Every finding on record at Encore at Wilmington

Based on record review and interview, it was determined that for one (R74) out of two residents reviewed for accidents, the facility failed to ensure R74 received adequate assistance and supervision to prevent accidents. R74, who required moderate assistance, sustained a facial injury after falling on the floor while receiving care from a staff member. Based review of the facility's evidence to correct the deficient practice and substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 1/6/26. Findings include:Review of R74's clinical record revealed:10/20/25 - R74 was admitted to the facility with diagnoses including congestive heart failure and cognitive communication deficit.10/20/25 - R74's care plan documented that he was at risk for falls due to chronic pain and weakness.12/24/25 - R74s's medications included Apixaban 5 mg (anticoagulant) twice daily for deep vein thrombosis.12/30/25 - R74's readmission MDS assessment documented a BIMS score of 5, indicating severely impaired cognition. The assessment also documented that R74 had right and left upper extremity impairments and required partial/maximal assistance to roll left and right.1/3/26 - A facility incident report documented, .found [R74] on the floor beside his bed on the window side. [R74] was lying prone [face down] with blood noted to flow from his face.[E27, CNA] and [E28, LPN] were in the room and stated that [R74] fell from the bed to the floor while [E27] was providing care.Skin tear noted to left cheek with bleeding, skin tears also noted on right elbow and bilateral knee.[R74] was sent to ER for evaluation.1/3/26 - A general note entered in R74's clinical record documented, [R74] returned from [hospital].had 5 stitches on his cheek to be removed in 5 days.1/5/26 4:11 PM - An IDT (interdisciplinary) Note entered in R74's clinical record documented, .RCA [root cause analysis]: Positioning near bed edge; bed not wide enough; insufficient guarding; absent floor mat use during care; update care plan and audit compliance.1/5/26 - R47's fall care plan was updated to include bilateral fall mats while in bed, resident bed in low position, wide bed replacement, and resident safe bed positioning.1/6/26 - A document entitled Investigation Report Interview, signed by E27 and E3 (DON), documented, I [E27] walked in around 9 am [9:00 AM] to do morning care to [R47]. The task was changing his brief, I pulled [R47] close to me and assisted [R47] on the right side, [R47] was on the right side. I [E27] was cleaning his brief and the task was done. I told [R47] to roll back and he began to roll the opposite way instead.1/6/26 2:00 PM - A document entitled Investigation Report Interview documented, Name of Person Interviewed: [E28, LPN].At around 1000 [10:00 AM] [E27] called and stated [R47] rolled off the bed while being changed. [R47] was found laying on the floor beside his bed on the window side. Blood was flowing from [R47]'s face.1/6/26 - A facility document entitled, Educational Opportunity Notice signed by E27 and E2 documented, .[E27] will be conscious of resident positioning when providing care to minimize risk of fall or injury. Verbal education provided. [E27] provide demonstration of what she would do differently and verbalized understanding of education provided.1/6/26 11:00 AM - A facility document entitled, Staff Development Program Attendance Record.Providing Safe Care in Bed documented a staff training was held and contained the signatures of nursing and CNA staff. A document entitled, Providing Safe Care While Patient In Bed dated 1/6/26 stated the contents of the education provided during the training.6/11/26 12:30 PM - E27 gave the surveyor a documented audit completed for 6 residents monitored for 3 shifts daily for 4 weeks from 1/5/26 to 1/26/26.6/11/26 1:32 PM - During an interview, E28 stated, [E27] told the [R47] to roll on his side and he rolled too much. I was not in the room when it happened. There was blood on [R47] and the floor. [R47] was sent out to the hospital. The surveyor asked E27 if had received training after the incident. E27 stated that he received training the next day or so and verbalized the training received.6/11/26 2:00 PM - Based on the surveyor's review of the facility's investigation, documented response, audit completion, staff interview, and no further resident falls while provided care, the deficiency was considered past non-compliance with a compliance date of 1/6/26.6/15/26 1:15 PM - Findings reviewed with E1 and E2.6/15/26 4:15 PM - Findings were reviewed with E1, E2 and E3 (ADON) during the Exit Conference.

Based on interview and record review, it was determined that for one (R73) out of three residents reviewed for falls, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by failing to have a registered nurse (RN) complete and document a RN post-fall assessment. Findings include: Delaware State Board of Nursing - RN, LPN . Duties 2024. RN. Post Fall Assessment & Documentation. RN must do initial fall assessment; LPN can do subsequent assessments . updated 10/11/24. Review of R73's record revealed: 10/16/25 - R45 had a physician's order for Eliquis (blood thinner) tablet twice a day for a diagnosis of aFib (irregular heart rhythm). 12/16/25 2:45 PM - The facility's incident report by E29 (LPN) documented that R45 was found on his knees with left arm inside the drawer of the bedside table. Head resting on bedside table. Sent to ER [emergency room]. 12/16/25 2:45 PM - The facility's baseline and subsequent neurological check evaluations were documented by E29. 12/16/25 4:44 PM - A nursing note by E29 documented, S/p [Status post] fall with no injuries. Pulse ox [vital sign that measures oxygen saturation/normal levels 92% to 100%] at 70% on continuous oxygen. Oxygen increased and pulse ox at 88%. Orders given to send resident to hospital for further eval [evaluation]. Review of R45's clinical record lacked evidence that an RN performed the post-fall assessment and documentation on 12/16/25. 6/12/26 10:20 AM - During an interview, E29 recalled R45's 12/16/25 fall after reviewing the documentation. Despite remembering the details of the resident's fall, E29 stated that she could not tell the surveyor if an RN assessed R45 after the unwitnessed fall. E29 confirmed that she performed the baseline and subsequent neurocheck assessments. 6/12/26 10:32 AM - During an interview, finding was reviewed with E2 (DON). 6/15/26 4:15 PM - Findings were reviewed with E1 (ED), E2 and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R71) out of four residents reviewed for ADLs, the facility failed to ensure that R71, a dependent resident, was showered/bathed at least two times a week. Findings include:Review of R71's record revealed: 10/16/25 - R71 was admitted to the facility. 1/22/26 - R71 had a physician's order for a shower day every Wednesday and Saturday day shift and to notify the POA of refusal then enter a progress note. 4/24/26 11:54 AM - R71's physician order for a shower on Wednesday and Saturday day shift was discontinued because the resident was discharged to the hospital. 4/24/26 3:35 PM - R71 was readmitted to the facility. Review of the record revealed that R71's physician order for a shower or bathing on Wednesday and Saturday was never re-entered upon re-admission to the facility. The facility failed to ensure that R71 was showered/bathed at least two times a week upon readmission to the facility. 6/15/26 12:45 PM - During an interview, finding was reviewed and discussed with E2 (DON). 6/15/26 4:15 PM - Findings were reviewed with E1 (ED), E2 and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R68) out of two residents reviewed for hospitalization, the facility failed to ensure R68's physician order for trending weights was followed. Findings include: The facility's policy and procedure for weights, dated 9/2020, revealed, Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. 5. Consistent weighing process and technique is used to determine accurate body weight measurement. This includes weighing the resident at approximately the same time of day and using the same scale. Review of R68's record revealed: 3/13/26 - R68 was admitted to the facility with a diagnosis of congestive heart failure. 3/16/26 - R68's care plan created by E4 (RD) for nutrition/hydration listed an intervention that included to monitor weights. 3/23/26 - A cardiology consult note by P4 (Medical Provider) stated, . I will ask nursing to trend weights. 3/23/26 - A physician's order by P4 stated to weigh R68 every Monday and Thursday. Review of the dates and times of R68's documented weights according to the physician's order revealed:-Thursday, 3/26/26 at 11:04 AM;-Monday, 3/30/26, no weight obtained;-Thursday, 4/2/26 at 1:15 PM;-Monday, 4/6/26 at 11:55 AM;-Thursday, 4/9/26 at 1:43 PM;-Monday, 4/13/26 at 10:07 AM;-Thursday, 4/16/26, no weight obtained;-Monday, 4/20/26, no weight obtained; and-Thursday, 4/23/26, no weight obtained. 6/15/26 11:43 AM - During an interview, finding was reviewed and confirmed with E4. The facility failed to follow a physician's order to trend R68's weights. 6/15/26 4:15 PM - Findings were reviewed with E1 (ED), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R38) out of two residents reviewed for accidents, the facility failed to timely notify the provider when R38's ankle pain was reported to staff. Findings include:Review of R38's clinical record revealed:3/25/24 - R38 was admitted to the facility with diagnoses including age-related osteoporosis and left lower leg amputation.4/5/24 - R38's care plan documented dependence on two staff persons with mechanical lift for sit to stand transfers.10/2/25 - A quarterly assessment documented R38 had a BIMS of 10, indicating moderately impaired cognition. The assessment also documented that R38 had right and left lower extremity impairments and was dependent for assistance to stand and to transfer from bed to chair.10/24/25 - A Physical therapy Treatment Encounter Note signed by E30 (PT) documented, .Transfer: bed to chair via sit pivot in small increments and max A [assist] of 2. R [right ankle] appeared to have slightly more eversion [pointing outward].No swelling or redness noted. Nurse made aware and came to [R38]'s room.10/24/25 - An Occupational Encounter Note documented, [R38] required max A [assistance] x2 for squat pivot transfer from bed to wheelchair and reported no pain with transfer. [R38] reported 5/10 pain in R [right] ankle upon attempted PROM [passive range of motion].mobility stopped immediately d/t reported pain. [R38] further reported small cut on middle R [right] toe. Nursing notified of both cut and pain immediately. 10/24/25 1:27 PM - An Administration Note entered by E29 (LPN) documented that Tylenol was given to R38 for a complaint of right ankle pain.10/25/26 8:27 AM - An Administration Note documented entered by E31(LPN) documented, .[R38] c/o [complained of] right ankle pain. Supervisor and MD notified .The provider was notified of R38's change in condition 8 hours after it was reported to staff.10/25/25 12:46 PM - A General Note entered documented, [R38] reported pain on right ankle. [P1, NP] made aware. New order received for STAT right ankle x-ray two view x-ray. 10/25/25 10:53 PM - A facility incident report documented, [R38] reported pain on right ankle. [R38] stated pain increases with movement, right ankle noted with swelling. [P1, NP] made aware. New order received for STAT right ankle x-ray.At 2151 [9:51 PM] x-ray results received.acute fracture in distal shaft of the right fibula.[R38] left facility at 2252 [10:52 PM] for ER.10/26/25 1:05 AM - A hospital radiology report documented that [R38] had an acute distal fibular fracture.10/29/25 - A facility document entitled, Investigation Report Interview, documented, Name of Person Interviewed: [E29].Alerted by therapy that [R38]'s ankle appeared to be turned outward. PRN [as needed] Tylenol given. Cause unknown. [R38] stated she doesn't remember hitting her leg on anything. This was during 10/24/25 day shift.6/10/26 - During an interview R38 stated, I did not have PT on that Thursday. That Friday when PT came, my leg looked funny. I don't know how it happened.6/11/26 10:53 AM - During a joint interview with E30 (PT) and E33 (OT), E33 stated, [R38] always had right ankle eversion, but it was more everted than baseline. We did a squat pivot from the chair to the wheelchair. When I started the PROM, [R38] complained of pain. I stopped and we immediately let [E29] know. The surveyor asked what time this occurred. E30 stated, [R38]'s session was between 1:00 PM and 3:00 PM. We continued to work on upper body strength exercises. I did not notice any redness or swelling. E30 stated, [R38] has been transferred by stand pivot on the right leg previously with no issues.6/11/26 2:16 PM - During an interview, E29 stated that she was informed by PT and OT that R38 had ankle pain and gave her Tylenol. The surveyor asked E29, Did you assess R38's ankle pain or notify the provider? E29 stated, No, I didn't.6/15/26 1:15 PM - Findings reviewed with E1 (NHA) and E2 (DON).6/15/26 4:15 PM - Findings were reviewed with E1, E2 and E3 (ADON) during the Exit Conference.

