then [FM1] came in and took them and we searched them and didn't find anymore. 3. Review of R2's clinical record revealed: 8/6/24 - R2 was admitted to the facility with multiple diagnoses including age related physical weakness, unsteadiness of the feet, dementia and cognitive communication deficits. 8/6/24 - R2's admission elopement evaluation scored a 0 which indicated the resident was assessed as not a risk for elopement. 8/12/24 - An admission MDS assessment documented R2 as having a BIMS score of 10 indicating moderate cognitive impairment. R2 did not exhibit wandering behaviors and required moderate partial assistance to walk 10 feet and used both a wheelchair and a walker. 8/17/24 3:19 PM - A progress note in R2's clinical record written by E13 (RN) documented, Resident noted to be elopement risk. Found outside of building on 8/17/23, around 3:00 PM. Resident unharmed. In stable condition. Back in room. Resident's spouse informed and has given consent for a wander-guard. 8/17/24 - An un-timed statement written by E13 (RN) in the investigation documents indicated, It was nearing 3:00 on 8/17/24 on first floor. The speech therapist wheeled [R2] in through the side door and reported that he found him sitting by the pond outside in his wheelchair. Resident has a baseline as being confused and had already been redirected several times that day. I immediately spoke with the resident's POA and obtained consent for a wander-guard. An undated/un-timed statement written by E19 (SLP) in the investigation documents indicated, On 8/17/24 3:00 PM, I was approached by a visitor saying a resident [R2] was outside alone wheeling himself. I went to [R2] and bought him back to the facility and reported to nursing . I found him at the Independent Living side entrance door by the pond. 8/17/24 - R2's second elopement evaluation scored a 6 which indicated the resident was assessed as at risk for elopement. 8/17/24 - A physician's order was written for R2 to have a wander-guard and for staff to check placement and function each shift. During an interview on 8/23/24 at 11:11 AM, E15 (LPN) was asked if he was aware of any resident elopements in the facility. E15 responded, Yes, I worked on Sunday, there was an elopement. I can't remember the name of the resident. When asked if the elopement was regarding R1, E15 stated, No, I don't know about the resident. It was a gentleman, [R2]. During an interview on 8/26/24 at 2:03 PM, E13 (RN) confirmed the above written statement. E13 then confirmed the facility was unaware R2 was outside until E19 (SLP) wheeled him in. R13 was unsure of when or where R2 had last been seen prior to being found outside by E19. During an interview on 8/27/24 at 11:48 AM, E19 (SLP) confirmed the above written statement. E19 then accompanied the surveyor outside where R2 was found by him on 8/17/24. E19 confirmed R2 was found outside near the side entrance of the Independent Living area, at the edge of the turn. Across the fire lane there is a small man made pond and embankment. The facility provided the following corrective measures: During an interview on 8/23/24 at 4:09 PM with E1 (ED), E2 (DON) and E3 (ADON) the surveyor asked what the facility's plan is to prevent further elopements and E3 responded, For [R1] we had moved her upstairs. We attempted to move her Friday, but they refused. Moving her upstairs is another layer for her safety. In general, we had been communicating and educating the staff that when they hear the alarm to make sure that someone is there to disarm. We have families that like to go in and out it would be better if just the nursing staff only would put in the code. E1 then stated, I am going put a sign up. E3 then added, if we identify residents at risk on admission if we have a room, we will put them upstairs. We made sure the doors were working, notified staff and did frequent rounding E3 confirmed the frequent rounding was not documented. 8/23/24 4:13 PM - The surveyor requested any recent education provided to staff regarding wandering and elopements. 8/23/24 - 4:30 PM - E3 (ADON) provided the surveyor with education sign in sheet's regarding wandering and elopements dated 8/23/24. 8/23/24 4:31 PM - E1 (ED) Was shown the signs created by E22 (RN) that were to be placed by exit doors. E1 confirmed signs were not posted presently. 8/23/27 4:47 PM - Surveyor reported to E1 (ED), E2 (DON) and E3 (ADON) that an immediate jeopardy in the area of accidents hazards had been identified regarding the facility's failure to provide adequate supervision to prevent elopements. The surveyor asked how the facility would prevent residents from exiting the facility. E1 stated, Going forward only a nurse is to disarm the code. I will call the company about changing the alarm pin codes as soon as possible. E3 stated, yes, because the families have the codes. 8/23/24 -4:52 PM - E1 (ED) - Provided the surveyor with a sign to be posted on all exit doors. The sign read, DO NOT REMOVE SIGN. HIGH ELOPEMENT RISK ON FIRST FLOOR (WANDER GUARD SYSTEM IN PLACE). STOP. Only NURSING STAFF to DISARM the ALARM (Please make sure no residents are behind you before exiting) * If alarm goes off, please notify a nursing staff member to turn off the alarm before proceeding*. 8/23/24 5:08 PM - E1 (ED) was sent an email with an attached immediate jeopardy template. 8/23/24 5:09 PM - 5:53 PM - Signage was posted on all the entrance/exit doors Only nursing to disarm alarms. Warning high risk elopement residents in facility. 8/23/24 5:52 PM - 6:21 PM - All exit/entry Door alarm pin code changed. 8/23/24 5:53 PM - Set one of double doors closed with a verbal notice from E1 (ED) to dietary and other staff for the doors to remain closed. 8/23/24 - 6:00 PM - 6:09 PM - All residents with wander-guards belongings inspected for objects to remove wander-guard list provided by E3 (ADON). 8/23/24 6:20 PM - E1 (ED) provided written notice to dietary staff and surveyor to ensure double doors between the Healthcare center and Independent Living area remain closed. 8/23/24 7:13 PM - E1 (ED) provided a written removal plan to the State Agency via email. 8/26/24 - E1 provided additional sign in sheets for education regarding wandering, closing of the double doors, disabling of alarms and elopement dated 8/24/24. 8/26/24 - Staff interviews with E5 (FSD), E13 (RN), E23 (LPN), E24 (UC), E25 (LPN), E26 (H), E17 (CNA) confirmed the recent education. The facility completed the abatement on 8/24/24 at 2:30 PM. Findings were reviewed during the exit conference on 8/28/24 at 1:06 PM with E1 (ED), E2 (DON) and E3 (ADON).

Based on record review, staff interview, and review of hospital records, it was determined that the facility failed to ensure that one (R2) out of three (3) sampled residents reviewed for medication review was free from significant medication errors. R2 was ordered medication for a seizure disorder and the facility failed to ensure these significant medications were administered for three days after admission. This failure resulted in a change in condition, as evidenced by R2 being found unresponsive on 2/28/22 and was transferred to the hospital. R2 sustained harm when she did not receive five doses of Phenobarbital, an anti-seizure medication which resulted in R2 becoming unresponsive, having two uncontrolled seizures in the facility and required emergency transfer to the hospital for evaluation and treatment. R2 was also administered one dose of medication that she was not ordered. Findings include: Cross refer F580, example #2. The following was reviewed in R2's clinical record: 2/25/22 1:30 PM - R2 was admitted to the facility from another nursing home with diagnoses including epilepsy (seizure disorder). 2/25/22 - The previous nursing facility discharge orders sent to the facility upon R2's admission to the facility documented Phenobarbital 64.8 mg by mouth twice a day for epilepsy. 2/25/22 5:13 PM - A Physician Order was written for Phenobarbital 64.8 mg by mouth twice a day for seizures. 2/25/22 - R2's clinical record lacked evidence that R2 was administered her 9:00 PM dose of Phenobarbital. 2/25/22 11:52 PM - A Health Note by E10 (LPN, UM) documented that R2's medication review was completed with E5 (MD). 2/26/22 - Review of R2's clinical record lacked evidence that R2 was administered her 9:00 AM dose of Phenobarbital. There was lack of evidence of a hold order for the Phenobarbital for the two doses that were due on 2/25/22 at 9:00 PM and 2/26/22 at 9:00 AM. 2/26/22 9:00 PM - Review of the eMAR documented that E13 (Agency LPN) documented that Phenobarbital 64.8 mg was administered. However, on 2/28/22 at 3:58 PM, review of the State Agency's Incident Report revealed that the facility reported an incident in which R2 was administered Vimpat, an anti-seizure medication on 2/26/22 at 9:00 AM instead of Phenobarbital by E13. 2/27/22 9:00 AM and 9:00 PM - The eMAR lacked evidence that Phenobarbital was administered. 2/27/22 11:01 PM - A Health Status Note by E14 (RN) documented, Resident Phenobarbital on hold. Called Omnicare pharmacy who requested for order and script. NP on call made aware. 2/27/22 11:04 PM - Review of the corresponding Health Status Note, dated 2/27/22 and timed 11:04 AM by E19 (LPN, Agency Nurse) documented the medication was not given at 9:00 AM. The nurse placed a call to (name of the medical practitioner group) on call and a voicemail was left for a prescription to obtain the medication. 2/27/22 11:27 PM - An eMAR Administration Note documented Awaiting pharmacy delivery thus, the 9:00 PM Phenobarbital was not administered. 2/28/22 5:17 AM - A Health Status Note by E20 (LPN) documented, Received call from pharmacy re (regarding) Phenobarbital 64.8 mg. Dosage unavailable in facility start box. (E9/NP) notified and is unable to order Phenobarbital at this time. Pharmacy to Stat delivery of medication. 2/28/22 6:36 AM - A Health Status Note by E20 (LPN) documented, At approximately 0540 Resident requested to go (sic) BR. After assisting with transfer CNA called this nurse. Arrived to room and observed resident non (sic) verbally responsive but able to open eyes when called. L (left) hand weak. RN Supervisor notified to assess. 188/76, 78, 16 pulse ox 95% on RA (room air). Resident transferred back to bed. Daughter in law notified. Resident verbally responsive after transfer back to bed. L (left) hand/arm moving pushing staff away. Stated to nurse to 'go away and leave me alone.' Safety precautions maintained. On call notified. Lab unable to draw blood this a.m. 2/28/22 7:51 AM - A Health Status Note by E21 (RN) documented, At approx. 5:40 this RN was called by primary nurse to 2nd floor to assess a resident. Arrived at room and observed resident sitting in wc (wheelchair) not verbally responsive but able to open eyes when called. L (left) hand weak, resident transferred back to bed. Resident verbally responsive after transfer. L (left) hand/arm moving .On call notified and no new orders at this time. 2/28/22 8:41 AM - A Health Status Note by E10 (LPN, UM) documented Received resident awake, alert, verbal and interacting with staff. No distress noted, moving all extremities .Called to the spa room where resident was receiving a shower, observed her in an unresponsive state, both eyes was (sic) focused and glazed looking, tremor observe (sic), with heavy breathing. She was taken back to her room, O2 sat (saturation) 80% (low) on RA (room air), resident placed on O2 at 10 L (liter) via rebreather mask, O2 sat went up to 100%. E5 (MD) was in and came to assess the resident and 911 call placed and transferred at 8:50 AM. 2/28/22 9:14 AM- Review of the hospital emergency department (ED) records documented, .patient was admitted to the nursing facility 3 days ago. Reportedly they have been unable to give patient her Phenobarbital since admission. This morning patient had 2 witnessed seizures so was brought to the ED for evaluation and currently the patient has a headache which is consistent with other headaches she has after a seizure. On review of prior records, patient recently had a UTI which provoked seizures as well . 3/3/22 - Review of the hospital's discharge summary documented, .1. Seizures, 2. Epilepsy .presented to hospital on 2/28/22 after x 2 seizures after reportedly missing 3 days of her Phenobarbital. She had 1 x seizure in the ED which was ceased with 2 mg. Ativan (anti-anxiety medication). Her UA in the ED was positive for Pseudomonas (bacteria) and she was started on Cefepime (an antibiotic). She was admitted for seizures suspected to medication nonadherence, (did not receive Phenobarbital at NF (Nursing Facility) for 3 days) . 9/14/22 2:30 PM - An interview with E10 (LPN, UM) who verified the admission orders with E5 (MD) and entered the orders revealed the root cause of R2 not receiving her Phenobarbital was due to the previous nursing facility's failure to send the prescription for the Phenobarbital with R2. The facility failed to identify that their failure to obtain R2's Phenobarbital, a significant medication, contributed to the outcome. 9/15/22 2:00 PM - An interview was conducted with E3 (ADON) and E10 (LPN, UM). E3 confirmed that R2 was not administered five doses of Phenobarbital after admission on 2/25/22 and confirmed the medication error on 2/26/22 at 9:00 PM when R2 was administered Vimpat instead of Phenobarbital. The facility failed to ensure that R2 was administered her Phenobarbital as ordered resulting in an omission of five doses, a significant medication error resulting in seizure activity and hospitalization . In addition, R2 was administered the wrong anti-seizure medication. 9/16/22 beginning at approximately 12:55 PM - Findings were reviewed during the Exit Conference with E2 (Interim NHA and DON), E3 (ADON), and E4 (Clinical Specialist).

Based on interview, record review, review of the facility's policy, and review of the hospital records, it was determined that for one (R1) out of three (3) resident's sampled for urinary incontinence reviews, the facility failed to ensure that R1 received appropriate treatment and services to prevent urinary tract infections (UTIs). R1 had a known history of recurrent UTIs and was readmitted to the facility on [DATE]. From 7/7/22 through 7/13/22, the facility failed to identify a significant change of condition, a potential worsening of signs and symptoms (s/s) of UTI (lower abdominal pain and inability to urinate), they failed to immediately consult with the Attending Physician and failed to closely assess and monitor R1's condition. On 7/13/22, R1's son (FM1) requested that R1 be sent to the hospital due to worsening of s/s of UTI. Due to the above failures, R1 was harmed, requiring hospitalization and IV antibiotics. Findings include: The National Institute of Diabetes and Digestive and Kidney Diseases, a division of National Institutes of Health, information on bladder infections in adults identified risk factors for developing a urinary tract infection (UTI): female gender and inability to empty bladder completely (R1 had both risk factors). UTI prevention included drinking enough liquids (six to eight 8-ounce glasses of fluid), urinating often and when the feeling to urinate first happens since bacteria can grow when urine stays in the bladder too long. (https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-infection-uti-in-adults) Review of the facility's policy titled Urinary Continence and Incontinence -Assessment and Management, with a revision date of September 2010, stated, POLICY STATEMENT .5. Identification and management of urinary tract infections will follow relevant clinical guidelines. Antibiotics will be used appropriately . Cross refer F580, example 1. Cross refer F641. Cross refer F713. Cross refer 842. Review of R1's clinical records revealed the following: 2/5/20 - R1 was admitted to the facility. 4/28/22 - R1 was transferred to the hospital. 5/3/22 - R1 was readmitted to the facility with a primary diagnosis of chronic respiratory failure with hypoxia. 5/4/22 - The 5 day MDS assessment documented that R1 remained independent with daily decision making with a BIMS of 14, required extensive assist of two (2) plus staff for transfers, extensive assist of one (1) for toileting, hygiene and dressing, and was occasionally incontinent of urine, always incontinent of bowel and had no UTIs in the last 30 days. 5/6/22 - A Physician's Order was written by E5 (MD) to monitor the resident every shift for s/s of UTI and document. 5/9/22 - A Physician's Progress Note by E5 (MD) documented, .Dysuria . History of Present Illness: .Nursing reports that patient with complaints of dysuria. The patient was requesting additional testing. Her urine was tested with dipstick analysis. This was unremarkable. Consequently no further testing was ordered. The patient reports improvement in her symptomatology. She did undergo laboratory testing earlier today. Results pending at this time .Dysuria. Appears intermittent and chronic in nature. Patient and family requesting work-up due to symptomatology. Appears self-limiting at this time. Urine dip analysis unremarkable. Avoid unnecessary testing and indiscriminate antibiotic use especially in light of multiple drug allergies. Patient remains at risk for antibiotic resistance . 6/13/22 11:59 PM - A Physician's Order was written to collect urine for UA and C & S. May straight cath for UA and the indications were due to s/s of pressure, frequency and urgency of the bladder. 6/14/22 - A Review of the Medication Notes documented the following: - 5:21 PM - R1 had right sided pain with a pain rating of 3 out of 10 and was administered pain medication. - 10:46 PM - R1 had nausea and one episode of vomiting and was administered medication to treat nausea. - 10:57 PM - R1 had right upper quadrant abdominal pain and was administered pain medication. 6/15/22 - A Progress Note by E7 (MD, covering Physician for R1's Attending Physician [E5]) stated, . Urinary symptoms including frequency, burning, and right flank discomfort .for the last several days been complaining of dysuria, frequency and incontinence. Last night she had some right flank and right upper abdominal discomfort. She feels this is one of her urine infections which she gets about twice a year . LABS/ . Urinalysis and culture on June 14 3+ leukocytes and greater than 100 WBCs noted PCR noted high levels of Proteus Mirabilis and Enterococcus and B fragilis but this specimen was not a catheterized urine and was likely contaminated. Acute cystitis without hematuria . We will start nitrofurantoin therapy for her acute urinary tract infection Discussed allergies can occur since patient seems to be getting 1 about twice a year . 6/15/22 - A Physician's Order was written for Nitrofuratoin Macrocrystal (Macrobid, an antibiotic) capsule 100 mg twice a day for 7 days for an indication of UTI. 6/15/22 at 5:00 PM and 6/16/22 at 9:00 AM - The electronic Medication Administration Record (eMAR) documented that Macrobid was administered to R1. 6/15/22 2:25 PM - A Physician's Order was written to discontinue the Macrobid. 6/15/22 6:28 PM - A preliminary urine culture result revealed 75,000 gram negative rods, 75,000 gram negative cocci and a possible additional organism with C & S pending. A handwritten note stated, ok to D/C (Discontinue) Abx (antibiotic). 6/18/22 12:19 PM - The final urine C & S report documented #1 organism 75,000 Klebsiella Pneumoniae, #2 organism 75,000 Proteus Mirabilis, #3 organism Enterococcus Faecalis. This report included the following handwritten notes by staff of the facility: - By E15 (RN) 6/18/22 7-3 called MD . - By E14 (RN) NP (E9) notified N.O. (new order) Fosfomycin 3 gm one time. - By E5 (MD) (Initials of E5 [MD] 6/23/22. 6/18/22 - A Physician's Order was written by E5 (MD) for Fosfomycin Tromethamine (Monurol, an antibiotic) 3 grams by mouth for one dose for UTI. 6/19/22 2:51 PM - The eMAR documented the administration of Monurol 3 gm by mouth. 6/27/22 - A Physician's Progress Note by E5 (MD) stated, . Urinary frequency and urgency. Questionable urinary tract infection . The patient continues to have complaints of urinary frequency and urgency. She was recently treated for urinary tract infection with single dose of Fosfomycin therapy. The patient reports some intermittent dysuria. She denies any incontinence, abdominal or flank pain. She denies fever or chills. We did review the possibilities of other medical issues which may be contributing to her symptomatology . Urinary frequency associated with urgency and intermittent dysuria. Does not appear to be related to urinary tract infection . Appears more likely related to overactive bladder. Will start patient on Myrbetriq therapy. Continue to monitor status, Additional work-up and treatment as indicated. Consider urology evaluation . 6/27/22 - A Physician's Order was written for Myrbetriq ER (extended release) 25 mg by mouth daily at bedtime related to overactive bladder. 6/29/22 2:58 PM - A Physician's Order was written by E5 (MD) for UA (urinalysis) and C & S for UTI monitoring. 6/30/22 5:08 PM - A Progress Note by E10 (LPN, UM) documented, Received residents UA results called in to (E5/MD). Clarity is turbid, 1+ protein, positive nitrate, 3+ leukocytes, 25-50 WBC/HPF, +4 bacteria, rare epithelial cells and rare hyaline casts. No new order, pending C & S. Resident and family made aware. 6/30/22 - A Physician's Progress Note by E5 (MD) stated, .Family concerns Extensive discussion with patient's son in addition to facility staff as documented below .Summary of Plans .Goals: Extensive discussion with patient's son (Name of R1's son) via telephone regarding multiple issues Discussed patient's complaints of recurrent urinary symptomatology Reviewed patient's history of multiple diagnosed urinary tract infections Reviewed most recent urine culture which revealed polymicrobial growth For organisms were noted each with less than 100,000 colonies of growth Reviewed treatment at that time which included Macrobid which was changed to a single dose of fosfomycin secondary to resistance patterns Explained at length concerns are regarding indiscriminate antibiotic use due to resistance patterns noted Discussed patient's multiple drug allergies limiting options regarding antibiotic therapy if indicated Reviewed my most recent visit with the patient a couple of days ago Suggested that her symptomatology may be related to overactive bladder rather than infection Family insisted on additional urinary testing Urine dipstick testing was positive for bacteria Urinalysis sent out this morning Explained rationale for no empiric treatment until urine culture results back Patient's son became increasingly upset Conversation deteriorated as he became more argumentative, confrontational and condescending Suggested he might be more comfortable finding another physician to care for his mother Emailed corporate staff to apprise them of the situation Reviewed at length with director of nursing and executive director at facility At this time will await final urine culture results to determine if any additional medical treatment is indicated Will await family decision regarding primary care provider . 7/5/22 10:59 AM - A Health Note by E10 (LPN, UM) stated, Received residents C & S results called to (E5/MD) with no new orders. Organism 1 Klebsiella Pneumonise with colony count of 75,000, Organism 2 is Proteus Mirabilis with colony count of 75,000, Organism 3 is Enterococcus Faecalis with colony count of 75,000. Resident made aware of lab results and no ordered treatment due to colony count been (sic) less than 100,000 . 7/6/22 9:55 AM - A Health Note by E17 (Agency LPN) stated, This shift, resident complaining of frequency, urgency, and burning on urination. VSS (vital sign stable) and will continue to monitor. There was lack of evidence that E5 (MD), R1's Attending Physician was notified of the possible s/s of UTI. 7/6/22 Untimed - A meeting note by E18 (MSW) documented that R1, along with R1's family members, FM1 and FM2, requested to change R1's Attending Physician and the facility was to coordinate the change. 7/7/22 - A Physician's Order entered by E10 (LPN, UM) stated that the Attending Physician changed to E6 (MD) and R1 was no longer under the care of E5 (MD). 7/10/22 7:50 AM - A Health Note by E16 (LPN) documented Resident c/o lower abdominal pain 6/10, offered Tylenol 650 mg tabs (Administered on 7/10/22 at 5:57 AM), results pending. Resident stated she feels her bladder is full but could not urinate and will like to [be] straight cathed. On call for (E6/MD) paged twice no call back yet, f/u by nurse on next shift . 7/10/22 12:51 PM - A Health Note by E12 (RN Supervisor) documented, Resident out of bed in w/c stated she feels better at this time, denies pain with urination, frequency, and urgency. (E6/MD) called awaiting response. 7/10/22 - A Physician's Order entered by E12 (RN Supervisor) and obtained from E6 (MD) stated, Alert Charting to monitor for urinary output and urinary discomfort every shift for 3 days. There was lack of evidence that the facility consulted R1's Attending Physician regarding the significant change of condition, as evidenced by a new onset of lower abdominal pain 6/10, inability to urinate, and that R1 requested to be cathed as documented in the 7/10/22 Health Status Note timed 7:50 AM. 7/10/22 thru 7/13/22 - Review of the eMAR stated to monitor for urinary output and urinary discomfort every shift for 3 (three) days. The staff documented checks per shift, however, there was no other information in R1's clinical records related to monitoring the frequency of urination and/or the amount of R1's urinary output. There was lack of evidence of the facility monitoring R1's urinary output following R1's complaint that she was unable to urinate. 7/11/22 3:48 PM - A Health Status Note by E10 (LPN, UM) documented, Called (E6/MD)'s answering service this afternoon to find out when MD will be able to come see resident per resident's request. Pending call back. 7/12/22 11:17 PM - A Health Status Note by E15 (RN) documented, Resident stable and alert. Able to make needs known to staff. Minimal urinary discomfort and minimal amounts of dark, amber, slightly cloudy urine noted. MD aware. Afebrile (no fever) . There was lack of evidence that R1's Attending Physician was notified of R1's complaints of urinary discomfort and the dark amber and slightly cloudy urine. 7/13/22 10:34 AM - A Health Status Note by E17 (Agency LPN) documented Resident alert and oriented able to make needs known, resident c/o dysuria. Tylenol offered and refused. VSS. Call bell within reach. Again, there was lack of evidence that R1's complaints of possible worsening UTI s/s were communicated to R1's Attending Physician. 7/13/22 1:07 PM - A Health Status Note by E10 (LPN, UM) documented, Resident's son (FM1) called this afternoon and spoke to nurse about resident c/o back pain and dysuria. Son requested resident to be sent out to ER for evaluation. Nurse told son an order would have to be obtained from attending physician prior to sending resident out. No c/o of pain or dysuria to staff. Spoke to resident who confirmed what son had said about going to ER for eval. Per resident she had pain on and off yesterday and currently is experiencing pain associated with urination, pressure and frequency. Resident has had 2 UA C&S done and both results were less than 100,000. Call placed to (E6/MD) who gave order to sent (sic) resident out to ER for eval. 911 called, pending arrival. Son (FM1) called and updated. Resident made aware. 7/13/22 9:55 PM - A review of the hospital Emergency Department (ED) records revealed: . ED Physician Record documented, Triage Chief Complaint . upper back pain, dysuria . History of present illness . female with .several weeks of dysuria and urinary frequency now with right sided flank pain .patient reports has been having urinary urgency and frequency for roughly 6 weeks. She has had multiple positive urinalysis but the cultures showed 75,000 CFU she did not meet some criteria for antibiotic treatment. She continued to have urinary symptoms and how has had progressive worsening pain in the right flank and right upper abdomen. She was referred to emergency department for further evaluation . Assessment and Plan . Urine here does suggest infection. Creatnine 1.3 with most recent of 0.6 suggesting AKI. Exam concerning for ascending UTI, possible pyelonephritis or obstruction. She will be evaluated with CT of the abdomen as a kidney stone protocol . will cover with IV antibiotics and IV hydration. I anticipate hospitalization for ongoing care . Final impression: Choledocholithiasis (gallstones), UTI . 7/15/22 8:25 AM - A review of the hospital's final Urine C & S report, related to the urine specimen obtained on 7/13/22, documented, .>100,000 CFU/ml mixed gram negative and gram positive growth. Mixed flora may represent colonization or contamination. Repeat collection if clinically indicated . 7/16/22 - A review of the hospital's Discharge Summary documented the following discharge diagnoses, 1) sepsis 2) UTI 3) New onset Afib. 9/8/22 beginning at approximately 12:30 PM - An interview with E5 (MD) revealed he was R1's Attending Physician until E6 (MD) became R1's new Attending Physician. E5 recalled, although R1 insisted on having a UTI in late June and early July 2022, based on her medical history, it was E5's opinion that she did not have UTI, as documented in E5's Progress Note dated 6/30/22, therefore, E5 did not order an antibiotic after the results of the urine C & S on 7/5/22. 9/9/22 10:43 AM - An interview with E2 (Interim NHA and DON) revealed Alert Charting was ordered by the Physician and specific interventions would be ordered. E2 was asked What does monitoring urine output mean? E2 replied It was not clear, maybe frequency of urination? 9/9/22 11:40 AM - A telephone interview was conducted with E6 (MD) who stated he received a call from the facility requesting for him to be the new Attending Physician for R1 and E6 stated he would begin as R1's Attending Physician once he assessed the resident during the next routine visit to the facility. E6 stated that he does not recall receiving any telephone calls from the facility related to any potential s/s of UTI or ordering Alert Charting for monitoring urinary output. E6 stated for monitoring urinary output, he would expect minimally, that frequency and volume be documented, however, again, E6 stated he does not recall ordering Alert Charting on 7/10/22. 9/11/22 3:00 PM - An interview with E15 (RN) revealed that she does not recall if she reported the above possible s/s of UTI as documented on the Health Status Note dated 7/12/22 and timed 11:17 PM. E15 was asked what she meant by MD aware and in response, E15 stated, They all knew. E15 did not recall if she notified R1's Attending Physician of these s/s of UTI. 9/12/22 12:15 PM - During a follow-up interview, E5 (MD) communicated to the Surveyor that he was advised by his corporation that he was no longer to have any conversation with the Surveyor. E5 stated if this changes, he will notify the Surveyor. 9/12/22 1:30 PM - An interview with E12 (RN Supervisor) in the presence of E3 (ADON) was conducted. E12 worked day shift on 7/10/22 and recalled during shift report that she was made aware by the ongoing nurse (E16/LPN) that he had paged E6 (MD), however, no return call was received. In addition, E12 stated that the 7/10/22 order for Alert Charting was a nursing intervention by her, thus, E6 (MD) was not consulted regarding R1's complaint of lower abdominal pain, inability to urinate, and R1's request to be catherized. 9/12/22 beginning at 5:00 PM - During a telephone interview with FM2 (R1's Family Member), FM2 stated that R1's urine was malodorous (foul smelling) and murky and was observed by another family member (FM1) and E15 (RN) on 7/12/22. 9/13/22 12:30 PM - A written document from E2 (Interim NHA and DON) confirmed that the facility was unable to provide evidence that R1's Attending Physician was consulted when R1 experienced potential worsening s/s of UTI on 7/6/22 at 9:55 AM, 7/10/22 at 5:57 AM, and 7/12/22 at 11:27 PM. 9/16/22 beginning at approximately 12:55 PM - Findings were reviewed during the Exit Conference with E2 (Interim NHA and DON), E3 (ADON), and E4 (Clinical Specialist).