Based on observation, review of facility documentation and staff interviews, it was determined that the facility failed to post the required federal staffing information. Findings include:6/11/26 12:00 PM - An observation in the healthcare's nursing station revealed that the staffing posting did not contain the total worked hours per shift for each discipline, Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNA). 6/11/26 12:16 PM - In an interview, E23 (Scheduler) stated that ever since she joined the company under the previous ownership, the staffing postings did not contain the hours worked by the nurses and the nursing aides (CNAs). 6/15/26 2:00 PM - Finding was discussed with E1 (ED) and E2 (DON). 6/15/26 4:15 PM - Finding was reviewed with E1, E2 and E3 (ADON) during the Exit Conference.

Based on interview and record review, it was determined that the facility failed to provide a satisfactory water management plan to prevent the growth of Legionella and other water borne pathogens. Findings include: 6/5/25 1:17 PM - During the document review and interview with E3 (DPO), the surveyor found the water management plan lacked description and diagram of water flow in the facility, potential infection sites, prevention and treatment plans. The findings were confirmed with E3. 6/5/25 2:31 PM - Findings were reviewed with E1 (NHA). 6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (regional nurse) and E9 (regional reimbursement) (via phone) at the exit conference.

Based on record review and interview, it was determined that for one (R13) out of two residents reviewed for hospitalizations, the facility failed to notify the Ombudsman of R13's transfers to the hospital on [DATE], 12/26/24, and 5/11/25. Findings include: 1/6/22 - R13 was admitted to the facility. 11/13/24 - Per R13's progress notes, F1 (R13's POA) was notified by the facility that R13 was hospitalized on [DATE] after his nephrostomy (a tube that drains the kidneys) tube was dislodged. 12/27/24 - Per R13's progress notes, F1 was notified by the facility that R13 was hospitalized on [DATE] with pain at his nephrostomy site and was diagnosed with a urinary tract infection. 5/12/25 - F1 was notified by the facility that R13 was hospitalized on [DATE] due to the dislodgement of his nephrostomy tube. 6/5/25 11:30 AM - A review of R13's hospital transfer paperwork revealed that the Ombudsman was not notified on the facility's monthly Ombudsman report of R13's hospital transfers on 11/13/24, 12/26/24 and 5/11/25. The facility failed to notify the Ombudsman as required of R13's frequent hospitalizations. 6/5/25 2:45 PM - E1 (NHA) confirmed that R13's name did not appear on the November 2024, December 2024 and May 2025 monthly Ombudsman reports. 6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (regional nurse) and E9 (regional reimbursement) (via phone) at the exit conference.

Based on observation, interview and record review, it was determined that for one (R44) out of 15 residents reviewed, the facility failed to ensure that R44's toileting care plan was revised when toileting plan changed. Findings include: Review of R44's clinical records revealed: 12/18/24 - R44's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. R44's clinical record also documented, Always incontinent of bowel and bladder, dependent on staff for toileting. 3/12/25 - R44's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. R44's clinical records also documented, Always incontinent of bowel and bladder Partial to moderate assistance of (staff) to get on and off the toilet. 6/6/25 9:00 AM - A review of R44's revealed that the facilty failed to review her care plan when her transfer status changed from dependent to partial/moderate assistance to promoted continence . 6/6/25 10:00 AM - During an interview E1, (NHA) stated, No, the care plan was not reviewed or revised. 6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (Regional Nurse) and E9 (Regional Reimbursement) (via phone) at the exit conference.