Based on clinical record review, interview, hospital record review, professional clinical resources, and review of other documentation as indicated, it was determined that for one (R52) out of one sampled residents, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent a pressure ulcer and ensure that a pressure ulcer does not develop unless clinically unavoidable. R52 was admitted to the facility without any pressure ulcers. R52 was at risk for pressure ulcers due to immobility and other medical diagnoses. The facility lacked evidence of turning and repositioning R52 to prevent pressure ulcers. On 12/23/18, the facility identified R52's skin alteration and conducted partial assessments. The assessments were not accurate and were contradictory in regard to the location, size, and description of the wound. From 12/23/18 to 12/26/18, the facility documentation continued to lack evidence of thorough assessments of R52's skin and the facility, therefore, failed to identify R52's pressure ulcer. This resulted in harm when R52 was sent to the hospital on [DATE] from [MEDICAL TREATMENT] and was diagnosed with [REDACTED]. coli bacteremia. R52 continued treatment with IV antibiotics and underwent a debridement of the left ischial pressure ulcer in the hospital. Findings include: According to the National Pressure Ulcer Advisory Panel (April (YEAR)), the stages of pressure injuries/ulcers (categorization system used to describe the severity of PUs): Stage I (1) - a reddened area of intact skin usually over a boney prominence, that when pressed does not turn white. This is a sign that a PU is starting to develop. Stage II (2) - skin blisters or skin forms an open sore. The area around the sore may be red and irritated. This stage should not be used to describe MASD. Stage III (3) - skin develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Undermining may occur. Stage IV (4) - ulcer has become so deep that there is damage to the muscle and bone and sometimes to tendons and joints. Unstageable - Tissue loss in which actual depth of the ulcer is unable to be determined due to the presence of slough (yellow, tan, gray, green or brown dead tissue) and/or eschar (dead tissue that is tan, brown or black and tissue damage is more severe than slough in the wound bed). The NPUAP Prevention and treatment of [REDACTED].Additional Recommendations for Individuals with Existing Pressure Ulcers 1. Do not position an individual directly on a pressure ulcer .Continued pressure on an existing pressure ulcer will delay healing and may cause additional deterioration. Review of R52's clinical record revealed: 2/7/18- R52 was admitted to the facility with [DIAGNOSES REDACTED]. 2/7/18- A care plan was initiated for R52, which stated that R52 had potential for impairment of his/her skin integrity. Interventions included to have R52 on a low air loss mattress, to monitor/document the location, size, and treatment of [REDACTED]. 2/14/18- Review of R52's admission MDS assessment revealed that R52 did not have any pressure ulcers. 11/12/18- Review of R52's quarterly MDS assessment revealed that R52 required extensive assistance of two staff for bed mobility (included the ability to turn side to side and position self while in bed). It was documented that R52 was at risk for pressure ulcers, and did not have any current pressure ulcers. November (YEAR)- Review of R52's Documentation Survey Report (tool where CNAs would document turning and repositioning) revealed that staff did not document turning and repositioning of R52 for the entire month. 12/21/18- The [MEDICAL TREATMENT] nurse stated on the [MEDICAL TREATMENT] Communication Record that R52 was having a lot of pain to his/her bottom and needed to get a seat cushion for [MEDICAL TREATMENT]. There was no evidence that the facility completed a skin assessment of R52's bottom on this date. 12/23/18 Evening Shift (3:00 PM-11:00 PM)- R52's Documentation Survey Report indicated that during a skin check E16 (CNA) noted a new open area on the residents skin (location not documented). 12/23/18- An Initial Wound Review form was completed by E15 (LPN) and documented that R52 had a 2.0 cm x 2.0 cm wound to his/her left buttock. The wound bed was documented to be brown with minimal drainage. 12/23/18 6:57 PM- A Skin & Wound Evaluation form documented that R52 had a new blister to his/her right rear thigh that was in-house acquired. It was documented to be a 10.2 cm area with a length of 3.9 cm and width of 3.5 cm. The primary dressing was documented to be a [MEDICATION NAME] dressing. There were discrepancies between the location, size, and description of the wound in this assessment and the Initial Wound Review completed on the same day. 12/23/18 7:04 PM- A progress note by E4 (RN Unit Manager) stated that the unit manager was called by E15 (LPN) to assess a left thigh wound. R52 was observed to have an open blister to the area with hardness of the surrounding tissue. There was no description of the wound bed or size documented by E4. 12/23/18 7:08 PM- A physician order [REDACTED]. This was another discrepancy in the location that was documented on prior assessments the same day. 12/23/18 7:10 PM- A progress note stated that the treatment was applied to R52's left inguinal area and clarified that the dressing was not applied to R52's left thigh. 12/23/18-12/25/18- Review of R52's EMAR/ETAR revealed that staff failed to document application of R52's [MEDICATION NAME] dressing. 12/24/18- The [MEDICAL TREATMENT] nurse stated on the [MEDICAL TREATMENT] Communication Record that R52 complained of a lot of pain to the left buttock and requested that the facility please follow up for a special cushion and pain management. This was the second reference to R52 having left buttock pain and the facility again failed to document an assessment of the resident's pain site. 12/25/18 6:56 AM- R52 was administered [MEDICATION NAME] 325 MG 2 tablets was administered for a complaint of buttock pain. There was no documentation that nursing assessed R52's buttocks at that time. 12/25/18 1:49 PM- R52 was noted to be more tired this shift with some confusion. Vital signs were documented as stable. There was no assessment of R52's buttocks noted. 12/25/18 3:02 PM- A progress note stated that a physician telephone order was obtained for R52 to receive [MEDICATION NAME] 500 mg twice daily for 7 days for a wound infection (wound location not specified). There was no documented assessment of R52's wound. 12/26/18 5:48 AM- R52 received [MEDICATION NAME] 325 MG 2 tablets for an elevated temperature of 100.7 F. 12/26/18 7:18 AM- A progress note stated that R52 was ready for pick up for [MEDICAL TREATMENT]. Vital signs were taken and documented in R52's [MEDICAL TREATMENT] book. R52's temperature was noted to be 100.7 F and Tylenol 650mg given was given at 5:48 AM. Upon recheck at 7:05 AM, R52's temperature was 100.1 F. 12/26/18- A [MEDICAL TREATMENT] Communication Record documented that upon arrival to [MEDICAL TREATMENT], R52's blood pressure was 92/45, temperature was 100.6 F, and pulse was 114. Repeat vital signs were taken, time unknown, and R52 had a blood pressure of 83/42, temperature was 100.8 F, and pulse was 124. The [MEDICAL TREATMENT] nurse stated that [MEDICAL TREATMENT] was not initiated and that R52 complained of severe pain to his/her left gluteus. Per physician orders, R52 was sent to the emergency room from the [MEDICAL TREATMENT] unit for evaluation and treatment for [REDACTED]. December (YEAR)- Review of R52's Documentation Survey Report revealed that staff did not document turning and repositioning of R52 for the entire month prior to him/her being discharged to the hospital. 12/26/18 10:00 AM- Review of R52's hospital ED Physician Record revealed that on R52's left gluteal he/she had a stress and pressure ulcer present. When the physician inquired if the facility knew about the wound, R52 stated that he/she thinks the nursing home knew about the wound and was not sure if he/she was seen for wound care at the facility. The physician documented that on R52's left gluteal region near the anus 4 cm in diameter ulcer present with clotting blood and purulence present . The plan was to order wound cultures, blood cultures, CT Scan, labs, and start IV antibiotics. 12/26/18 5:54 PM- Review of R52's hospital History and Physical revealed that in the ED, R52 had transient low blood pressures, dipping down as low as 88/61 with [MEDICAL CONDITION] the 110's. R52 was febrile with a temperature of 37.9 C (100.2 F) and inspection of his/her sacral area showed a large ulcerated purulent and bloody 4 cm wound with surrounding [DIAGNOSES REDACTED] that was painful on palpation. A follow up CT scan revealed bilateral decubitus ulcers with an abscess on the left. 12/27/18- An Incident Report Form was completed by the facility and stated that on 12/23/18, R52 was noted to have an open area to the left buttock. It was documented that the physician was notified, the wound was cleansed, and a [MEDICATION NAME] dressing was applied. The investigation report interview stated that at about 7:10 PM, E16 (CNA) reported that R52's buttock was bleeding. Upon assessment, an open area was noted to the left buttock, which measured 1.0 cm x 1.0 cm with minimal bloody drainage, and the resident complained of pain when the site was touched. This was another documented discrepancy in the documented size, location, and description of the wound from prior facility assessments. The outcome noted that the resident was currently at the hospital. 12/27/18 10:07 AM- Review of R52's hospital record revealed a consult note from the plastic surgeon stating that R52 had a left ischial pressure ulcer with necrosis and non stagable. The plan was for debridement tomorrow (12/28/18). 12/29/18 9:02 AM- Review of R52's final wound culture report revealed growth of [MEDICAL CONDITION] and E. coli bacteria. 1/1/19 3:54 PM- Review of R52's final blood culture report revealed growth of E.coli bacteria. 1/8/19 12:42 PM- Review of R52's hospital Discharge Summary revealed that during his/her stay, R52 received three IV antibiotics per infectious disease recommendations. Plastic surgery completed a debridement of R52's wound, a wound VAC was placed, and R52 would be discharged with it in place. R52 was to receive IV antibiotics as an outpatient until 1/18/19 due to his/her infected wound and bacteremia. R52 was to follow up with the infectious disease and plastic surgery physicians as an outpatient. 1/9/18 10:51 AM- An Operative/Procedure Report stated that on 12/28/18, R52 had an excisional debridement of a stage 4 left ischial ulcer. It was documented that the wound measured 4 x 4 x 3 cm. 2/5/19- Review of a follow up note from the plastic surgeon revealed that R52's pressure ulcer was healing well and was now 1 x 1 x .3 cm. 2/26/19 12:40 PM- Review of R52's progress notes revealed his/her wound resolved. 3/22/19 approximately 9:00 AM- During an interview, E12 (Medical Director) stated that he/she was on call when R52's wound was identified on 12/23/18 and when R52's wound required antibiotics on 12/25/18. E12 stated that he/she never observed the wound and just trusted the nurse's assessments. 3/22/19 11:55 AM- During an interview with E2 (DON), it was confirmed that prior to R52 going to the hospital on [DATE], his/her wound was not observed by any physician or a wound care nurse. 3/22/19 at 2:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON, and E3 (ADON). The facility failed to: - have evidence of turning and repositioning R52, a resident who was an extensive assist for bed mobility and at risk for pressure ulcers. -complete an assessment of R52 when notified by a [MEDICAL TREATMENT] nurse that R52 was having a lot of pain to his/her bottom. - conduct a thorough and accurate assessment of R52's left ischial wound on 12/23/18 when the wound was first identified by the facility. - conduct thorough, accurate and consistent assessments of the left ischial wound from 12/23/18 through 12/26/18. These failures resulted in harm. On 12/26/18, R52 was sent to the hospital (from a [MEDICAL TREATMENT] facility) where R52 was diagnosed with [REDACTED]. R52 was placed on IV antibiotics and underwent surgical debridement of the wound while in the hospital.

Based on observation and interview it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as is possible for 9 (R83, R99, R111, R131, R140, R212, R215, R216, and R217) out of 101 stage 1 residents. The listed residents resided in rooms 134, 135, 136, 137, and 139 (there were 2 residents in 4 of the rooms and 1 resident in a room by herself). The bathroom doors (accordion style) locked on the inside and were unable to be opened from the outside by staff; thereby the facility lacked the ability to have rapid access to remove the affected residents in an emergency such as fire, falls, and other urgent and emergent medical conditions such as a stroke or heart attack. The doors had a small keyhole on the outside, however, facility staff did not carry keys to open the doors or know that they existed. Findings include: On 10/27/14 at approximately 1:00 PM, a surveyor was in room 135 when a family member advised the surveyor that the bathroom door in the room locked on the inside, but could not be opened from the outside. The visitor stated they were concerned about something happening to a resident while inside the locked bathroom and no one being able to get in to help. After confirming the family members concern regarding the bathroom door, the surveyor interviewed E3 (maintenance worker) on 10/27/14 at 1:03 PM. E3 stated he was unable to get into the bathroom in room 135 when the surveyor locked himself in the bathroom and stated he could remove the locks and use magnets to close the doors to correct the problem. Two surveyors toured the building on 10/27/14 at approximately 1:05 PM and checked all resident bathroom doors to ascertain which ones were affected. It was determined that rooms 134, 135, 136, 137, and 139 were affected for a total of 9 residents. E4 (CNA) was interviewed on 10/27/14 at 1:15 PM. E4 stated she had worked in the facility for about 2 months and replied she did not know how she would get into one of the locked bathroom doors after the surveyor demonstrated by locking herself into one of the affected bathrooms. E4 was unable to open the door from the outside. E5 (maintenance assistant) was observed working on a light fixture in one of the affected rooms on 10/27/14 at 1:20 PM. E5 stated he had worked in the facility since spring and responded "I don't know" when asked what he would do if a resident was locked in the bathroom and needed help. After showing E5 a small round hole that was observed on each of the affected bathroom doors, the surveyor asked E5 what the hole was for and E5 replied it was a "simple keyhole." The surveyor asked if he had a key for the door(s) and he replied he did not know, then he looked through his keys and found one that fit in the lock. E6 (LPN) was interviewed on 10/27/14 at 1:25 PM. E6 confirmed she was the day shift nurse assigned to the affected rooms on this date and stated she had worked at the facility for 7 years on an as needed basis all over the facility. When asked how she would get into a locked resident bathroom, E6 replied she would "break the door down." E2 (DON) was interviewed on 10/27/14 at 1:30 PM. After the surveyor locked herself in one of the affected bathrooms, E2 confirmed he was unable to open the door. When asked what he would do, E2 stated that the maintenance director had recently left. E2 also stated that no residents had been affected by this; the surveyor replied there was potential for residents to be locked in the bathrooms and in need of help. E1 (NHA) was interviewed on 10/27/14 at approximately 4:00 PM and advised that the inability of staff to rapidly unlock and remove residents in the affected bathrooms was an immediate jeopardy (IJ). Findings were confirmed with E1. At 4:20 PM, E1 advised the surveyor that the issue was abated. Tour of the affected rooms at 4:22 PM with E1 confirmed that E3 (maintenance worker) removed the lock mechanisms from the doors and the IJ was abated at this time. The following two (2) examples were identified during Stage 2 of the annual survey and are not included in the above Immediate Jeopardy identified during Stage 1. Consequently, the following based on statement refers only to these two (2) examples. Based on observations, record reviews and interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards and received adequate supervision and assistance devices as is possible for 2 (R30 and R79) out of 28 Stage 2 sampled residents. For R30, the facility failed to perform a proper transfer from bed to wheelchair using a sliding board (assistive device used to transfer between surfaces when residents are unable to use their legs) and 2 staff, which resulted in R30 being lowered to the floor (fall) without injury. For R79, the facility failed to ensure that her assistive devices (alarms) were functioning. Findings include: The facility policy entitled, "Fall Management & Investigation Program", last reviewed on 7/2/13, stated, "... Purpose: to utilize all reasonable efforts to provide a system to review the resident's risk potential for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify resident's continued needs ...". 1. R30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], stated R30 was moderately impaired for daily decision making and required total assistance with transfers with two staff members. R30 was care planned for self care deficit, last reviewed on 10/14/14, with interventions that included "... Transfers with 2 person assist ... slideboard txfers (transfers) bed <-> (vice versa) w/c (wheelchair) c (with) gait belt Ext (extensive) (A) (assist) x 2 ...". In addition, R30 was care planned to be at risk for falls, last reviewed on 10/14/14, with interventions that included "... recommend to use transfer board ...". The facility's incident report form, dated 9/15/14 and timed 5:00 PM, stated that R30 was "lowered to the floor by CNA attempting to transfer ... from bed to wheelchair. No apparent injury noted ... Referral made to rehab (rehabilitation)". Although R30 was to be transferred with 2 staff members, she was transferred with one. The facility's investigation report, dated 9/15/14, revealed that E33 (CNA) stated, "Resident was lowered to the floor while being transferred from bed to wheelchair when resident's legs buckled under her". The Occupational Therapy's Treatment Flow Sheet, dated 9/16/14, stated, "Per report ... 'lowered to floor' last night ... assisting her to w/c not clear but appears sliding board was not used for transfer ... continue to recommend slide board for safe functional transfers ...". In an interview on 11/7/14 at 12:17 PM, E3 (ADON) confirmed the findings of an improper transfer which resulted in R30 being lowered to the floor without injury. The facility failed to ensure R30 was properly transferred from her bed to her wheelchair using a sliding board and with 2 staff members. 2. Review of R79's Quarterly MDS assessment, dated 9/2/14, revealed that R79 was coded as severely impaired for decision making and had a history of [REDACTED]. On 11/7/14 from 9:28 AM to 10:45 AM, R79 was observed sitting in her wheelchair in front of the nurse's station, people watching and conversing with other residents and staff. During an observation on 11/7/14 at 10:45 AM, R79 stood up from her wheelchair, removed her chair sensor/pressure alarm from under her and then replaced it, however, the alarm failed to sound. E10 (UM) went over and redirected R79 to sit back down, but failed to identify that the chair alarm had not sounded. E10 then proceeded to move R79 to another area for activities. The surveyor stopped E10 and asked why the chair alarm had not sounded. E21 (CNA) came to assist E10. They stood R79 up and again, the alarm failed to sound. E10 stated that staff should be checking that the alarms are functional (working properly) when the resident is placed in the wheelchair and the bed. E10 stated that the battery needed to be changed. When asked who was responsible to check the batteries and how often they were checked for functionality, E10 stated that staff should check them whenever they move or transfer residents. When asked if there was anywhere that staff document that they check the functionality of alarms, she stated, "no". On 11/7/14 at 10:50 AM, E24 (assigned CNA), replaced the battery in R79's chair alarm. E24 transferred a battery from one of R79's bed alarms into the chair alarm. E24 denied checking the functionality of any of R79's alarms that morning, stating that R79 was already up in her wheelchair when he received her at the beginning of his shift. On 11/7/14 at 10:55 AM, E10 and E24 were interviewed. E10 confirmed that she did not notice that R70's alarm failed to function when the resident stood up from her wheelchair. E24 stated that E10 gave him a new battery, but when he placed it in R79's chair alarm, the alarm remained non-functional. E24 stated that he went to the resident's room to get another alarm since they were interchangeable. E24 stated he then placed the new battery from the nonfunctioning chair alarm into one of the bed alarms which also had a dead battery. A third alarm was functional. R79 had 3 alarms, one chair and two bed alarms to be placed on either side of her bed. On 11/7/14 at 11:05 AM, during an interview, E10 stated that she only had one new battery and she had just brought more batteries and a new alarm. When informed about the other nonfunctioning alarm in R79's room, she stated that she was unaware of that. On 11/7/14 at 11:20 AM, E10 informed the surveyor that a tab alarm (pull cord alarm clipped on the back of the resident's clothing so that if they move too far the pull cord will release the magnet or tab and the alarm will sound) was being added to R79, in addition to her chair and bed alarms. During an interview on 11/7/14 at 2:15 PM, E11 (assigned LPN) was asked about resident alarms and to explain what was being documented on the TAR. She stated that documentation on the TAR was for both the use and functionality of the alarms. E11 stated that she checked on her residents throughout the shift, but not necessarily at the beginning of her shift. E11 stated that if the CNAs have a problem with an alarm, they will report it to nursing. E11 stated that R79 was already seated in her wheelchair across from the nurse's station when she came on duty. E11 stated that R79 was taken to her bathroom for morning care and the CNA would have told her if the alarm was not working. E11 denied checking R79's alarms that morning and stated the CNAs would have checked the alarms when they dressed or toileted R79 in the morning. The surveyor informed E11 that E24 denied checking R79's alarms and the TAR lacked evidence that R79's alarms were checked for function. R79's care plan, dated 3/19/14 and entitled, "Risk for falls R/T (related to) Hx (history) of falls... listed approaches included, "...fall/safety devices - fall mat/fall alarm...fall alarm to bed/wheelchair--whichever resident is occupying - poor safety awareness...sensor alarm @ (at) bedside... Pressure sensor alarm mat @ bedside AAT (at all times) - while resident in bed...". Despite the need for continuous alarms, the facility failed to ensure that 2 of 3 alarms for R79 were functional. Additionally, review of R79's CNA Care Card, lacked evidence of R79 having alarms. The facility failed to ensure that R79's assistive devices (alarms) were functioning and failed to identify that R79's sensor alarm was not functioning on 11/7/14 at 10:45 AM, when R79 stood up from her wheelchair and the alarm failed to sound.

Based on observation, record review and interview, it was determined that the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to restore as much bladder function as possible for four (R4, R30, R70, and R107) out of 28 Stage 2 sampled residents. The facility failed to accurately assess R107's urinary status upon admission, failed to evaluate a 3 day voiding diary and failed to care plan accordingly based on the resident's individualized needs. As R107's urinary continence declined, the facility failed to comprehensively reassess and they again failed to care plan based on the individualized needs. Although the facility revised the care plan on 9/12/14 to toilet R107 at specific times, there was no evidence that this was being done. R107 was incontinent of bladder on eight (8) out of 55 shifts in June 2014, and progressed to being incontinent on 87 out of 93 shifts in October 2014. The facility failed to attempt to prevent a decline or maintain normal bladder function for R4 by failing to comprehensively assess R4's urinary incontinence on admission; failing to follow R4's incontinence care plan intervention to complete a bladder assessment; failing to identify that R4's bladder function was not recorded consistently by CNA's from 6/30/14 through 10/31/14; failing to identify a potential cause for R4 being treated for [REDACTED]. For R30, the facility failed to comprehensively assess R30's bladder function three times since admission and failed to identify potential causes for two UTI's, which resulted in two hospitalization s. For R70, the facility failed to evaluate a 3 day voiding diary, failed to individualize a care plan based on the resident's toileting needs, and failed to follow R70's toileting schedule. Findings include: The facility policy entitled "Bladder Elimination Assessment," revised 6/30/06, stated, "...Each resident will be assessed on admission to determine bladder continence or incontinence. If it is determined that the resident is incontinent an in-depth assessment will be completed using the Bladder Incontinence Evaluation Form. The resident will be re-assessed if there is a significant change and annually. A 3-day bowel and bladder flow sheet will be completed on each incontinent resident. Utilizing the Evaluation Form and the Flow Sheet, the recommendation will be made for a retraining program if appropriate..." The facility policy entitled "Toileting Program Guidelines," dated 1/1/01, stated, "...Purpose To improve and/or maintain a resident's ability to control their elimination and decrease episodes of incontinence...Assessment 1. The assessment includes an evaluation of their incontinence, their voiding pattern, and an appropriate physical examination and testing. 2. It is essential that residents who are incontinent be assessed specifically to identify the cause of their incontinence and to decide if it is reversible..." 1. R107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Data Collection Tool, dated 6/12/14, completed on admission, noted the resident was continent of urine and that pads/briefs were used. A Bladder Incontinence Assessment, dated 6/12/14, stated R107 was alert and had complete control of bladder function. The Summary portion of this assessment stated after review of the Bladder Incontinence Assessment and the 3 Day Bowel and Bladder Flow Sheet, a determination was to be made if the resident was a candidate for a retraining program. This information was not completed (as R107 was identified as being continent). A 3-day Bowel and Bladder Flow Sheet was completed from 6/13/14 through 6/15/14, however, it did not capture or identify any episodes of urinary incontinence. The admission MDS assessment, dated 6/19/14, stated R107 was cognitively intact (able to make daily decisions), required limited assist of one staff for transfer and extensive assist of one staff for toilet use. The same MDS stated R107 was always continent during the seven (7) day review time period (6/13/14 through 6/19/14). Review of the electronic Bowel and Bladder Detail Report, completed by CNAs, from 6/13/14 through 6/19/14, revealed R107 had episodes of urinary incontinence on 6/16/14 and 6/19/14. The facility failed to accurately complete the 6/19/14 admission MDS assessment when R107 had episodes of urinary incontinence during the seven (7) day review period. The MDS should have been coded as occasionally incontinent (less than 7 episodes). The CAA Summary, dated 6/24/14, triggered urinary incontinence as a potential problem area and was checked off to proceed with care planning. The CAA Summary Report, dated 6/24/14, stated, "Needs assistance with toileting. He is continent...Will care plan for toileting with ADLs (Activities of Daily Living)." On 6/13/14 a care plan for "self care deficit" was developed and included the following interventions: resident able to make needs known; resident able to use call bell; transfers with 1 person assist limited; requires assist with toileting; wears briefs/pull-ups-change as needed; keep urinal within reach." Due to an inaccurate MDS assessment, the facility failed to develop a urinary incontinence care plan for R107. Review of the electronic "Resident Bowel and Bladder by Shift Chart," completed by CNAs revealed the following: - 6/12/14 through 6/30/14 consisted of a total of 55 shifts (3 shifts per day) during which R107 was incontinent on 8 out of the 55 shifts (14.5%). - 7/1/14 through 7/31/14 consisted of a total of 93 shifts during which R107 was incontinent on 16 out of the 93 shifts (17.2%). - 8/1/14 through 8/31/14 consisted of a total of 93 shifts during which R107 was incontinent on 34 out of the 93 shifts (36.5%). - 9/1/14 through 9/30/14 consisted of a total of 90 shifts during which R107 was incontinent on 44 out of the 90 shifts (48.8%). - 10/1/14 through 10/31/14 consisted of a total of 93 shifts during which R107 was incontinent on 87 out of the 93 shifts (93.5%). - 11/1/14 through 11/4/14 consisted of a total of 12 shifts during which R107 was incontinent on 12 out of the 12 shifts (100%). Review of the clinical record revealed that on 9/12/14 a care plan for "Needs assist with participating in scheduled toileting" was developed. The goal of this care plan stated, "will accept assistance from staff with scheduled toileting through next review." Interventions included: check to see if resident has voided; follow schedule for toileting; provide prompt incontinence and prevention care; call bell available and within reach; toilet upon rising, before meals, and at bedtime. Review of the clinical record lacked evidence that a 3 day voiding diary was completed and analyzed prior to development of this toileting schedule. There was no evidence that the facility developed an individualized toileting schedule based on R107's voiding diary and assessed toileting needs for managing his incontinence. A quarterly MDS assessment, dated 9/15/14, stated R107 was cognitively intact, required extensive assist of one staff for transfer and toilet use. The same MDS assessment stated R107 was frequently incontinent (7 or more episodes, but at least one continent voiding). Review of Bowel and Bladder Detail Reports (completed by CNAs) from 9/12/14 through 11/5/14, and since the introduction of the scheduled toileting care plan, lacked evidence that the toileting schedule was being followed. Documentation was only being completed once per shift and did not coincide with the proposed toileting schedule time frames. Additionally, there were various responses such as; "resident asked to be toileted," "resident toileted self," "used bedpan/commode/urinal," and "Checking and changing pads during rounds." The following observations were made of R107: 11/5/14 8:00 AM - observed lying in bed asleep, call light in reach, no urinal within reach. 11/5/14 9:45 AM - observed lying on bed, eyes open, stated has been here for several months. When asked if he is assisted to the bathroom he stated he was but when asked if he was on any schedule to use the bathroom, he stated "no". There was no urinal observed within the resident's reach. 11/5/14 10:40 AM - seated in wheelchair in room next to bed, call light in reach. 11/5/14 11:30 AM - remains seated in wheelchair next to bed; no urinal observed near resident. 