Based on observation, interview and record review, it was determined that for two (R35 and R44) out of three residents reviewed for bowel and bladder incontinence, the facility failed to ensure that R35 and R44 received appropriate services and treatment to promote continence of bladder and bowel to the extent possible. Findings include: 2001 - A facility document entitled, Behavioral Programs and Toileting Plans for Urinary Incontinence, and revised 10/2010, included, The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. 1. Review of R35's clinical record revealed: 5/20/25 - R35 was admitted to the facility with diagnoses including acute respiratory failure and muscle weakness. 5/21/25 - R35's toileting care plan documented, At risk for altered bladder elimination d/t (due to) requiring assist of one with toileting. The goals included, Resident will regain prior level of elimination. The interventions included, 3 day voiding to establish and need for bladder training/voiding diary. 5/26/25 - R35's admission MDS documented a BIMS score of 15, indicating a cognitively intact status. The MDS also documented that R35 required partial to moderate assistance of one staff member for transfers from the bed to the wheelchair and was occasionally incontinent of bladder and frequently incontinent of bowel. 6/2/25 - R35's Kardex lacked evidence of the formulation of a toileting program. 6/3/25 12:30 PM - During an interview R35 stated, I am going home back with my husband after I am done here. I really want to be able to use the toilet. I am tired of wetting myself. The Surveyor asked R35 if she was on a toileting program or if she was encouraged or assisted by staff members to use the toilet. R35 stated, I don't know anything about a toileting program. They change my diapers when I am wet. I am wet right now. 6/5/25 1:30 PM - During an interview, the Surveyor asked E6 (CNA) if R35 uses the toilet. E6 stated, No, I change her in the bed when she is wet. E6 stated that R35 required minimum assistance with transfers. 6/5/25 3:00 PM - During an interview E7 (CNA) stated, I don't know if the resident is able to use the toilet. I usually just change her when she is wet. E7 stated that R35 required minimum assistance with transfers. 6/6/25 12:30 PM - A review of R35's clinical record from 5/20/25 through 6/6/25 revealed forty-one (41) episodes of urinary incontinence out of 51 (fifty-one) opportunities for continence. 6/6/25 1:00 PM - During an interview E8 (RN) stated, We do the voiding diary on admission. The facility was unable to provide evidence of the assessment of the voiding diary. 2. Review of R44's clinical record revealed: 6/3/24 - R44 was admitted to the facility with diagnoses including a fracture of the left lower extremity and congestive heart disease. 12/18/24 - R44's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. R44's clinical record also documented, Always incontinent of bowel and bladder, dependent on staff for toileting. 3/12/25 - R44's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. R44's clinical records also documented, Always incontinent of bowel and bladder Partial to moderate assistance of (staff) to get on and off the toilet. R44's clinical documents lacked evidence of an assessment or interventions for a toileting program (to improve continence status) when her transfer status improved from dependent on staff to partial to moderate assistance. 6/6/25- 8:30 AM - During an interview R44 stated, I would really like to use the toilet. I would like to get rid of these diapers and use pullups instead. R44 was observed sitting up in bed independently. R44 stated, I am wet right now. I think I might be able to move back to the Assisted Living if I can use the toilet. The aides change me when I am wet. 6/6/25 11:20 AM - During an interview, the Surveyor asked E6 (CNA) if R44 uses the toilet. E6 stated, No, I change her in the bed when she is wet. I don't know if she is on a toileting program or anything. 6/6/25 12:30 PM - During an interview E7 (CNA) stated, I don't know if she (R44) can use the toilet. I usually just change her when she is wet. The Surveyor asked E7 how much assistance was provided to R44 for toileting, E7 stated, She is easy to take care of. She uses the walker to stand up and I change her. 6/6/25 1:00 PM - A review of R44's clinical record from 5/8/25 through 6/6/25 revealed seventy-nine (79) episodes of urinary incontinence out of 90 (ninety) opportunities for continence. 6/6/25 1:30 PM - During an interview E2 (DON) stated that E35's and R44's 3 day voiding diaries were completed but the person centered toileting interventions were not implemented because the residents were incontinent on admission. The facility failed ensure that R35's and R44's received person centered services and treatment to promote continence to the extent possible. 6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (Regional Nurse) and E9 (Regional Reimbursement) (via phone) at the exit conference.

Based on record review and interview, it was determined that for one (R33) out of seven residents reviewed for vaccines, the facility failed to ensure that R33 was free from a significant medication error, R33 was given two (2) sets of the PNA, influenza and COVID vaccines twelve hours apart.Findings include: Centers for Disease Control (CDC) Vaccines & Immunizations - Timing and Spacing of Immunobiologics .General Prinicples for vaccine scheduling .Vaccination providers should adhere to recommended vaccination schedules .certain vaccines produce increased rates of local orsystemic reactions in certain recipients when administrered more frequesntly than recommended Extra Doses of vaccine antigens - .However, the risk for an adverse event might increase when extra doses are administered at an earlier time than the recommended interval for certain vaccines . Updated July 24, 2024 CDC's Recommended Adult Immunization Schedule by Age Group - For adults greater than or equal to sixty-five (65) years- COVID-19 Vaccine - 2 or more doses of 2024-2025 vaccine . Influenza Vaccine - 1 dose annually .Pneumococcal Vaccine - No prior pneumococcal vaccines, recommend PCV20 (Pneumococcal conjugate PCV20 vaccine). Revised 5/28/25 Facility's Administering Medications Policy - Policy Interpretation and Implementation . 22. The individual administering the medication initials the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones. Revised April 2019 Review of R33's clinical record revealed: 3/23/23- R33, who was seventy-three (73) years old, was admitted to the facility with diagnoses including but not limited to multiple sclerosis and dementia. 12/30/24 - C1 (consulting physician) ordered in R33's EMR, Resident may have flu vaccine when available. C1 also ordered, Resident may have pneumovax every five (5) years. 2/5/25 9:30 AM - E11 (RN/Infection Preventionist) documented in R33's Immunization tab in R33's EMR administering pneumococcal conjugate PCV20 vaccine, influenza, high-dose, trivalent, PF (135) vaccine and COVID -19 Moderna Booster (208) to R33 intramuscularly in her left deltoid. 2/5/25 9:10 PM - E10 (LPN) documented in R33's February 2025 MAR administering pneumococcal 20-[NAME] conjugate vaccine and Fluzone high-dose intramuscular suspension vaccine intramuscularly to R33. 2/5/25 9:24 PM - E10 (LPN) documented in R33's February 2025 MAR administering Spikevax Intramuscular suspension (COVID-19 (SARS-CoV-2) mRNA virus vaccine intramuscularly to R33. 2/5/25 10:11 PM - E10 documented in R33's progress notes, Resident has one-time orders for Fluzone vaccines (sic), COVID -19 vaccine, and Pneumococcal vaccine. Vaccines were administered by nurse at 2110 (9:10 PM) today after POA (power of attorney) consent verified. Flu & COVID administered on the left thigh, and pneumococcal administered on the right thigh. Nurse noted when about to document the vaccines administrations on the Immunization Tab that all the vaccines were administered this morning @ (at) 9:30 AM. Resident was immediately assessed and NP (Nurse Practitioner) [name] called at 2120 (9:20 PM). R33, who was seventy-five (75) years old, was administered two doses of three vaccines within a twelve-hour period, when the order was for one dose of each of three vaccines. 6/4/25 10:30 AM - A review of the DELVAX website revealed R33 had no documented previous immunizations for influenza or pneumococcal infections. R33 was documented on DELVAX to have received the COVID 19 vaccine on 10/28/22. 6/5/25 11:30 AM - A review of the MAR (Medication Administration Record) for February 2025 revealed that E11 failed to document the administration of these three vaccines in R33's MAR as per the facility policy. The failure to document the administration of the vaccines resulted in R33, who was bedbound and medically frail, receiving two doses of the same sets of vaccinations within a twelve hour period, which was not inaccordance with the CDC recommendations for these vaccines' schedules. Per the CDC Adult Vaccination Schedule guidelines, the influenza vaccine was recommended for one dose annually. The COVID-19 vaccine recommendation for persons, who were previously COVID-19 vaccinated before the 2024-2025 vaccine, included two doses of the vaccine with a minimum interval of two (2) months between the vaccinations. The CDC recommendations for the pneumococcal vaccine for persons who were not previously vaccinated for pneumococcal included one dose of PCV20. R33 did exhibit an adverse reaction with a fever of 101F and was sent to the hospital for an evaluation. 6/6/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E8 (regional nurse) and E9 (regional reimbursement) (via phone) at the exit conference.