11/5/14 12:10 PM - interviewed resident after lunch brought into room. R107 was asked if he had been assisted to the bathroom before lunch and he stated "no." When asked if he was aware of when he needed to urinate, he stated, "not always, but most of the time." 11/6/14 8:10 AM - seated in wheelchair eating breakfast in room, call light in reach, no urinal within reach; urinal observed hanging in bathroom. 11/6/14 9:25 AM - seated in wheelchair next to bed, call bell in reach, wearing eyeglasses. R107 again asked about toileting, he stated he has not used the bathroom today, stated he usually knows when he has to go, but sometimes does wet and that is why he wears a brief. When asked if staff come regularly to assist him to the bathroom, he stated "no". On 11/6/14 at 2:30 PM during an interview with E3, she stated that after a 3 day voiding diary is completed, the nurse is to analyze it and develop a plan for toileting. On 11/6/14 at 2:45 PM during an interview with E9 (CNA), she stated that if a resident is on a toileting schedule they are able to enter the time of the toileting into their electronic charting system more than once per shift. E9 opened R107's electronic documentation screen and it did not identify that the resident was on a scheduled toileting program. Observation of the CNA care card, taped inside R107's closet, revealed that the resident was to be toileted upon rising, before meals and at bedtime. During an interview on 11/6/14 at 3:20 PM with E2 (DON) and E3 findings were reviewed. E2 acknowledged inaccuracy of the admission MDS and lack of appropriate care planning for R107, who was occasionally incontinent upon admission. Review of electronic data revealed that as each month progressed R107's continence status declined. Despite this progressive decline there was no revision to the care plan until 9/12/14 when a "toileting schedule" was added to the interventions. E2 confirmed there was no evidence that the facility completed a voiding diary at this time to reevaluate R107's current voiding patterns and confirmed there was no individualized toileting plan based on this assessment. Upon review of CNA electronic data, E2 confirmed it lacked evidence that the toileting plan was being implemented. R107 progressed from being occasionally incontinent (4-5 episodes in June) to frequently incontinent of urine. 2. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's medical record revealed an Interagency Nursing Communication Record (document completed by the hospital to communicate the patient's current medical status to the receiving facility), dated 6/30/14 and timed 10:20 AM, which stated that R4 was "mostly continent with bladder ... wears attends (incontinence briefs)". The 6/30/14 Data Collection Tool (facility's admission assessment) documented that R4 was continent of bladder and pads/briefs were used. Attached to the Data Collection Tool was an undated Bladder Incontinence Assessment, which listed R4's contributing factors/[DIAGNOSES REDACTED]. The additional 3 pages of the Bladder Incontinence Assessment remained blank. Despite the hospital communication and the contributing factors noted on the Bladder Incontinence Assessment, the facility failed to perform a comprehensive assessment of R4's bladder function, including initiating a 3-day Bowel and Bladder Flow Sheet (voiding diary that is analyzed to determine voiding pattern). R4 was care planned for occasional incontinence, initiated on 6/30/14 and last revised on 7/24/14, with interventions that included: "... Brief or incontinence pad for protection & provide incontinent (sic) care each round & prn (as needed) ... Complete bowel and/or bladder assessment per protocol." While R4 was care planned for incontinence, the facility failed to follow their intervention of completing the bladder assessment. Review of R4's clinical record from 7/1/14 through 11/7/14 revealed the absence of a completed bladder assessment and 3-day voiding diary. A nurse's note, dated 6/30/14 and timed 3:40 PM, stated that R4 "... does have some control of bowel and bladder ...". Review of the Caregiver's Information Form (completed by nursing), dated 6/30/14, stated that R4 was incontinent of bladder and required the assistance of 1 staff person. This document was used by both nurses and CNA's as a reference tool for providing care to R4. The physician's admission history and physical, dated 7/3/14, documented a review of urinary system as "? (question mark) incontinence". The admission MDS assessment, dated 7/7/14, revealed that R4 was moderately impaired for daily decision making and required extensive assistance of two (2) staff with toileting. The same MDS assessment also stated that R4 was occasionally incontinent of urine and not on a trial or toileting program. Review of the electronic "Resident Bowel and Bladder by Shift Chart," completed by CNA's, revealed the following: - 6/30/14 through 7/31/14 consisted of a total of 95 shifts (3 shifts per day) during which R4 was incontinent on 36 out of 95 shifts (38%). - 8/1/14 through 8/31/14 consisted of a total of 93 shifts during which R4 was incontinent on 56 out of 93 shifts (60%). - 9/1/14 through 9/30/14 consisted of a total of 90 shifts during which R4 was incontinent on 54 out of 90 shifts (60%). - 10/1/14 through 10/31/14 consisted of a total of 93 shifts during which R4 was incontinent on 63 out of 93 shifts (68%). - 11/1/14 through 11/9/14 consisted of a total of 27 shifts during which R4 was incontinent on 22 out of 27 shifts (82%). From 6/30/14 through 10/31/14, the facility lacked evidence of complete CNA documentation on whether R4 was continent or incontinent each month, which ranged from 3% to 36%. The facility failed to identify that R4's bladder function was not recorded consistently by CNA's. Review of the at risk for UTI care plan, last revised on 9/13/14, revealed that R4 was treated for [REDACTED]. The quarterly MDS assessment, dated 9/26/14, stated R4 was moderately impaired for daily decision making and required extensive assistance with toileting with one staff person. The same MDS assessment also stated that R4 was frequently incontinent of urine, which signified a decline in bladder function since the admission MDS assessment on 7/7/14. R4 was not on a toileting program. Although R4's bladder function decline was identified on the 9/26/14 quarterly MDS assessment, the facility failed again to comprehensively assess R4's bladder function. A physician's orders [REDACTED]. This was added to R4's care plan on 10/10/14, however, the facility failed to individualize R4's toileting program. In an interview on 11/10/14 at 2:46 PM, E21 (CNA) stated that she could not recall a 3-day voiding diary being done when R4 was admitted on [DATE]. E21 stated that a 3-day voiding diary was typically done with residents shortly after admission. E21 stated that she could not recall a toileting program for R4, but she checked R4 at least every 2 hours and as needed due to urinary accidents. When asked if R4 is more continent or incontinent, E21 stated that she is more continent. In an interview on 11/13/14 at 8:55 AM, E3 stated that the Restorative Nurse assisted nursing with admissions to the facility. E3 stated that she was the Restorative Nurse from 6/23/13 through 3/30/14. E3 stated the Restorative Nurse position was not filled from 3/30/14 until recently. In an interview on 11/13/14 at 9:30 AM, E10 (UM) stated that the Unit Manager, Restorative Nurse or any nurse could do admissions, which included the Data Collection Tool and initiating the Bladder Incontinence Assessment/3-day voiding diary. E10 stated the 11 PM-7 AM shift would start the 3-day Bowel and Bladder Flow Sheet following admission of a resident. E10 stated after the 3-day voiding diary was done, the Bladder Incontinence Assessment would be analyzed by a Registered Nurse and a toileting program would be recommended. E10 stated that the Restorative Nurse completed the bladder assessments. When asked who was responsible when the Restorative Nurse position was vacant, E10 stated that the Unit Manager was responsible to follow-up on the bladder assessments. The facility failed to attempt to prevent a decline or maintain normal bladder function for R4 by failing to comprehensively assess R4's bladder incontinence on admission; failing to follow R4's incontinence care plan intervention to complete a bladder assessment; failing to identify that R4's bladder function was not recorded consistently by CNA's from 6/30/14 through 10/31/14; failing to identify a potential cause for R4 being treated for [REDACTED]. 3. R30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/30/14 Data Collection Tool (facility's admission assessment) stated that R30 was continent of bladder and pads/briefs were used. On 6/30/14, the Bladder Incontinence Assessment was initiated and listed R30's contributing factors/[DIAGNOSES REDACTED]. A nurse's note documented on the Bladder Incontinence Assessment, dated 6/30/14 and timed 11:00 PM, stated "Pt (patient) has been continent this shift since admission ... Reported as incontinent per hospital ...". A 3-day Bowel and Bladder voiding diary was recorded from 7/1/14 to 7/3/14, however, the diary was not reviewed and analyzed for a voiding pattern. Despite having initiated the Bladder Incontinence Assessment and recorded the 3-day voiding diary, the facility failed to analyze and complete the comprehensive bladder assessment for R30. The admission MDS assessment, dated 7/7/14, revealed that R30 was moderately impaired for daily decision making and required extensive assistance of two (2) staff with toileting. The same MDS also stated that R30 was frequently incontinent of urine and not on a trial or toileting program. R30 was care planned for incontinence, last reviewed on 7/25/14, with interventions that included: "... Brief or incontinence pad for protection & provide incontinent (sic) care each round & prn (as needed) ... complete bowel and/or bladder assessment per protocol ...". While R30 was care planned for incontinence, the facility failed to follow their intervention to complete the bladder assessment. A nurse's note, dated 9/19/14 and timed 12:10 PM, stated that R30 had a change in mental status and was lethargic (abnormal drowsiness). A physician's orders [REDACTED]. On the following day, 9/20/14, R30 was prescribed an antibiotic, Cipro, for seven (7) days for [DIAGNOSES REDACTED]. R30 was hospitalized from [DATE] through 9/25/14 for urosepsis (severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream). R30 was readmitted to the facility on [DATE]. The 9/25/14 Data Collection Tool documented that R30 was incontinent of bladder and pads/briefs were used. On 9/25/14, the Bladder Incontinence Assessment was initiated and listed R30's contributing factors/[DIAGNOSES REDACTED]. The facility failed to identify on the 9/25/14 Bladder Incontinence Assessment that R30 had an additional contributing factor/Diagnosis: [REDACTED]. A 3-day Bowel and Bladder voiding diary was recorded from 9/26/14 to 9/28/14, however, the diary was not completed as the documentation stopped mid-day on 9/28/14. The facility failed to identify that the 3-day voiding diary was incomplete. Furthermore, the facility failed to follow-up and complete the comprehensive bladder assessment for R30. Review of R30's incontinence care plan noted that she was readmitted to the facility on [DATE]; however, the interventions remained the same. The quarterly MDS assessment, dated 10/2/14, revealed that R4 was moderately impaired for daily decision making and required extensive assistance of two (2) staff with toileting. The same MDS also stated that R30 was always incontinent of urine and not on a toileting program. On 10/11/14, R30 fell and was sent to the hospital for evaluation. R30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon R30's 10/14/14 readmission, she was placed on comfort care (care that helps or soothes a person who is dying). The 10/14/14 Data Collection Tool documented that R30 was incontinent of bladder and pads/briefs were used. However, a comprehensive bladder assessment, including a 3-day voiding diary, were not completed for R30 as per the facility's policy entitled "Data Collection Tool Guidelines," which stated to be completed on readmission. Review of R30's incontinence care plan noted that she was readmitted on [DATE]; however, the interventions remained the same. In an interview on 11/6/14 at 2:38 PM, E3 stated that upon admission or readmission to the facility the Data Collection Tool would be completed and if the resident was incontinent a Bowel and Bladder assessment would be completed, which included the 3-day voiding diary. The facility failed to comprehensively assess R30's bladder function three times since admission; failed to follow R30's incontinence care plan intervention to complete a bladder assessment; failed to identify a potential cause for R30's two UTI's, which resulted in two hospitalization s; and failed to review and revise R30's incontinence care plan. Findings were confirmed by E2 on 11/12/14 at 11:50 AM. 4. R70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The same MDS stated R70 was frequently incontinent and on a toileting program. The Annual MDS assessment, dated 7/11/14, stated R70 was now moderately impaired (decisions poor; cues/supervision required). The same MDS stated he was now a one person, extensive assist for transfer and toilet use, and was still frequently incontinent, but no longer on a toileting program. The CAA Summary dated 7/11/14, triggered urinary incontinence as a potential problem. The CAA Summary Report under the area of incontinence stated, "Resident has had incontinence with both bowel and bladder. Resident is on a toileting schedule...is to be toileted upon rising, before and after meals, and at bedtime." A Bladder Incontinence Assessment, dated 7/11/14, stated R70 was alert/oriented X1, confused, and had daily incontinence episodes (some control). The summary portion of this assessment states that after review of the Bladder Incontinence Assessment and the 3 Day Bowel and Bladder Flow Sheet, a determination was to be made if the resident was a candidate for a retraining program. This summary portion also stated that a 3 day Bowel and Bladder Flow Sheet was initiated. There was no evidence that this was done until 8/12/14, a month later. A care plan for R70, entitled "Incontinence" initiated on 7/23/14 and reviewed on 10/13/14 has listed as a plan of action/approach to establish and follow toileting plan. Another care plan entitled "Self Care Deficit R/T" (related to) cognitive impairment, impaired mobility, and decondition/weakness initiated 7/23/14 and reviewed on 10/13/14 listed - establish toileting schedule: upon arising, before and after meals, and at bedtime, as an intervention and approach. Review of the clinical record revealed a 3-Day Bowel and Bladder Flow Sheet was completed from 8/12/14 through 8/14/14. The front of the document was filled out, but the back portion was not. There was no evidence the 3-Day Bowel and Bladder data was analyzed in order to develop an individualized toileting schedule for R70. Review of the clinical record revealed that an undated CNA resident care card indicated that R70 was incontinent of bladder and needed one person assist. It also stated, "please toilet resident upon rising, before and after meals, and at bedtime". Review of the clinical record lacked evidence that this toilet schedule was based on analysis of the 3-Day Bowel and Bladder data. There was no evidence that the facility developed an individualized toileting schedule for R70. Review of Bowel and Bladder Detail Reports (completed by CNAs) from 7/4/14 through 11/5/14, and since the introduction of the scheduled toileting care plan, lacked evidence that the toileting schedule was being followed. Documentation was only being completed once per shift and did not coincide with the proposed toileting schedule time frames. Additionally, there were various responses such as; "resident asked to be toileted," "used bedpan/commode/urinal," and "Checking and changing pads during rounds." Review of the electronic " Bowel and Bladder Detailed Entry Report," from 7/4/14 through 8/14/14, completed by CNAs revealed there was no evidence that R70 was toileted on 7/4/14. This report also revealed the following: -7/7/14 from 1:06 AM to 1:22 PM (no evidence R70 was toileted for over 11 hours). -7/8/14 from 2:21 AM to 2:15 PM (no evidence R70 was toileted for over 11 hours). -8/12/14 from 12:36 AM to 11:03 AM (no evidence R70 was toileted for over 10 hours). -8/13/14 from 12:54 AM to 10:23 AM (no evidence R70 was toileted for over 9 hours). -8/14/14 from 2:27 PM to 11:04 PM (no evidence R70 was toileted for over 8 ? hours). R70's Quarterly MDS assessment, dated 10/8/14, stated he remained moderately cognitively (thinking and memory) impaired and was still a one person, extensive assist for transfer and toilet use. He was now coded as always incontinent, and not on a toileting program. The following observations were made of R70: -11/5/14 from 10:55AM through 12:00PM, R70 was observed sitting in his room. At 12:00 PM, E9 (CNA) took R70 into the dining room, R70 was not taken to the bathroom or offered to be toileted prior to going to lunch. -11/6/14 at 8:34 AM, R70 returned to his room after eating breakfast. Surveyor observed R70 until 9:37AM (1 hour and 3 minutes) after returning from breakfast, R70 was not toileted after breakfast or offered to be toileted. The facility failed to follow R70's toileting schedule upon rising, before and after meals, and at bedtime. Review of the electronic "Resident Bowel and Bladder by Shift Chart," completed by CNAs revealed the following: - 7/4/14 through 7/31/14 consisted of a total of 84 shifts (3 shifts per day) during which R70 was incontinent on 76 out of the 84 shifts (90.5%). - 8/1/14 through 8/31/14 consisted of a total of 93 shifts during which R70 was incontinent on 85 out of the 93 shifts (91.4%). - 9/1/14 through 9/30/14 consisted of a total of 90 shifts during which R70 was incontinent on 88 out of the 90 shifts (97.8%). - 10/1/14 through 10/30/14 consisted of a total of 89 shifts during which R70 was incontinent on 80 out of the 89 shifts (89.9%). During an interview with E10 on 11/5/14 at 11:36 AM, E10 stated that interpretation of any 3-Day Bowel and Bladder data collected on a resident would be written on the back of this flow sheet to determine a pattern and develop a care plan for that resident. E10 confirmed the findings that the back of R70's flow sheet that would have evaluated his voiding pattern was blank. E10 stated that interpretation of the 3 Day Bowel and Bladder Flow Sheet dated from 8/12/14 to 8/14/14, despite the back portion being blank, was when the undated toileting schedule listed on the CNA resident care card was implemented. On 11/5/14 at 3:24 PM E17 (CNA) stated that it was the practice of the CNA's to chart at the end of the day (shift) when they toileted someone, with the exception of residents that were on a 3 day bowel & bladder program or a toileting program. In these cases the CNA's had to chart immediately after the resident was toileted. On 11/12/14 at 10:59 AM, interview with E16 (MDS Coordinator) confirmed that the resident was on a toileting schedule at the time that she completed R70's Annual MDS assessment on 7/11/14. E16 stated that when assessing a resident's bowel and bladder function, within that 7day window look back, there are several tools used to gather information. She would look at the CNA electronic "Resident Bowel and Bladder by Shift Chart," 3 Day Bowel & Bladder Flow Sheet, and the Data Collection Tool. On 11/12/14 at 11:50 AM, during an interview E2 confirmed that R70's toileting schedule was not followed. On 11/16/14 at 2:30 PM during an interview with E3, she stated that after a 3 day voiding diary is completed the nurse is to analyze it and develop a plan for toileting. For R70 the facility failed to evaluate a 3 day voiding diary, failed to care plan accordingly based on the resident's individualized needs, and failed to follow R70's toileting schedule.