Based on record review, and interviews, it was determined that for one (R172) out of two residents reviewed for accidents, the facility failed to ensure adequate supervision was provided to prevent accidents. This failure caused R172 to roll out of the bed while one staff member was providing care. R172 sustained harm, an injury to the back of the head and fractures to her left leg. Findings include: Review of R172's clinical records revealed: 11/14/21 - R172 was admitted to the facility with diagnoses including breast cancer, dementia, heart failure, depression. 11/21/21 - An order for a low air loss mattress (for wound pressure relief). 12/13/21 12:26 PM - A nursing progress note documented, Resident with a new stage 3 (three) wound to the sacrum . 12/20/22 3:27 PM - A nursing progress note documented, .Continued to be followed by wound care to due to stage 4 (four) to sacrum .low air loss mattress in place. 2/26/23 2:30 AM - A review of the facility incident report revealed that she fell from the bed to the floor and sustained a left leg fracture. This fall was reviewed by the facility's interdisciplinary team, and a care plan to provide a safe environment, and fall mats to both sides of the bed were added. 1/24/24 - R172's quarterly MDS assessment documented that the resident was completely dependent on staff for all activities of daily living including turning, repositioning, showers, and transfers. R172's BIMS assessment score was 6, which indicated severe cognitive impairment. 3/15/24 2:00 PM - A facility incident report submitted to the State Agency documented that R172 fell out of the bed while receiving care from an aide. R172 sustained a head injury and was sent to the hospital for evaluation. R172's hospital records documented, .Left lower leg . nondisplaced (broken bone that did not move out of alignment) fracture impaction fractures of the (left) proximal tibia (upper part of the shin bone) and fibula (lower leg bone) and a head injury. 3/16/24 - A facility document titled, Educational Opportunity Notice, and dated, 2017, documented, [E17] will be conscious of resident positioning when providing care to minimize risk of fall or injury. Verbal education provided and discuss (sic) resident handling. [E17] provided demonstration of what she would do differently, and verbalized understanding of education provided. 7/1/24 9:20 AM - A review of R172's [NAME] (electronic document for the aides to inform the staff of the residents' care needs) lacked information of how many staff members were needed to assist with turning, repositioning in bed. R172's care plan also lacked evidence of how many staff members were needed for turning and repositioning. 7/1/24 1:15 PM - During an interview, E5 (Unit Manager) stated, Physical Therapy determines how many staff members are needed for transfers, and turning and repositioning. This information is then communicated to nursing, and the order then obtained from the doctor, the [NAME] and the care plan are updated. 7/1/24 2:17 PM - During an interview, E6 (Physical Therapy Director) stated, The residents are seen on admission and evaluated for bed mobility and transfer status. This information is given to nursing for the resident's records. E6 failed to give the surveyor any documents of R172's evaluation and recommendations for bed mobility upon request. 7/1/24 2:30 PM - During an interview, E14 and E19 (CNAs), stated that they look at the [NAME] for information on residents' care including bed mobility and transfers. 7/2/24 10:30 AM - During an interview, E17 (CNA) stated, I was cleaning up the lower part of the resident's body and the top half started to roll off the bed. I tried to grab her feet but I was not able to prevent her from falling. The surveyor asked E17 if she knew how many persons were needed for R172's bed mobility, E17 stated, I usually look at the [NAME] or ask other aides about the residents' care including bed mobility and transfer status but this resident did not have any information about her bed mobility or transfers on the [NAME], so I looked to see what the other aides documented and that's what I did. The surveyor then asked E17 if R172 was able to participate in bed mobility, E17 stated, Sometimes she would reach for something, but she was not able to help with turning or anything. 7/2/24 11:30 AM - During a telephone interview F3 (R172's daughter) stated, The only thing my mother was able to do was feed herself, and that was only when the spoon was put in her hand. She was not able to move or do anything else. The facility failed to evaluate how many staff members were needed for R172's bed mobility including turning and repositioning, and that the information was documented on the [NAME] for staff to care for her safely. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).

Based on record reviews and interviews, it was determined that for seven (R13, R22, R33, R34, R47, R54, R270) out of seventeen residents reviewed for Infection Control, it was determined that the facility failed to establish and maintain an infection prevention and control program that included Enhanced Barrier Precautions (EBP). Additionally, it was determined that for 3 (three) R34, R47, R270 residents reviewed for urinary catheter care the facility failed to ensure a safe and sanitary process regarding urinary collection bags. Findings include: Facility Enhanced Barrier Precautions (EBP) Policy Statement- Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Policy Interpretation and Implemenetation 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room) .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube .); .10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . May 4, 2024 1.Review of R13's clinical record revealed: 5/24/24 - R13 was admitted to the facility into room [ROOM NUMBER]b. 6/19/24 - R13's hospital records documented prior MDROs infections and a diagnosis of extended spectrum beta-lactamase (ESBL) urinary tract infection (UTI). R13's medical history indicated that EBPs would be required. There was no evidence of EBP signage or personal protective equipment (PPE) outside R13's room. 2. Review of R22's clinical record revealed: 4/27/21 - R22 was admitted to the facility into room [ROOM NUMBER]a. 6/26/24 9:10 AM- Observation of the wound team rounding and providing care to R22's left heel resolving wound without any gown. Gloves were worn. R22's medical diagnosis list in his electronic medical record (EMR) documented ICD 10 code Z16.12 Extended spectrum beta lactamase (ESBL) resistance of his left heel wound. R22's medical record also documented a history of methicillin-resistant Staphylococcus aureus (MRSA) infection. Both of these infections qualified as MDROs and therefore, R22 required EBP. 3. Review of R33's clinical record revealed: 11/30/23 - R33 was admitted to the facility into room [ROOM NUMBER]b. 12/28/23 - R33's medical record documented a urine culture with Escherichia (E) coli ESBL infection. 4/28/24 - R33's medical record documented a second urine culture with E.coli ESBL. Review of R33's hospital records revealed a MRSA positive culture while hospitalized in November 2023. Both of these infections (E.coli ESBL UTI and MRSA) qualified as MDROs and therefore, R33 required EBP. There was no evidence of EBP signage or personal protective equipment (PPE) outside R33's room. 4. Review of R34's clinical record revealed: 5/4/23 - R34 was admitted to the facility into room [ROOM NUMBER]b. 5/10/24 - R34's medical record documented a urine culture with Klebsiella pneumoniae ESBL. 5/10/24 - E36 (DO) ordered in R34's EMR, Document indwelling foley catheter output Q (every) shift related to urinary retention. Both the infection (Klebsiella pneumoniae ESBL UTI), which was a MDRO, and the indwelling foley catheter (medical device) were indications for EBP; therefore, R34 required EBP. There was no evidence of EBP signage or personal protective equipment (PPE) outside R34's room. 5. Review of R47's clinical record revealed: 2/12/23 - R47 was admitted to the facility into room [ROOM NUMBER]a. 3/7/24 - E36 (DO) ordered in R47's EMR, Check foley catheter Q shift for clogging. 5/29/24 - R47's medical record documented a urine culture with Vancomycin resistant enterococcus faecalis (VRE) and MRSA. Both of the infections (VRE and MRSA UTIs), which was a MDRO, and the indwelling foley catheter (medical device) were indications for EBP; therefore, R47 required EBP. There was no evidence of EBP signage or personal protective equipment (PPE) outside R47's room. 6. Review of R54's clinical record revealed: 5/16/23 - R54 was admitted to the facility into room [ROOM NUMBER]b. 5/16/23 - E36 (DO) ordered in E54's EMR, Check placement of tube (G-tube) and residual every shift . 6/27/24 8:05 AM - Observation of E26 (LPN) administering R54's medications via her G-tube without utilizing EBP. E26 did have gloves on. The presence of the G-tube (feeding tube) was an indication for R54 to be on EBP. There was no evidence of EBP signage or personal protective equipment (PPE) outside R54's room. 7. Review of R270's clinical record revealed: 6/19/24 - R270 was admitted to the facility into room [ROOM NUMBER]b from another facility. R270's transfer paperwork listed a diagnosis of history of ESBL infection. 6/16/24 - E36 (DO) ordered in R270's EMR, Empty foley catheter bag every shift. The presence of the indwelling foley catheter (medical device) and history of ESBL infection were both indications for R270 to be on EBP. 6/27/24 2:37 PM - During an interview, E43 stated that she does not wear any protective clothing or coverings other than gloves when emptying the foley catheter bag for R 270. 6/27/24 2:56 PM - During an interview, E26 (LPN) stated, We do use yellow gowns at times. If the resident is on precautions, the facility puts a sign up. I don't get a lot of residents on precautions because this is the long-term care wing of the facility. 7/1/24 10:52 AM - Observation of rooms 508b, 512b, 514b, 615b, 707a, and 712b revealed no signage stating the residents in those rooms were on EBPs. 7/2/24 10:35 AM - A poll of all five surveyors revealed that at no point during the previous six days of the survey had any surveyor observed any staff providing direct patient care to any residents while utilizing EBP (wearing a yellow gown and gloves). 7/2/24 11:04 AM - During an interview, E4 (Clinical Specialist) stated, We are doing EBP. We list it on [the EMR] next to the resident's name. E4 pulled up a resident on the EMR to show the surveyor the EBP order. E4 stated, Oh my God, it's not there and there is no order (pointing to the EMR). We are doing it our other two facilities. 48409 8. Review of R34's clinical records revealed: 5/4/24 - R34 was admitted to the facility with diagnoses including adult failure to thrive, seizure, and neurogenic bladder. 5/10/24 - R34's clinical records included, Ensure that tubing and dignity bag are off the floor. 5/13/24 - R34's care plan included, Privacy bag at all times. 6/24/24 10:30 AM - R34 was observed lying in the bed, an uncovered, undated urinary collection bag with yellow urine was observed on the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom. 6/24/24 1:30 PM - R34 was observed lying in the bed, the uncovered, undated urinary collection bag with yellow urine continued to be on the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom. 6/25/24 - 10:30 AM R34 was observed lying in the bed, an uncovered, undated urinary collection bag with yellow urine was observed on the right side of the bed on the floor. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom. 6/25/24 - 2:30 PM: R34 was observed lying in the bed, an uncovered, the undated urinary bag with yellow urine continued to be observed on the right side of the bed on the floor. An undated/unlabeled urinary collection container was observed on the toilet seat of the shared bathroom. 6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist) stated. 9. Review of R47's clinical records revealed: 1/6/22 - R47 was admitted to the facility with diagnoses including urinary tract infections, neurogenic bladder, hypertension, and seizure disorder. 5/10/23 - R47's clinical records documented, Check tubing for kinks, and privacy bag at all times, secure catheter to reduce friction. 6/24/24 10:30 AM - R47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine was observed touching the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom. 6/24/24 2:30 PM - R 47 was observed lying in bed, the undated, uncovered urinary collection bag with yellow urine continued to be touching the floor on the left side of the bed. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom 6/25/25 10:00 AM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine hanging on the right side of the bed and visible from the doorway. An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom 6/25/24 2:30 PM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine in a wash basin was on the left side of the bed on the floor.An undated/unlabeled urinary collection container was observed on the grab bar of the bathroom 6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist). 10. Review of R270's clinical records revealed: 6/19/24 - R270 was admitted to the facility with multiple diagnoses, including obstructive uropathy, and R270 had a foley utinary catheter in place at admission. The following observations were made on 6/25/24 of R270's foley urinary catheter drainage bag: 10:30 AM - The foley urinary catheter drainage bag was on the facility floor. 11:30 AM - The foley urinary catheter drainage bag was on the facility floor. 11:41 AM - R270 was observed to be wheeled by a CNA the facility shower room with an uncovered foley urinary catheter bag dragging on the floor. 6/25/24 11:41AM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist). Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist) and State of DE Ombudsman (via telephone).