Based on record review, observation and interview, it was determined that the facility failed to ensure that 4 (R19, R218,R136 and R67) out of 41 Stage II sampled residents environments remained as free of accident hazards as possible; and that each resident received adequate supervision and assistive devices to prevent accidents. R19 required a 2 person transfer using a gait belt according to her care plan. She was transferred to the bathroom with 1 person without using a gait belt on 8/12/12 and sustained a fall in which R19 sustained harm- specifically a fractured left ankle which required surgery. Additionally, the facility failed to supervise R218 and failed to ensure that the wanderguard system was fully operational when R218's wanderguard did not alarm and R218 eloped and fell outside the facility. Observations of R136's wanderguard which failed to consistently alarm and allowed R136 to exit the health care center and proceeded into the independent living portion of the facility posed an accident hazard. R67 had [DIAGNOSES REDACTED]. This placed R67 at a high risk for choking and/or aspiration during mealtimes and bed time snacks. As per E40's (SLP-Speech Languages Pathologist/Therapist) assessment and plan of care, R67 ate meals and bedtime snacks independently in her room that required monitoring and "distant supervision". The facility failed to ensure that this was consistently implemented to prevent potential risks of choking or aspiration accidents. Findings include: 1. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS Assessments dated 7/30/12 and 8/6/12 indicated that R19 required extensive, 2+ person physical assistance for transferring to and from bath/toilet and the same level of assistance for toilet use. The facility developed a care plan for R19 on 7/24/12 for Self-care Deficit with an approach that stated to provide assist for transfers as needed, extensive assist of 2 with gait belt (device worn around waist used to transfer from one position or place to another). R19 also had a care plan for "Risk for falls" developed on 7/24/12 with the goal "Will be free of injury from falls through target date (10/12/12)." A nurse's note dated 8/12/12 and timed 9:15 AM stated that R19 was assisted to the bathroom by E45 (CNA). R19 "was assisted off the toilet by the CNA (E45). Pt fell slowly. CNA (E45) was there to lower her to the floor, however, R leg and ankle were wedged against the wall and toilet. Several staff & associates assisted pt. from the floor to the wheelchair and then to bed... c/o pain in R knee and L lower leg. Possible fx (fracture) of R foot noted because of deformity seen... to (hospital) via 911 ambulance. R19 was hosptalized on [DATE] for a left ankle fracture which required surgery (ORIF- open reduction internal fixation). She was readmitted to the facility on [DATE]. The facility incident report and investigation was reviewed. R19 was interviewed by the facility on 8/12/12 and written statements included, "I told her (CNA- E45) at the beginning; you're supposed to have 2 people with me to get me on. CNA (E45) said, 'we made it with just me' from the bed to w/c (wheelchair) so she thought we could be good c (with) just her.'" Review of E46's (LPN) written statements revealed she was one of the staff members that came to assist R19 after she fell . While in the bathroom with R19, E46 asked the resident what happened and R19 stated, "I kept telling her (E45) she needs to get another person to help with me but she wouldn't listen. She went ahead and took me to the BR (bathroom) by herself." E46 also wrote, "CNA (E45) had resident this past week and aware of transfer status through report given to her when assumed care 8/8/12. CNA also had cared for resident previously prior to this week." In contrast to the 8/12/12 nurse's note, an employee incident report for E45 (CNA), dated 8/12/12, stated she hurt her shoulder while trying to get R19 off the floor. E45 stated "due to residents size (350 lbs) employee was not able to move her and she was a 2 person assist. Emp stated she didn't know this and also she did not use a gait belt." R19 was interviewed on 10/25/12. R19 was also asked if she recalled telling the CNA (E45) that she needed two people to help her. R19's stated "yes" and she said she kept saying "I need two people. There was only 1 girl, she said we can do it. I was holding onto the rail and I started slipping, going down, then I hit the floor." R19 confirmed that prior to the fall on 8/12/12, 2 people were used to transfer her. The 5 day follow up for the 8/12/12 fall with injury submitted to the DLTCRP by the facility stated, "... Investigation was conducted and facility determined Aide did not adhere to care plan which required assist of two. Therefore the facility has substantiated that the aide placed the resident at risk. Aide was suspended on 8/13/12 and will be terminated. E45 was terminated on 8/17/12. The facility failed to adhere to R19's care plan developed on 7/24/12 for 2 person transfers with an assistive device (gait belt). Additionally, E45 ignored R19's repeated requests for the assistance of 2 for the transfer which resulted in harm with a fall with a left ankle fracture that required surgical repair. Findings were confirmed with E1 (Administrator) and E7 (Corporate Nurse) during an interview on 10/31/12. 2. R218 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R218's admission MDS (Minimum Data Set) assessment, dated 11/20/11 revealed that he was moderately impaired for cognition and he had wandering behavior which put him "at a significant risk of getting to a potentially dangerous place". R218 used a wheelchair for locomotion. Review of the CAA (Care Area Assessment) analysis revealed that R218 had a [DIAGNOSES REDACTED]. R218's fall risk assessment, dated 11/14/11, revealed he was a high risk for falls. R218's Wandering/Elopement Risk Review Tool, dated 11/14/11, revealed a score of 16 (7-12+ is at risk) with "comments: Increased risk for elopement." Review of R218's OT (Occupational Therapy) Treatment Flow Sheet for 11/15/11 through 11/18/11 included "Additional comments: "Pt (patient) presents c (with) decreased cognition, decreased B (body) wt (weight) strength, decreased standing balance and L (left) hip pain. As a result Pt at high risk for a fall. Recommend constant S (supervision) for safety." Review of R218's care plan, dated 11/14/11 and entitled "Risk for elopement. Has attempted to leave facility. (not this facility) Dx (Diagnosis) - Vascular dementia c (with) depressed mood." The stated goal was "Resident will not wander from unit without supervision through target date 2-12." Approaches included use of a "Wanderguard in place L ankle". Additionally, R218's care plan, dated 11/15/11 and entitled, "Risk for falls R/T (related to) Hx (history), (decreased) mobility, disease process", updated on 11/17/11, stated, "s/p (status [REDACTED]. Approaches included: "1. Keep call bell within reach... remind to call for assistance... 5. Provide assist for transfers as needed 6. Fall/safety devices Alarm to bed/chair... 9. Complete fall assessment per protocol. 14. Standup lift for transfers c assist (2)." Nurse's notes revealed: 11/14/11 (5:50 PM) - "... alert and oriented c episodes of confusion..." 11/14/11 (6 PM) - "Fall precautions maintained. Resident high risk for elopement. Wanderguard placed on L ankle as ordered...." 11/15/11 (3:20 AM) -"Pt alert c confusion. Awake until 0200 (2 AM) @ (at) nurses station in w/c (wheelchair). Kept attempting to stand - redirected to sit down. Stated he wanted to go upstairs to bed. Placed in bed and resting quietly. No s/s (signs/symptoms) of decreased neuro status s/p intraventricular (brain) hemorrhage... Fall precautions maintained. Call bell within reach. Continue to monitor..." 11/16/11 - "Alert and verbal c confusion. OOB (Out of bed) to w/c several times and needs to be redirected several times. Taking off alarm .... Gait unsteady...Taking off clothes several times and redirected as needed. ... Fall precautions in place 2430 (12:30 AM)... 11/17/11 (11 PM) - "... 1730 (5:30 PM) to 1st floor D.R. (dining room) went thru double doors to IL (Independent Living) and was promptly returned by ACT (activity) personage. Educated pt on topic of wandering by self about facility not a recommended activity..." 11/19/11 (11:30 PM) - " ...Able to self propel w/c (wheelchair)..." A nurse's note, dated 11/20/11 and timed 11:30 PM stated, "Called by (E50/nurse) to come see pt just outside the facility. Pt. lying on pavement on his L side. W/C noted to be upright position. Brief noted to be on pavement near pt. Pt stated he followed someone out door (before door closed). Pt currently stated he had to get inside building to vss (visit) his brother (name) told another nurse a different name for his brother, wife stated brother's name is (name-which was different). A & O X 1 (Alert & Oriented times 1) (person) 0 (no) SZ (seizure), H/A (headache), N/V (nausea/vomiting). denies pain @ first then c/o (complained of) L hip pain. PERRL (pupils equal round reactive to light), + (positive) hand grasps bil (bilaterally) equal, speech normal, follows commands. Wanderguard on ankle (Intact/functioning). Send to ER for eval (evaluation) s/p fall/family request. 911 called @ 1901 (7:01 PM). 911 arrived 1911 (7:11 PM) and assumed medical control. 911 departed for hospital (name) @ 1915 (7:15 PM). Wife aware of fall/transfer. Report called to ER." R218's nurse's note, dated 11/20/11and timed 12 AM stated, "ER called stated pt to return to facility 2 (secondary to) wife states pt at baseline and pt has no pain. Pt has N.O. (new order) from NP (Nurse Practitioner) to be transferred to (room on 2nd floor) for safety/elopement issues." R218's incident report, dated 11/20/11 and timed 7:17 PM indicated the incident occurred on 11/20/11 6:45 PM - 7PM and described it as "Unknown injury level c/o pain L hip s/p fall just outside facility." The 5 day follow up incident report stated, "Unknown injury level c/o pain L hip s/p fall just outside facility." s/p fall outside of facility unsupervised resident to the ER for eval c/o hip pain per wife (Chronic) No negative outcome. No negative outcome. resident continues c unsafe behavior. Resident relocated to second floor." MD & Family notified." During an interview on 11/7/12 at 9 AM, E1 (Administrator) stated that R218 must have followed someone through the double doors and out the service entrance. He stated that when the doors were opened the Wanderguard system might not alarm if the door was already open. At the surveyor's request, E1 reconstructed R218's elopement and explained how the Wanderguard system was supposed to work. During the demonstration, E1 took a Wanderguard bracelet and wheeled himself through the double doors that R218 used to elope on 11/20/11. It was observed for at least 12 to 15 trials, that the Wanderguard alarm system did not consistently alarm. The Wanderguard/alarm system trials included E1 using 2 different wanderguards on his right ankle during multiple trials and him pushing R136 (another resident) in her wheelchair while she had her Wanderguard on her left ankle for multiple trials with the same inconsistent results. The Wanderguard failed to set off alarm while E1 and R136 travelled in the center of the hallway. The facility contacted the Wanderguard company to evaluate the system. During a telephone interview on 11/8/12 at 8:05 AM, E51 (dietary aide) stated that while outside on a cigarette break, she heard someone calling for "help" and found R218 lying on the ground behind the building with his wheelchair tipped over in the road. E51stated she retrieved a pillow from her car to help position R218 and informed the resident she was going to get a nurse and would be right back. E51 stated R218 was wearing his Wanderguard and stated he wanted to visit his brother... E51 stated the resident somehow got through the double doors into IL then went through service entrance.... there is something with those systems... that happened one time before... If a visitor or someone goes through, doors don't always alarm..." During an interview on 11/8/12 at 8:50 AM, E1 acknowledged that the facility failed to ensure that the Wanderguard system was fully operational when R218's Wanderguard did not alarm and R218 eloped and fell outside of the facility. E1 confirmed that R218 was able to exit though the first floor double doors into IL and continue through the service door to the outside. He stated there was a sign posted to alert all staff/visitors to be aware that no one is following them through the double doors which was placed above the keypad after R218 eloped on 11/20/11. Additionally, the facility failed to provide adequate supervision to R218 as per OT's recommendations. 3. Review of R136's clinical record revealed that she lived in the facility in Independent Living (IL) since 2003 prior to her admission to Health Care on 2/27/12. R136's Admission MDS (Minimum Data Set) assessment, dated 3/6/12 indicated she was severely impaired for cognition. Review of R136's Wandering/Elopement Risk Review Tool: (scoring legend 7-12+ is at risk for elopement) on 2/27/12 and 7/25/12 was scored as an "8" (at risk). The 9/14/12 Wandering/Elopement Risk Review Tool: readmission ... indicated that R136 was "not an elopement risk at this time." However, it was noted on 10/19/12 that R136 "...made several attempts to push herself via w/chair passed the double doors towards Independent living area. Resident was brought back by staff in the evenings." On 10/19/12, the approach of "wanderguard ordered and in place" was added to her 2/27/12 "Risk for falls" care plan. R136's care plan, dated 2/27/12 and entitled, "Risk for Elopement" was reviewed on 9/11/12 which included the short term goal; "resident will not wander from unit without supervision through target date". Approaches included: "orient res (resident) to person, place and time; assess for potential triggers to wandering; assess need for wanderguard and apply if necessary, applied to walker 2/27/12... " R136 had a physician's order, dated 10/19/12 and timed 5 PM that stated, "wanderguard on L ankle at all times; check wanderguard function every week on Wednesday; Check wanderguard placement q (every) shift." Nurse's notes revealed: 2/28/12 (3 PM) - "... risk for elopement. Has a wanderguard in place. Pt noted always walking to the independent area redirected ... " 3/16/12 - " ...Walking c walker I (Independently), Wanderguard to w/c to alarm staff the resident is leaving the nursing unit to IL. Staff will then assist/escort her to IL ... " 3/17/12 (2:15 PM) - " ...wanderguard attached to RW (Rolling Walker). Assts (assistance) by staff when going to IL ... " 5/3/12 (5:19 PM) - "D/C (discontinue) wanderguard from the walker; Place wanderguard in the walker bags and check placement q shift." 10/19/12 (6 PM) - "new orders for wanderguard rec'd (received) and all procedures completed as per protocol. Family aware. Noted assessment done and noted. Placed on L ankle intact and functioning well. Continue to monitor." 