Based on record review and interview, it was determined that for nine (R4, R13, R18, R19, R33, R45, R51, R60 and R223) out of seventeen residents reviewed for vaccines, the facility failed to document in each resident's medical record the administration of the pneumococcal and/or influenza vaccines. Additionally, it was determined that for one (R22) out of seventeen residents reviewed for immunizations, the facility failed to offer R22 an updated pneumococcal vaccine. Findings include: Vaccinations of Residents Policy Statement- All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .All new residents shall be assessed for current vaccination status upon admission .If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration; b. date of administration; c. lot number of the vaccine (located on the vial); d. expiration date (located on the vial); and e. name of person administering the vaccine . October 2019 Pneumococcal Vaccine Policy Statement- All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission .6. For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record . October 2019 Influenza Vaccine Policy Statement- All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza . 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents .5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record .6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record .10 Residents .may obtain their influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility . October 2019 1. Review of R4's clinical record revealed: 1/21/24 - R4 was admitted to the facility. 2/20/24 - R4 received the PCV20 (pneumococcal 20-valent conjugant) vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R4's electronic medical record (EMR) revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of the influenza vaccine that R4 received at the hospital on 1/14/24, which was documented in DELVAX. 2. Review of R13's clinical record revealed: 5/24/24 - R13 was admitted to the facility. 2/20/24 - R13 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R13's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility. 3. Review of R18's clinical record revealed: 6/1/22 - R18 was admitted to the facility. 2/20/24 - R18 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R18's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. 4. Review of R19's clinical record revealed: 4/2/16 - R19 was admitted to the facility. 2/20/24 - R19 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R19's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility. 5. Review of R33's clinical record revealed: 11/30/23 - R33 was admitted to the facility. 2/20/24 - R33 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R33's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. 6. Review of R45's clinical record revealed: 6/23/23- R45 was admitted to the facility. 2/20/24 - R45 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R45's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. 7. Review of R51'sclinical record revealed: 12/22/22 - R51 was admitted to the facility. 2/20/24 - R51 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R51's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023/24 influenza vaccine or the declination of that vaccine provided by the facility. 8. Review of R60's clinical record revealed: 11/1/23 - R60 was admitted to the facility. 2/20/24 - R60 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R51's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. 9. Review of R223's clinical record revealed: 6/22/24- R223 was readmitted to the facility. 2/20/24 - R223 received the PCV20 vaccine, which was documented in the DELVAX website. 6/27/24 8:00 PM - Review of R223's EMR revealed the PCV20 pneumococcal vaccine that was administered on 2/20/24 was not documented. There also was no documentation of a 2023 influenza vaccine or the declination of that vaccine provided by the facility. 6/28/24 8:49 AM - During an interview, E4 (Clinical Specialist) stated, We had a pharmacy clinical in February. They came in and vaccinated the residents. They entered the vaccines in DELVAX. So if we put the vaccine dates in PCC under the immunization tab, we will be in compliance, right? The facility failed to document in the EMR's the dates of pneumococcal vaccines for nine residents and the dates or declinations of influenza vaccines for five residents. 10. Review of R22's clinical record revealed: Centers for Disease Control and Prevention (CDC) Guidelines for Pneumococcal Vaccine Timing for Adults, [AGE] years, in order for an adult older than [AGE] years to be up-to-date/complete with the pneumococcal vaccination, a Prevnar20 (PCV20) vaccine should be administered 1 year after that adult received PCV13. CDC, April 2022 Facility Pneumococcal Vaccine Policy- .upon admission .will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .For residents who receive the vaccines .will be documented in the resident's medical record . Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. October 2019 4/27/21 - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia. 6/27/24 -Review of R22's immunizations in the EMR revealed no documentation of a pneumococcal vaccine. DELVAX, Delaware's online immunization documentation system, documented that R22 received a Prevnar13 (13-valent pneumococcal conjugate) vaccine on 8/27/2015. The facility was unable to produce documentation of a recent pneumococcal vaccination, a medical contraindication, or a declination declaration for R22. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).

Based on record review and interviews, it was determined that for three (R18, R34 and R270) out of the survey sample of seventeen residents reviewed for resident rights, the facility failed to ensure that the residents had the right to a dignified existence. Findings include: 1. Review of R270's clinical record revealed: 6/19/24 - R270 was admitted to the facility with multiple diagnoses, including obstructive uropathy, and R270 had a foley catheter in place at admission. 6/25/24 - A review of R270's electronic medical record (EMR) revealed the presence of an admission care plan with interventions to care for R270's catheter, which included to place the catheter bag away from the entrance room door. The following observations were made on 6/24/24: 10:29 AM - An uncovered urinary catheter bag hanging on the right had side of the bed, visible from the entrance room door. 12:30 PM - An uncovered urinary catheter bag hanging on the right side of the bed, visible from the entrance door. The following observations were made on 6/25/24: 10:30 AM -R270 was sitting in his wheelchair with the 3/4 urine filled catheter bag hanging on the wheelchair, and which was visible from the doorway. 11:41 AM - R270 was observed sitting in his wheelchair in the doorway of his room, with an uncovered catheter bag hanging on the back of his wheelchair. Additionally, the CNA wheeled R270 to the shower room with the uncovered catheter bag dragging on the floor. 6/26/24 10:45 AM - The above 11:41 AM observations were confirmed with E3 (ADON) and E4 (Clinical Specialist). Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone). 48409 2. Review of R34's medical records revealed: 5/4/24 - R34 was admitted to the facility with diagnoses including neurogenic bladder. 5/10/24 - R34's clinical records documented, Ensure that tubing and dignity bag are off the floor. 5/13/24 - R34's care plan included, Privacy bag at all times. 6/24/24 10:30 AM - R34 was observed lying in the bed, an uncovered, an undated urinary collection bag with yellow urine was observed on the floor on the left side of the bed. 6/24/24 1:30 PM - R34 was observed lying in the bed, the uncovered, an undated urinary collection bag with yellow urine continued to be on the floor on the left side of the bed. 6/25/24 10:30 AM - R34 was observed lying in the bed, an uncovered, an undated urinary collection bag with yellow urine was observed on the right side of the bed on the floor. 6/25/24 2:30 PM - R34 was observed lying in the bed, an uncovered, the undated urinary bag with yellow urine continued to be observed on the right side of the bed on the floor. 3. Review of R47's clinical records revealed: 1/6/22 - R47 was admitted to the facility with diagnoses including neurogenic bladder. 5/10/23 - R47's clinical records documented, Check tubing for kinks, and privacy bag at all times, secure catheter to reduce friction. 6/24/24 10:30 AM - R47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine was observed touching the floor on the left side of the bed. 6/24/24 2:30 PM - R 47 was observed lying in bed, an undated, uncovered urinary collection bag with yellow urine continued to be touching the floor on the left side of the bed. 6/25/25 10:00 AM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine hanging on the right side of the bed and visible from the doorway. 6/25/24 2:30 PM - R47 was observed lying in bed, an uncovered, undated urinary collection bag with yellow urine in a wash basin was on the left side of the bed on the floor. 6/25/24 3:00 PM - Findings were confirmed with E3 (ADON) and E4 (Clinical Specialist). Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).

2. Review of R4's clinical record revealed: 1/21/24 - R4 was admitted to the facility. 1/23/24 - R4 participated in his Care Plan conference and signed his Care Plan Conference Summary dated 1/23/24. 4/26/24 - R4's quarterly Minimum Data Set (MDS) assessment was completed. The facility was not able to produce any documentation of R4 participating in any other Care Plan conferences. 6/28/24 12:20 PM - During an interview, E4 (Corporate CNS) stated, The facility did not do a care plan meeting in April with [R4]. We are scheduling one ASAP. We did not update the care plan in April because we didn't have a care conference. 32545 3. R13's clinical record revealed: 5/24/24 - R13 was admitted to the facility after being hospitalized . 5/30/24 - R13's admission MDS assessment stated that she had a moderate cognitive impairment. 6/7/24 at 6:47 PM - A physician's order by E5 (NP) discontinued R13's Flomax medication with a diagnosis incorrectly listed as benign prostatic hyperplasia (BPH). There was no evidence in R13's clinical record that F1 (R13's POA) was notified of this medication change. 6/9/24 at 6:45 PM - A physician's order by E5 (NP) discontinued R13's Primidone medication with a diagnosis incorrectly listed as depression. There was no evidence in R13's clinical record that F1 was notified of this medication change. 6/28/24 at 10:35 AM - During an interview, F1 confirmed that she was R13's Power of Attorney for Care. F1 confirmed that she was not notified that E5 (NP) discontinued R13's Flomax medication prescribed for urinary retention and the Primidone medication as F1 stated it was prescribed for R13's tremors. 6/28/24 at 11:30 AM - Finding was reviewed with E2 (DON) and E3 (ADON). 7/2/24 at 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).

Based on observation and interview, it was determined that for three (R19, R33 and R45) residents reviewed, the facility failed to ensure that the call bells were within their reach on three observed occasions. Findings include: 1. Review of R19's medical records revealed: 4/2/2016 - R19 was admitted to the facility with diagnoses including shortness of breath, asthma, and congestive heart failure. 517/24 - R19's significant change MDS assessment documented a BIMS score of 14 (fourteen), indicating no cognitive impairment. 6/24/24 10:15 AM - R19 was observed lying in bed. The bell was observed on the floor near the head of the bed. 6/24/24 11:30 AM - R19 was observed lying in bed. The call bell was observed on the floor near the head of the bed. 6/24/24 1:00 PM - R19 was observed lying in bed. The call bell continued to be on the floor near the head of the bed. 6/24/24 1:10 PM - The surveyor asked R19 if she used the call bell to let the staff know if she needed assistance, R19 stated, Yes, where is my call bell?. 2. Review of R33's clinical records revealed: 11/30/23 - R33 was admitted to the facility with diagnoses including acute respiratory failure, congestive heart failure and chronic pain. 6/24/24 - R33's quarterly MDS assessment documented a BIMS score of 14, indicating no cognitive impairment. 6/24/24 10:30 AM - R33 was observed sitting in the wheelchair in her room. The call bell was observed lying on the floor behind the wheelchair. 6/24/24 12:30 PM - R33 was observed sitting in the wheelchair in her room. A CNA brought R33's lunch. The call bell was observed lying on the floor behind the wheelchair. 6/24/24 1:30 PM - R33's call bell continued to be on the floor behind the wheelchair. 6/24/24 1:45 PM - The surveyor asked R33 if she used the call bell to let the staff know if she needed assistance, R33 stated, Yes. 3. Review of R45's clinical records revealed: 6/23/23 - R45 was admitted to the facility with diagnoses including heart disease, depression, dementia, and muscle weakness. 6/21/24 - R45's annual MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment. 6/24/24 10:35 AM - R45 was observed lying on the bed. The call bell was on the floor behind the bed. 6/24/24 11:35 AM - R45 was observed lying on the bed. The call bell was on the floor behind the bed. 6/24/24 1:35 PM - R45 observed lying on the bed. The call bell continued to be on the floor behind the bed. 6/24/24 1:50 PM - The surveyor asked R45 if she used the call bell to get the staff's assistance, R45 stated, Yes. 6/24/24 2:00 PM - Findings were confirmed with E3 (ADON). Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON) E3 (ADON), E4 (Clinical Specialist), E32 (Corporate PT) and State of DE Ombudsman (via telephone).

F609 Report Allegation of Abuse- Based on record review and Interviews, it was determined that for one (R28) out of two residents reviewed for Abuse, the facility failed to report R28's allegation of abuse within the two hour time frame. Findings include: 10/15/16 - R28 was admitted to the facility. 12/28/23- R28's quarterly MDS assessment documented a BIMS score of 7, which was reflective of moderate cognitive deficit. 1/23/24 6:30 PM - While providing care to R28, E37 (CNA) noted a left forearm skin tear, which E37 reported to E38 (LPN). 1/24/24 - While investigating R28's left forearm skin tear of unknown origin, R28 stated that the CAN hurt her ( causing the skin tear) and she (R28) doesn't know why the CAN wants to hurt her. 1/24/24 - R28 was care planned for making false accusations. 1/24/24 4:12 PM - The allegation of abuse was reported to the State agency. This allegation of abuse was reported to the State agency twenty-two hours after the incident was [NAME] to the attention of facility staff. 6/28/24 10:48 AM - During an interview, E3 (ADON) stated, The reason it was not reported until late was that [ E38] (LPN) did not report the allegation to management until 1/24/24. She was counseled in writing and educated about reporting all allegations of abuse immediately. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).

Based on record review and interview, it was determined that for one (R5) out of one resident reviewed for hospitalization , the facility failed to notify the resident and the resident's representative in writing of R5's transfer to the hospital, including the reason for the transfer. Findings include: Review of R5's clinical record revealed: 6/13/23 - R5 was admitted to the facility. 5/15/24 - R5 was transferred to the hospital because of chest pain. R5 was admitted to the hospital and was discharged back to the facility on [DATE]. 6/27/24 2:20 PM - During an interview, E3 stated that the facility's process for hospital transfer communications is to provide verbal communication to resident representatives when residents are transferred to the hospital, not written communication. R5's representative would not have received written communication related to E5's 5/15/24 transfer. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).

Based on record review and interviews, it was determined that for one (R44) out of seventeen reviewed for Resident Assessments, the facility failed to assess R44 no less than once every three months. Findings include: 11/14/23 - R44 was admitted to the facility. 1/3/24 - R44's admission Minimum Data Set (MDS) assessment was completed. 1/29/24 - R44 was hospitalized . 1/30/24 - R44 was readmitted to the facility. 2/6/24 - R44's admission MDS was completed. As of 6/26/24, there were no other MDS assessments completed for R44. There has been more than 141 days since the last MDS assessment. 6/27/24 1:26 PM - During an interview, E33 (MDS coordinator) confirmed that R44 was past due for a quarterly MDS assessment. E33 stated, I'm not sure why the system did not flag him. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).