11/4/12 (7:40 PM) - "... very restless, was agitated, found resident crossing the IL door 3 times, initiated one on one (supervision) ..." During an interview on 11/7/12 at 9 AM, E1 explained and demonstrated how the Wanderguard system was supposed to work. The Wanderguard/alarm system trials included E1 using 2 different wanderguards on his right ankle during multiple trials and him pushing R136 in her wheelchair while she wore her Wanderguard on her left ankle for multiple trials with the same results. The Wanderguard failed to function consistently while E1 and R136 travelled in the center of the hallway. The facility contacted the Wanderguard company to evaluate the system. During an interview on 11/8/12 at 8:35 AM, E44 (Director of Plant Operations) stated it was discovered that there was "one loose wire on one of the wands" (part of the Wanderguard alarm system) and that the repair company would install another wand on the ceiling to cover the area not in range of the wand/transmitter/antenna on 11/8/12. During an interview on 11/8/12 at 8:50 AM, E1 stated the Unit manager is to check placement and check if the Wanderguard was present and functioning. This is done weekly. E1 stated that R136 was able to self-propel in her wheelchair and was moved to a room upstairs yesterday after the Wanderguard system was found to be malfunctioning. He stated there was a posted sign to alert all staff/visitors to be aware that no one is following them through the double doors. E1 acknowledged that the facility failed to ensure that the Wanderguard system was fully operational when R136's Wanderguard system did not consistently alarm the Wanderguard system during the trial demonstrations by E1, especially while travelling in the center of the hall. This malfunction posed a potential for an accident or elopement for R136 when she was able to exit through the first floor double doors leading to IL. 4. R67 had [DIAGNOSES REDACTED]. According to R67's annual Minimum Data Set (MDS) assessment dated [DATE] and quarterly assessment dated [DATE], her cognitive skills for daily decision-making were consistent and reasonable. R67 needed extensive assistant of staff for all activities of daily living (ADL's). R67 was non-ambulatory and sat on her wheelchair all day in her room next to her bed. R67 was on a mechanical soft diet. R67 was independent with eating and used swallowing strategy (with emphasis on left head turn technique) taught by the Speech Therapist (E40). Example of R67's mechanical soft diet consisted of pureed tuna on wheat bread with tomatoes and mayonnaise, soup, saltine crackers 2 packets, pretzel ice cream, vanilla, whole milk, ice tea and margarine on the sides. On 10/24/12, R67 was observed eating her lunch independently in her room by herself. Next to her meal setting was a small bowl that contained a few packets of cracker and a few wrapped hard mint candies . According to a nurse's note dated 9/28/12 , R67 "reported that she was choking on a mint". According to this nurse's note of 9/28/12, "Resident reminded not safe to eat hard candy while lying in bed". R67 stated "I eat mints-I used to have them all the time". In an interview with R67 on 10/26/12, she stated that she choked on a candy mint (9/28/12) that her roommate (R65) gave to her after dinner. She stated that this incident happened at bedtime between 9:00 PM to 10:00 PM when she felt like eating one and decided to try it. R67 stated that when she was choking with a candy mint, she did not turn on her call bell because it was not within her reach. She "got scared" so, she threw her big bottle of Vicks Vaporub on her doorway to attract staff's attention. By the time a staff arrived, she had already coughed out the mint candy while continuously pressing on her stomach to push the candy out (self Heimlich maneuver). R67 was a retired RN. During the interview it was observed that R67 continued to have a few supplies of hard candy mint in her small bowl on top of the bedside table within her reach. Staff failed to monitor this. In addition, review of R67's record revealed a nurse's note dated 4/21/12 and stated "difficulty swallowing medication, one episode of aspiration noted". On 11/5/12 R67 stated that she had difficulty swallowing her medication "Preservision" soft gel capsule on 11/2/12 which she stated "got stuck in her throat". According to R67 she had to request E41 (LPN-medication nurse on 3-11 PM shift) to pat her back to get it down. E5 (LPN) and E41 (LPN) confirmed this incident happened. During an interview with E5 (LPN) and E41(LPN) on 11/ 05/12 at 4:30 PM, it was revealed that R67 had a behavior problem of non-compliance with hoarding of hard mint candies. E41 (LPN) stated that R67 kept them in her hooded jacket's pocket and or other places where staff would not be able to find. Even though the facility had identified this hazards of hoarding/hiding hard mint candies and risks, the facility failed to apply this findings to the development of interventions to reduce Resident's potential for choking and aspiration accidents. Additionally, on 10/24/12 approximately between 12:15 PM to 12:45 PM, R67 was observed eating lunch in her room by herself. There were no available nursing staff seen nearby while R67 was eating. R67 stated that the surveyor will not find nursing staff on the hallway because they were all out in the dining rooms with the residents. On 10/25/12, R67 was observed eating breakfast in her room alone and without staff supervision. Also,there were no nursing staff available on the hallway. Interview with R67 on 10/25/12, she stated "nobody comes to look inside my door to check on me while I eat". "Everybody (staff) goes to the dining room to serve and help the other residents eat". The facility established a care plan dated 6/29/12 (last reviewed on 10/4/12) entitled "Needs Mechanically altered Meals d/t (due to) inability to swallow regular texture/consistency foods/liquids". The care plan goals included: Will tolerate diet with no episodes of aspiration daily thru next review." The care plan approaches included: 'Assess need to change consistency thru supervision at meal times; ST (Speech Therapy) consult prn (as needed); Assess for pocketing of food; Monitor for s/sx (signs and symptoms) of Aspiration, i.e choking, coughing, increased temperature; "gurgly' voice, audible wheezing, rales, rhonchi; Provide supervision at each meal; potato chips allowed-no other regular consistency foods at meals (dated 10/4/12) On 10/31/12, according to E3 (ADON) and E40 (SLP), R67 did not need close supervision (assistant stands close to person, ready to give assistance if needed), at meal times. She only needed "distant supervision" (assistant can see the person and offer verbal assistance but is not close enough to touch the person) because she ate her meals independently in her room, also bedtime snacks. R67's room was located 6 doors away from the nursing station and therefore R67 could not be seen from a distance from the nursing station. Additional interview with E40 (SLP) on 11/2/12 at 11:57 AM, she stated that R67 refused to stay in the dining room to eat her meals. Since she ate independently and knew how to implement her swallowing technique "to tuck her chin and tilt head to the left" so she only needed "distant supervision" at mealtimes in her room. According to E40 (SLP), "from the hallway would be an adequate supervision". She stated that meal supervision would be between tray delivery and pick up. Staff walking by on the hallway would, by "earshot" hear her having symptoms of coughing and choking and could check her. Review of R67's clinical record with E40 (SLP) revealed that the last documented Speech therapy evaluation was done on 9/23/11. The evaluation stated that "Resident has been D/C (discharged from SLP (Speech Language Pathology) treatment secondary to goals met after 36 sessions. Treatment focused on dysphagia techniques and compensatory strategies during meals. Resident (I) independent uses (L) head turn to close her airway during meals...continued to use strategies at meals and be followed by SLP in 3-4 months for any changes" However, this system of distant supervision did not reflect on the evaluation progress and the existing care plan interventions. E40 (SLP) stated that the last time she saw R67 was in January 2012, but not for evaluation and therefore there was no progress note documented for that visit. The facility's policy and procedure entitled "Aspiration Management" was reviewed. Record review revealed that there was no physician's order for a PRN evaluation by Speech Therapy for screening via recommendations by Nursing and/or physician's order for this approach as per facility policy/procedure. Resident was identified as a high risk for aspiration due to 1)medical diagnosis, 2)swallowing problems and 3)refused to stay in the dining room for meals. Additionally, there was no strategies reflected in the care plan to address Speech therapist's plan of care, how monitoring will be conducted by staff as identified by Speech Therapist and how facility policy on aspiration management would be implemented. R67's record was reviewed on 11/5/12 . A physician's order dated 11/2/12 was revealed for Speech therapist to "evaluate 1 x treatment patient's safety swallowing, diet consistency and recommendations of meals placement and use compensatory strategies". According to E5 (ADON) E40 (SLP) called the physician for an order to evaluate R67. On 11/2/12 a Speech-Language Pathology Progress Notes/evaluation was written by E40 that stated "SLP observed and believes pt. (patient) alert, problem solves , + (positive) control and use strategies (I) independently that distant supervision is beneficial". R67 adamantly refused dining placement secondary to: "loud", "embarrassed", "prefers quiet", "needs to concentrate", "feels rushed", "requires time", "looks different", "have to wait", "believes she is a burden". Subsequently, on 11/2/12 at 2350 (11:50 PM) the physician prescribed the following: "Resident requires more time to complete meals at meal times Choking precaution Aspiration precautions Resident requires distance supervision during meal time". On 11/7/12, observation by the surveyor during lunch time between 12:00 PM and 12:45 PM revealed there was no staff consistently available to monitor R67 during meal time in the hallway. E3 (ADON) had to remind E5 (LPN-Medication Nurse) to check on R67. Interview with E3 (LPN) on 11/7/12 at approximately 4:30 PM, revealed that R67 used to eat in the Assisted Dining room and then moved to the Independent Dining Room per resident's request. While in this environment staff were able to provide distant supervision. R67 developed MRSA (Methycilline Resistant Staphylococcus) infection on her groin and buttock lesions ( 6/14/12 per nurse's note) and therefore, R67 was placed on isolation in her room including mealtimes. Since then R67 refused to return to the dining room and now eats her meals/snacks in her room. In addition, E3 stated that R67 was not supervised during meal times because she ate independently even though the care plan stated "Provide supervision at each meal". R67 ate in her room which was located 6 doors away from the nursing station and was not within hearing distance and visual distance from the nursing station. The facility failed to ensure that the Speech Therapist's process of providing "distant supervision" to R67 was communicated to all relevant staff, assigned responsibility and ensured that interventions were implemented correctly and consistently to reduce the potential for aspiration/choking consistent with the physician's order/ facility's policy for Aspiration Management on aspiration precaution, choking precaution and supervision ("distance supervision) during meal times including snack times. This finding was discussed on 11/7/12 with E1 (administrator) E2 (DON), E3 (ADON) and E7 (RN).

Based on observation, record review and interview, it was determined that the facility failed to ensure that five (R3, R9, R27, R78 and R216) out of 41 Stage II sampled residents received the necessary care and services to attain or maintain the highest practicable physical, well-being, in accordance with the comprehensive assessment and plan of care. R3 sustained harm from lack of ongoing thorough nursing assessments of her right foot after it was found to be cold and pulseless on [DATE]. Nursing assessments after [DATE] lacked circulation checks to the right foot and recognition of the resident's declining mental status. R3 was hospitalized on [DATE] per family request; the resident was found to have a right femoral stent occlusion with ischemia (insufficient blood supply usually due to blocked artery) and gangrene of the right great toe with some gangrenous changes in other toes and she was responsive to painful stimuli only. R3 was deemed to not be a surgical candidate. She was placed on hospice and died on [DATE]. For R78, the facility failed to identify the need to hold the stool softener in the presence of her having liquid bowel movements which was a contraindication. For R3, R9 and R27, the facility failed to initiate the bowel protocol when these residents had no bowel movements (BMs) for 3 days. For R216, E44 (LPN) failed to follow the PRN (as needed) pain medication protocol and failed to monitor and to evaluate the resident's response to the medication. In addition, the facility failed to ensure R216's needs were met including perineal care and application of an adult pad. Findings include: 1. R3 was admitted to the facility in 2010. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) Assessment, dated [DATE], revealed that R3 was non-ambulatory and she required ,[DATE]+ person extensive to total assistance with activities of daily living (except eating). R3 had clear speech, was understood and she understood others. A care plan entitled potential for alteration in skin, dated [DATE] included a note dated [DATE] for "redness on feet." A care plan was developed on [DATE] for a skin tear to the elbow area. A physician progress notes [REDACTED]. [DIAGNOSES REDACTED] dissipated when R3's legs were elevated, there were no visible [MEDICAL CONDITION] or open areas and capillary refill was < 3 seconds (normal). The progress note stated, "... ? [MEDICAL CONDITIONS]...". A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A nurses note, dated [DATE], stated that R3's R foot was cold and pulseless. A physician order [REDACTED]. R3 was evaluated by a physician on [DATE] and labs, elevation of the legs at all times, [MEDICATION NAME] (to decrease swelling/fluid) 20 mg by mouth daily for 5 days and [MEDICATION NAME] (antibiotic) 875 mg by mouth twice daily for 5 days was ordered for lower extremity [MEDICAL CONDITION]. R3 was evaluated by a podiatrist on [DATE] per facility request. The podiatrist wrote, "... s/p (status [REDACTED]." Much of the podiatry note was difficult to decipher due to poor handwriting. The podiatrist removed R3's right great toenail. Wound treatments were ordered to cleanse right great toe with normal saline solution, apply [MEDICATION NAME] (topical antibiotic) and cover with a dry dressing daily for 10 days. A [DATE] nurse's note stated, "... Alert & verbal... podiatrist on [DATE] removed R greater toenail nail appeared to be split & seperated (sic) off of nail bed... bloody drainage in prior dressing, toe area c (with) bloody drainage & discolored area to R great toe area... ate small bites of breakfast...". A [DATE] nurse's note stated, "Weekly IDT (interdisciplinary team) meeting held today to discuss resident wound on L... (elbow area). Steri-strips intact. No s/s (signs/symptoms) of infection noted...". There was no mention of the R foot. A [DATE] nurse's note stated, "Tx (treatment) to R greater (sic) toe- nail area bed, (change) of color, darker area to top of toe & yellow-bloody drainage to nail bed nurse informed (physician), cont. (continue) c (with) ABTx (antibiotic treatment) & dressing (changes) c [MEDICATION NAME] daily." There were no telephone orders written. There were no nurse's notes written on [DATE] and [DATE]. A [DATE] nurse's note stated, "... site nail bed area c (with) darken (sic) area to toe, on sides of R nail removal area site." A [DATE] nurse's note stated, "Tx to R greater toe... slightly discolored- dark area to base, redness to bilateral (lower) extremities." The only nurse's note written on [DATE], stated, "Weekly IDT meeting held today to discuss resident alteration in skin integrity area healing no s/s of infection. Steri-strips intact." There was no mention of the R foot. A [DATE] nurse's note stated, "... informed (Nurse Practitioner) with (change) in color & drainage to toe... cont. to monitor site." A [DATE] nurse's note stated, "... R greater toe nail area bed c discoloration , darker area to top of toe... cont. to observe R toe & feet for (changes)." A [DATE] nurse's note timed 3:30 PM, stated, "... R greater toe nail area c (with) slightly (sic) beeding (sic) & discoloration of toe... nurse called (physician)... new order for ABTx (antibiotic treatment) [MEDICATION NAME] 875 mg BID (twice a day) x seven days, until resolved, (physician) to be in on Monday to see resident [DATE]... New order to see podiatry- consult ordered...". A [DATE] nurse's note timed 8 PM, stated, "... daughter concerned about change in mental status and lethargy; she requested that resident be sent to the ER for evaluation... responds when called but very sleepy... ordered by MD to be sent to... ER for evaluation...". A [DATE] nurse's note timed 10 PM, stated, " ... picked (up) from facility... Tx to right big toe done before sending resident out of facility. Slight bleeding from toe noted and tip of toe discolored." Review of hospital records included a STAT H&P (history and physical), dated [DATE] (admitted ) which stated, "... decreased mental status, getting more and more confused... did develop right foot swelling and redness with gangrene on the big toe with some gangrenous changes in other toes, so sent to the emergency room ... In emergency room ... found to have ischemia of the right foot with right great toe... underwent arterial Doppler that showed... acute femoral stent occlusion with ??