Based on record review and interviews, it was determined that for one (R6) out of three residents reviewed for discharge, the facility failed to develop and implement an effective discharge planning process. The facility failed to determine and document the feasibility of R6 returning to live in the community independently. The facility failed to ensure R6's health and safety needs were able to be met at her discharge destination. The facility failed to ensure R6 had the ability to fill her medication prescriptions. The facility failed to ensure that R6's discharge prescriptions for PT/OT, home health aide and nursing were referred to an accepting agency and the first visit by the agency was scheduled for R6. These failures placed R6 in Immediate Jeopardy (IJ). An IJ was called on 1/5/24 at 2:49 PM. The IJ was abated on 1/8/23 at 12:46 PM. Findings include: The facility's policy stated, Discharge Summary and Plan: Policy Statement- When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .If a resident indicates interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post discharge preferences .A member of the IDT (interdisciplinary team) will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 2001 MEDPASS (Revised December 2016). Cross refer F622, F644 and F745 Review of R6's clinical record revealed: 11/3/23 - R6 was admitted to the facility with diagnoses including, but were not limited to morbid obesity, right elbow bursitis, weakness, COPD (chronic obstructive pulmonary disease) and major depressive disorder. 11/30/23 2:38 PM - E11 (LSW) documented in a Social Services Note in R6's EMAR, .Resident (R6) was requesting to speak to SW (social work) .I introduced myself and stated who I was as this was my first time meeting the resident. Resident stated that she needed my help with discharge plans because her managed care plan as (sic) issued her a discharge notice and she is scheduled for discharge on Saturday, 12/2/23. Resident asked if I could order her a bariatric wheelchair and set up transportation through [transport company] to get her a ride home. SW asked her what time she wanted to discharge, and she stated 11 AM would be ideal. Resident did ask how much the daily rate was to stay privately. SW (social worker) informed her the daily rate was $367 a day and resident stated she does not have the money and she will choose to go home and was in agreement with discharging .A call was placed to resident's son [F1] to inform him of his mother's discharge. F1 stated he understood the process and would go see the resident at home over the weekend to help her fill out the LTC (long term care) Medicaid application. The son never stated any additional information in regard to money, resident staying paying privately or refusing to accept the fact that the resident was discharging. 12/1/23 - E7 (MD) entered an order in R6's EMAR that stated, Discharge Home: D/C (discharge) resident from skilled services PT/OT/ST to home/ALF (assisted living facility) on 12/2/23 with Home Health services, RN eval (evaluation), PT, OT HHA (home health aide). R6's discharge destination was an apartment in an independent living community, where R6 lived alone. 12/2/23 10:59 AM - E8 (RN) electronically signed R6's Transition of Care and Discharge Summary. R6's Discharge Summary documented, .Skin review .open area to LLQ (left lower quadrant)[abdomen]. Dressing completed this am . Skin issue type- incontinent associated dermatitis. Bowel and Bladder- Bowel continence- occasionally incontinent. Urinary incontinence- occasionally incontinent .Nursing Summary of Stay- .Resident is continent of bowel and bladder with use of bedpan. Resident is a Hoyer transfer . E9 (OTR) documented in R6's Transition of care and discharge Summary, .Therapy Assistance recommended- Transfers- substantial maximal assistance .Bathroom activity- substantial maximal assistance .Personal hygiene- substantial maximal assistance . Walking- dependent .Ability to move from one location to another- dependent .Bathing- substantial maximal assistance. Therapy summary of stay- .Patient with limited out of bed activity. Recommend 24 hour care at the time of discharge. The facility was unable to provide evidence that R6 was capable of transferring herself from the bed to the chair or to the commode or that R6 was capable of performing personal hygiene after toileting at the time of discharge. 12/2/23 10:59 AM - R6's Discharge Summary did not include any information regarding the transition of R6's care to a provider in the community. In fact, the Discharge summary read, Follow up with primary care physician: _______________________________. There was no information provided regarding R6's follow up care with a primary care physician. 12/2/23 11:00 AM - R6 was discharged home via stretcher in a [transport company] ambulance. R6 was given a paper prescription for community services that stated, PT, OT, RN and HHA (home health aide) 3X (times)/wk (week) X 1 month. The facility could not provide evidence that the prescription referrals for outpatient physical therapy (PT), occupational therapy (OT), and registered nurse and home health aide visits from a home health agency had been sent to and accepted by a home health agency. Nor could the facility provide evidence that the first visit for each outpatient service was set up and that information was communicated to R6. R6 was also given paper prescriptions for the eleven medications that she was continue at home. These medications included: Norvasc (blood pressure medication) 10 mg daily, metoprolol (blood pressure medication) 25 mg twice a day, Eliquis (blood thinner for Afib) 5 mg twice a day, Flovent inhaler 100 mcg inhaled twice a day for COPD, lisinopril (blood pressure medication) 30 mg daily, Wellbutrin (depression medication) XL 150 mg daily and Wellbutrin (depression medication) XL 75 mg daily. The facility could not provide any documentation that the medication prescriptions were called into a pharmacy or that arrangements were in place for R6 to fill the prescriptions and obtain her medications. From 12/2/23 (Saturday) at 11 AM until 12/4/23 (Monday) at approximately 7 AM, R6 was alone in her apartment without healthcare services. 12/4/23 7:20 AM - E12 (Emergency Department MD) documented in the ED (Emergency Department) Physician Record, . History of Present Illness .Says she [R6] lives at home, has no assistance at this time .They [the facility] reportedly were going to work on home health care but she (R6) said there (sic) been none there (sic). She [R6] is unable to ambulate at home, is incontinent of urine at baseline and has been unable to care for herself .Assessment & Plan: . She [R6] comes with no real new complaints .Her physical exam is unremarkable . 12/7/23 1:51 PM - E13 (ED DO) documented in ED Physician Record Addendum, . Nurse manager has been working with several hospital administrators and case management to help facilitate disposition as pt (patient) has been here in the ED for over 3 days . was able to secure a bed at a facility (in New Jersey), specifics are still in process. 12/8/23 3:16 PM - R6 was discharged from the hospital Emergency Department and transferred to a facility in New Jersey. R6 spent four days in the hospital Emergency Department while awaiting placement in long term care facility. 1/3/23 1:13 PM - During an interview, E9 (OTR) stated, .therapy recommended a hoyer lift with 24 hours care. Business office manager [E10] went over the Medicaid application process. So going into that weekend, I [E9] thought she [R6] was staying. I was there when she signed the NOMNC (notification of medical non-coverage) and the SNF ABN. I thought she was staying. The family said they would be in to fill out the Medicaid paperwork. Not sure what happened - you would need to ask the Business office. With regard to R6's therapy sessions, she [R6] got out to the wheelchair using a hoyer lift a couple of times. She [R6] had some straight out refusals (to get out of bed for therapy), some 'can we do stuff in bed?' Despite education about trying to get to a level of function where she [R6] could go home and be safe, she [R6] was minimal at participating. When R6 was asked about how she planned to function at home alone, E9 stated, she [R6] said I can't go home like this. I'll figure it out. E9 stated that she [R6] requested that therapy order a bariatric wheelchair but could not order a hoyer as someone has to be there on delivery to get training and R6 lived alone. When asked if AMA (against medical advice) ever came up, E9 stated, not that I remember. 1/4/24 10:26 AM - During an interview, E11 (Social Worker) stated, First time I met her [R6] was on 11/30/23 (Thursday), she [R6] said I need you [E11] to arrange transport with [transport company] at 11 am on Saturday (12/2/23) and a bariatric wheelchair. E9 in Therapy arranged for the bariatric wheelchair through [business name] (an application to order durable medical equipment) as I don't have access . When E11 was asked about community referrals, E11 stated, I did not fax any referrals. I arranged for the transport home that she [R6] requested. That was it. 1/4/24 2:43 PM - During an interview, E3 (Clinical Specialist) stated, Not having a social worker really caught us out . 1/5/24 1:56 PM - During a telephone interview, F1 (R6's son) stated, She [R6] called 911 to take her to the hospital. She could not walk or get out of bed. One neighbor helped her with food and water. She was incontinent the whole time in the same diaper that she left the facility in. 1/5/24 2:49 PM - The facility was notified of an Immediate Jeopardy (IJ) with respect to R6's discharge. 1/5/24 5:22 PM - The abatement plan for this IJ was accepted by the State Agency. This abatement plan included: -review of the Discharge Summary and Plan policy, education of 100% of Nursing and Administrative staff regarding the discharge planning process, audits of all current residents and all discharges in the last 30 days to ensure appropriate discharge planning is in placed or occurred, contacting all residents discharged in the last 30 days to ensure all care service referrals were completed, the creation of a Discharge Planning process checklist, the initiation and completion of the Discharge Assessment within 72 hours of admission, the coordination of post-discharge follow up appointments by the facility, scheduled calls to discharged residents to monitor their success in the community, and IDT (interdisciplinary team) review of all discharges. 1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON). 1/8/24 12:46 PM - The facility alleged that the abatement was completed. The abatement was confirmed by reviewing the staff education sign in sheets, interviewing nurse staff regarding discharge education, reviewing audit sheets of last 30 day discharges, reviewing the Discharge Planning Process checklist and reviewing the scheduled IDT discharge review appointments.