____ blood flow noted at mid thigh... She is not much responsive or communicable... Right lower extremity is cold with cold foot, peripheral pulses are not palpable... responds to painful stimuli... As per vascular surgery... not a surgical candidate...". A nephrology consult, dated [DATE], stated, "... right foot showing gangrenous changes with her first toenail along with significantly decreased/absent dorsalis pedis pulses and posterior to the tibialis pulses on the right side. There are some ulcerations appreciated and the foot overall is very cool to the touch... significant ischemia of her right foot secondary to arterial clot." An infectious disease consult, dated [DATE], stated, "... presently non-verbal... RLE (right lower extremity) colder than LLE, R great toe necrotic with discoloration of the R 2nd toe as well...". Review of the DLTCRP (Division of Long Term Care Residents Protection) investigator case notes revealed that R3 was discharged from the hospital to hospice on [DATE] and she expired on [DATE]. E6 (full-time day shift nurse) was interviewed on [DATE]. E6 stated the discoloration on R3's R great toe began on [DATE] when the podiatrist removed the toenail. E6 stated she notified the on call physician on [DATE] because the nailbed area was darker- "bluish/purple." E6 stated the R great toe was darkest at the tip of the toe. E6 stated she notified the NP #1 (Nurse Practitioner) on [DATE] because the wound was getting darker and was not getting better. E6 stated she was told by NP #1 on [DATE] to continue to observe the wound. E6 stated she called the on call physician on [DATE] because the toenail was not healing as fast as she thought it should. E6 denied any R foot ulcerations, necrotic or black areas on ,[DATE] and confirmed she did not check for a pedal pulse on [DATE] although she knew R3 had "circulation problems." When questioned about lack of pedal pulse checks in her nurse's notes, E6 confirmed she did not document any, but said "no one else did either." E6 was asked to demonstrate how to check for a pedal pulse on the surveyors foot- E6 incorrectly placed her fingertips at the top center of the foot between the ankles. E6 stated R3 was normally able to talk and make her needs be known. E6 stated R3 was sleepy the day she went to the hospital. E6 (nurse) was interviewed on [DATE]. E6 stated she wanted to clarify why she did the pedal pulse check incorrectly on [DATE]. She stated she did not palpate the top center of the surveyor's foot (mid section of foot- correct position) because "I didn't want you to think I was getting fresh." Concerns were discussed with E3 (Assistant Director of Nursing/ADON) about an hour earlier). E6 was asked to demonstrate how to check for capillary refill on the surveyors index finger (indicator of circulation- should be under 2 seconds). E6 incorrectly compressed the surveyor's finger above the nailbed the whole time (decreasing blood flow to the nailbed). When asked what the result was, E6 stated, "4 seconds" then changed her answer to "2 seconds." When asked if she notified the unit manager or nursing supervisor prior to contacting the on call physician and/or NP on ,[DATE], ,[DATE] and ,[DATE] about concerns regarding R3's R foot, she was unable to provide specifics, except that E3 (ADON) was the Unit Manager and he was aware of the situation when the toenail was removed on [DATE]. E6 was asked if the physician or NP looked at R3's foot after she first contacted them on [DATE] and she replied they would have written a progress note if the resident was seen. E3 (ADON) was interviewed on [DATE]. He confirmed that R3's R great toe was not evaluated by the wound care physician despite the presence of a wound after the podiatrist removed R3's toenail. Additionally, there were no wound sheets. E3 confirmed he was the unit manager on the floor where R3 resided from [DATE]- [DATE]. E3 stated he saw R3's R great toe on [DATE] when the podiatrist removed the toenail and it was the only time he observed it. E3 stated he did not recall anyone bringing ongoing concerns to him about R3's R foot. When questioned about why the R foot was not discussed in the [DATE] and [DATE] weekly IDT meetings, E3 stated it should have been picked up because there was an incident report for the [DATE] nail removal, but it was missed. Nurse's notes were reviewed and E3 confirmed the nursing assessments were not thorough (foot temperature (warm, cold, etc.), capillary refill, pedal pulse checks, level of consciousness, etc). To summarize, R3's R great toe wound deteriorated and became progressively darker after [DATE]. R3's mentation declined from alert and able to make needs known to only being responsive to painful stimuli and being non-communicable. There was no documentation of capillary refill or pedal pulses by nursing staff after the ,[DATE] note (lacked thorough assessments). Additionally, nursing staff failed to demonstrate how to check capillary refill and pedal pulse checks according to accepted professional nursing standards. The facility also failed to identify and act on her declining po intake mental status. E3 (ADON- was UM at the time) saw R3's R foot on [DATE] the day the toenail was removed and stated he was unaware of ongoing problems with the foot. There were 2 IDT meetings within this timeframe (,[DATE] & ,[DATE]) and no mention of R3's R foot, only a skin tear on the elbow. Additionally, E6 (nurse) called the on call physician for concerns about R3's foot on ,[DATE], ,[DATE] (NP) & ,[DATE]- ABT's were either continued or reordered for [MEDICAL CONDITION]. R3 was not re-evaluated by a physician after the toenail was removed on [DATE]. R3 was eventually sent to theER on ,[DATE] per the daughters request- R3 was found to have an ischemic R foot with gangrene of the R great toe extending into other toes. It is questionable whether E6 alerted the UM or nursing supervisor of ongoing concerns with the R foot so it could be more thoroughly assessed. There were no physician evaluations after ,[DATE]- the on call physician only had whatever information was provided. R3 sustained harm from lack of ongoing thorough assessments, including circulation checks to the right foot and recognition of her declining mental status and meal intake. R3 was a full code before being hospitalized on [DATE]. 2. R78 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." The facility developed a care plan for R78 for the potential for constipation on [DATE]. Approaches included to monitor bowel status and administer stool softeners per physician's orders [REDACTED]. Review of computerized CNA (Certified Nurse's Aide) data sheets from [DATE] through [DATE] revealed that R78 had a total of 23 liquid bowel movements documented as having occurred. Review of the clinical record lacked evidence that the liquid BMs had been identified by nursing. Review of the ,[DATE], ,[DATE] and ,[DATE] MARs revealed that on 19 of these days the [MEDICATION NAME] was documented as having been administered when it should have been held. The facility failed to follow physician's orders [REDACTED]. During an interview on [DATE] at 10:50 AM with E9 (nurse), he stated that the CNAs are suppose to tell the nurse when a resident has any abnormal stools and the nurse should hold the medication. E9 also stated that the nurse should then report it to the oncoming shift nurse. Findings were reviewed with E7 (Corporate Nurse) on [DATE] at approximately 2:00 PM. E7 acknowledged the findings. 3A. Review of R9's quarterly MDS assessment dated [DATE] revealed that R9 required extensive assistance of one staff person for toileting and R9 was always incontinent of bowel and frequently incontinent of bladder. R9's care plan, dated [DATE] entitled, "potential for constipation r/t (related to) hx (history) of, limited functional mobility, thickened liquids, med: regimen. Approaches included, "1. monitor bowel status & follow bowel protocol..." Review of R9's [DATE] physician's orders [REDACTED]. Milk of Magnesia (MOM, a laxative) 400 mg/5 ml Take 30 ml (2 Tablespoonfuls) by mouth every 3 days as needed for constipation per bowel protocol. Bisac-Evac (laxative) Insert 1 suppository rectally as needed - if no results from MOM per bowel protocol. Fleet enema Use rectally as needed -if no results from [MEDICATION NAME] (brand name) suppository per bowel protocol." Review of R9's "Resident Bowel and Bladder by shift Chart" revealed documentation that R9 had an "X-Large" bowel movement (BM) during evening shift on [DATE], followed by "No Bowel Movement" from [DATE] (night shift) through [DATE] (night shift) or 16 shifts without BM activity. R9 had a "Large" BM on [DATE] (day shift). Additional review of R9's "Resident Bowel and Bladder by shift Chart" revealed documentation of "No Bowel Movement" from [DATE] (evening shift) through [DATE] (evening shift) or 13 shifts without BM activity. R9 had a "Small" BM on [DATE] (night shift). There was no evidence that the facility assessed R9 for constipation and/or followed R9's physician orders. Additionally, review of the September and [DATE] MARs (Medication Administration Records) lacked evidence that any PRN (as needed) orders for constipation were implemented before [DATE]. During an interview on [DATE] at 10:45 AM, E3 (ADON) confirmed findings and agreed that medications should be signed out on the MAR indicated [REDACTED]. 3B. R9 had a physician's orders [REDACTED]. Review of the [DATE] MAR (Medication Administration Record) revealed that on three occasions (,[DATE], ,[DATE] and ,[DATE]), Tylenol was administered for complaints of pain. Review of the back of the MAR indicated [REDACTED]. There was no documentation on the back of the MAR for ,[DATE] and ,[DATE]. There were no corresponding nursing notes for these dates. Additionally, review of the "Pain Score Every Shift" on the ,[DATE] MAR indicated for every shift of the entire month. The facility failed to assess R9's pain including a description//location of pain, and they failed to assess the effectiveness of the medication (i.e.. use the pain scale pre and post administration). During an interview on [DATE] at 10:45 AM, E3 (ADON) confirmed the findings. 4. R27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R27's physician order [REDACTED]. 30 ml (2 tablespoonfuls) by mouth every 3 days as needed for constipation - per bowel protocol; Bisac -Evac 10 mg supp. (suppository) rect (rectal) for [MEDICATION NAME] insert 1 suppository rectally as needed if no results from MOM - per bowel protocol; and Fleet enema use rectally as needed if no results from [MEDICATION NAME] suppository - per bowel protocol." Review of the Care Tracker report for Bowel and Bladder by shift revealed that R27 had no bowel movements (BM's) for more than 3 days on the following dates: - From [DATE] shift 2 (day shift) until [DATE] shift 2, no BM for 5 days; - From [DATE] shift 3 (evening shift) until [DATE] shift 2, no BM for 4 days; - From [DATE] shift 2 until [DATE] shift 2, no BM for 5 days; - From [DATE] shift 2 until [DATE] shift 2 no BM for 4 days; - From [DATE] shift 2 until 10/ ,[DATE] shift 2, no BM for 4 days; - From [DATE] shift 2 until [DATE] shift 2, no BM for 6 days. Review of the Medication Administration Records (MARs) for ,[DATE] and ,[DATE] revealed lack of evidence that either Senna-Gen or the Bowel Protocol was initiated/administered as per physicians' orders when R27 had no BM's in 2 or 3 days respectively. Additionally, nurses' notes for R27 from [DATE] - [DATE] lacked documentation of R27 not having BMs for more than 3 days and that Senna-Gen or the Bowel Protocol were initiated. The facility failed to follow physician orders [REDACTED]. On [DATE] at 11:51 AM, E3 (ADON) confirmed the findings. 5A. R216 was admitted to the facility on [DATE] for 5 day respite care with [DIAGNOSES REDACTED]. R216 was alert and oriented with confusion. According to the admission "Data Collection Tool" this resident was incontinent of bowel and bladder, required physical assistance for dressing, grooming, bed mobility and bathing, was dependent for toilet use, and required physical assistance of 2 persons for non-weight bearing transfers. According to the "Resident Pain Review Tool" dated [DATE], R216's current pain management medication regime was Tylenol 500 mg at bedtime (9 PM). R216 identified the location of the pain as "legs", what precipitated/aggravated her pain was a "change in position" and described the pain as "aching". In addition to Tylenol at bedtime, R216's physician ordered, "[MEDICATION NAME] 325 mg tab take 2 tabs (650 Mg) by mouth q (every) 4 hrs prn (as needed) for pain (max 4gm/day)" The admission History and Physical by R216's Physician, dated [DATE], indicated the following: Skin - normal moisture, no pressure sores, nails WNL (Within Normal limits), no rashes, itching, excessive dryness; Extremities- full active/passive ROM upper (extremity), no [MEDICAL CONDITION], clubbing, cyanosis, no deformities musculoskeletal - no evidence of fractures, no contractures, no joint deformity, no missing limbs. On [DATE], the facility developed a care plan entitled, "Potential for Pain" (location was not identified) which included the interventions, "Evaluate effectiveness of [MEDICATION NAME] through verbal signs and non-verbal s/s (signs and symptoms) of pain relief using pain scale ,[DATE], Administer pain medication per MD order, and Pain evaluation per protocol". According to the "Medication Guide for the Long Term Care Nurse, 5th edition" entitled "Documentation of Medication Administration", "When pro re nata (PRN) medications are administered, the date, time, reason for giving the medicine, and initials of the nurse should be charted on the back of the MAR (Medication Administration Record). The results of the medicine should be charted after the effect is observed". A similar protocol was written on the back of the facility's MAR. Review of R216's [DATE] MAR (Medication Administration Record), revealed that on [DATE], R216 received PRN [MEDICATION NAME] 2 tabs (650 mg) at 3:30 AM for pain. The severity of the pain was scored as ,[DATE] (on scale of 5 out of 10). However, the facility failed to include the description, type, location/site of the pain when administering the prn pain medication and the outcome/effect on the MAR indicated [REDACTED]. 5B. Additionally, R216 had physician orders [REDACTED]. (every) week on Mon ,[DATE] shift" The "Self care deficit" care plan developed on [DATE] had the approach, "Inspect skin for potential areas of skin alteration - Notify MD of any noted changes..." R216 was discharged and left the faciity on [DATE] at 7:00 PM with family who discovered that she had a severely swollen knee shortly after arriving home on [DATE]. Family took her to the hospital ER for evaluation and treatment. Review of the hospital ER's record revealed that R216's right knee was swollen and tender and she was admitted to the hospital. Blood work was done as well as arthrocentesis ([DIAGNOSES REDACTED] fluid aspiration) which showed hemearthrosis (sic) (bleeding into joint spaces) without evidence of septic infection. On [DATE] at 5:00 PM in an interview, E34 (CNA) stated that she and E43 (CNA) did pericare and changed R216's adult pad in the afternoon of [DATE], prior to discharge. However, she stated that they only pulled R216's pants down to her midthigh to change her pad. E34 stated that they did not observe R216's knee. Changing of adult pads involves perineal care skills including, "turns resident to side or raises hips and places waterproof pad under buttocks, exposes perineum, separates labia, using water and soapy wash cloth, to turn onto side to clean rectal area", as per the "Delaware Candidate Handbook for the Delaware Nurse Aide". With R216's pants down on the midthigh and not completely removed from the resident, proper turning and positioning of the resident from side to side and completely exposing the perineal and rectal area would be difficult to accomplish without compromising the resident's comfort and the procedures. The facility failed to ensure R216 received the appropriate techniques for perineal care and changing of an adult pad. Consequently, the facility missed the opportunity to assess R216's legs/knees, skin for color, integrity and turgor in accordance with the physician's plan and the comprehensive plan of care. The facility failed to ensure that the necessary care and services to maintain the highest practicable physical well being to R216 was provided. This finding was discussed on [DATE] in the presence of E1 (Administrator), E2 (DON), E3 (ADON) and E7 (RN Corporate Nurse).