Based on observation, record review and interview, it was determined that for one (R62) out of 34 Stage 2 sampled residents, the facility failed to provide the necessary treatment and services to prevent pressure ulcers from developing. The facility failed to: consistently implement a turning and repositioning program for a resident who was identified at risk for developing pressure ulcers; failed to identify an area of pressure until it presented as DTI in evolution; and failed to consistently follow policy and procedure and the plan of care after the DTI was identified. Findings include: The facility policy titled Skin and Wound Management Program Overview, revision date 3/10/15, stated, 1.0 Purpose .The resident does not develop pressure ulcers unless clinically unavoidable and the facility provides care and services to: Promote the prevention of pressure ulcer development .3.0 Procedure .all residents will be screened to determine their risk of development of pressure ulcers using the Braden Scale Risk Assessment .2. Any resident identified at risk for development of pressure ulcers, as indicated by Braden Scale Risk Assessment score of 18 or less, will have the Initial Plan of Care initiated by the admitting nurse, to minimize the risk of developing a pressure ulcer .4. A visual 'head to toe' skin review will be performed at least weekly by a Certified Nursing Assistant (C.N.A.) .Results will be verified and documented by a licensed nurse .Whenever a new wound is identified, a licensed nurse will complete a comprehensive evaluation, and document the findings on the Initial Wound Review Form .7. ALL WOUNDS will be monitored daily, as required by a licensed nurse, with documentation on the Daily Wound Review form .8. All wounds will be monitored at least weekly by a licensed nurse during wound rounds, with documentation on the Weekly Wound Progress Review form .14 .For a pressure ulcer to be considered 'unavoidable', the following criteria must be met: c. Implementation and defined interventions consistent with resident needs and standards of practice . The User-Service Manual Joerns Support Surface Cair APM, 2010, states, .Optional Accessories .Integrated CairRails risk management side air bolsters--two-inch side bolsters that inflate on both sides of the patient along the mattress edge to provide additional support and to provide a gentle reminder to the patient that they are near the edge of the mattress .Nursing Procedures .Minimal amount of padding between the patient and bed for optimum performance .General Repositioning: Patients should be turned and repositioned per individual turning schedule or per facility policy . The NPUAP Prevention and treatment of [REDACTED].Frequent assessment of the individual's skin condition will help to identify the early signs of pressure damage and, as such, her/his tolerance of the planned repositioning schedule. If changes in skin condition should occur, the repositioning care plan needs to be re-evaluated .Additional Recommendations for Individuals with Existing Pressure Ulcers: 1. Do not position an individual directly on a pressure ulcer. 1.1 Position the individual off area(s) of suspected deep tissue injury with intact skin .Pressure reduces perfusion to injured tissues. Continued pressure on an existing pressure ulcer will delay healing and may cause additional deterioration. 2. Continue to turn and reposition the individual regardless of the support surface in use .No support surface provides complete pressure relief . R62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R62 had a care plan, developed on 10/8/13 and last revised on 9/8/15, for the problem, Potential for alteration in skin integrity related to decreased mobility, incontinence with brief use, fluctuating intake, restlessness, medications. The care plan's approaches included to document abnormal findings and notify MD/RP, encourage/assist to T&R q round and prn, mattress and W/C cushion -see care card, offload heels as needed, and weekly skin checks/daily observation of skin by direct care staff. The clinical record revealed a physician's orders [REDACTED]. A second physician's orders [REDACTED]. A Braden Scale, dated 6/6/15, revealed R62 scored 15 identifying him as being at risk for developing a PU. The annual MDS assessment, dated 6/12/15, stated R62's daily decision making skills were severely impaired; he required extensive assist of one staff for bed mobility, dressing, toilet use and hygiene, and extensive assist of two (2) staff for transfers. The MDS stated R62 was at risk of developing a PU, he had no current or unhealed PU, a pressure reducing device was in use for bed and chair, and he was not on a T&R program. Review of the Weekly Skin Check sheets revealed that on 8/4/15, 8/18/15 and 8/25/15 there were no open areas present. There was no evidence that a weekly skin check was completed on 8/11/15. The facility failed to follow R62's plan of care and failed to provide the necessary services. An undated CNA Kardex/care card did not list the use of any pressure reducing device for the bed and/or chair and stated R62 was independent for bed mobility. Additionally, the Kardex did not identify any T&R schedule, nor did it mention a need to offload R62's heels. Review of the electronic ADL Flow Sheet Log from 8/20/15 through 9/3/15 revealed R62 required extensive assist to total dependence on one (1) to two (2) staff for bed mobility. Review of the electronic Turn and Reposition Detail Report from 8/20/15 through 9/3/15 revealed that on 66 occasions when charting was done, on only 11 occasions was it documented that T&R was completed. All other entries stated, Activity Not Required. Review of the electronic CNA ADL sheet and the TAR from 8/1/15 through 9/3/15 lacked evidence of any offloading of R62's heels and/or feet. The Behavior/Intervention Monthly Flow Record, which monitored R62's combative behavior with care, revealed no evidence of combative behavior from 8/22/15 through 9/3/15. Additionally, review of NN's from 8/11/15 through 9/3/15 revealed only one (1) documented episode of combative behavior and refusal of care on 8/11/15 at 3:30 AM. Review of the clinical record revealed an order, dated 8/31/15, for R62 to receive SLP services for difficulty swallowing. A SLP evaluation, dated 9/1/15 stated R62 was referred to therapy due to reports from nursing of swallowing difficulties during meals for 2 weeks .presents with weight loss, persistent coughing .Patient will be downgraded to mechanical soft (diet) and honey thick liquids (honey consistency) . An order, dated 9/1/15, stated for R62 to receive Ensure plus 120 cc twice a day due to decreased meal intakes. Review of the MAR from 9/2/15 through 9/9/15 revealed R62 was accepting 50-100% of the Ensure twice daily, except on 9/8/15 when the 8:00 AM dose was not signed off as given. A Weekly Skin Check, dated 9/1/15, noted redness on the buttock area. A NN, dated 9/3/15 and timed 6:45 PM, stated, Resident noted c redness on L ankle resulting from pressure when laying in bed. Tx order written to apply skin prep on B/L ankles and also to offload BLLE while in bed. Supervisor notified. An Initial Wound Evaluation, dated 9/3/15, stated that a wound was identified on the lateral ankle (did not state right or left), was a suspected DTI and measured 1.5 cm (length) by 1.5 cm (width) with no depth. The sheet also stated that skin prep was ordered, a pressure relief mattress was in place, and the goal of treatment was improvement of the wound. physician's orders [REDACTED]. Review of the TAR from 9/3/15 through 9/23/15 revealed staff signed off that R62's heels were offloaded while in bed as tolerated. On 9/4/15, a physician's orders [REDACTED]. A physician's orders [REDACTED]. Results of this blood test revealed R62's value was below normal at 14.1 (normal limits: 18.0-38.0 MG/DL). On 9/4/15 a quarterly Data Collection Tool was completed which stated R62 was dependent on staff for all ADLs, including bed mobility. A physician's progress note, dated 9/4/15, stated Asked to see pt to F/U + .debility. + new wounds. (Decreased) PO intake .DTI LLE. PT screen .add ensure, comfort care . A nurse's note, dated 9/5/15 and timed 6:45 PM, stated On 9/3/15, during routine rounds, I noted a reddened area on residents L ankle. Resident was laying in bed. At assessment, determined the redness was from pressure on L ankle. Site is circular in shape with a diameter of 1.5 cm. Skin prep applied and BLE elevated. Supervisor on duty was notified and also did an assessment . The Weekly Wound Progress Note, dated 9/7/15, stated the wound was located on the L lateral malleolus, was a DTI and measured 1.9 cm by 1.4 cm with no depth. The summary stated, .skin prep per MD order .on low air loss mattress, (no) shoes. B/L heels offloaded in bed as tolerated . A Weekly Skin Check, dated 9/8/15, failed to identify the DTI on the L lateral malleolus. On 9/8/15 the potential for alteration in skin integrity care plan was revised to include the approaches skin prep to bilateral heels and lateral ankles, low air loss mattress and turn and reposition as indicated. A Physical Therapy Plan of Care, dated 9/9/15, stated that according to R62's current level of function, he required moderate assistance of two staff for rolling side to side while in bed and that he had impaired sensation to the BLLEs. A physician's orders [REDACTED]. A 9/9/15 significant change MDS assessment stated R62's daily decision making skills were severely impaired, he required extensive assist of two (2) staff for bed mobility and currently had a suspected DTI in evolution. The Weekly Wound Progress Note, dated 9/11/15, stated the wound measured 2.0 cm by 1.4 cm with no depth. The summary stated, Wound L lateral malleous (sic) intact, 100% purple DTI c blister formation noted. N/O to begin today for Marathon liquid Q 3 days B/L heels intact and offloaded c pillows . On 9/11/15 a care plan for Pressure ulcer DTI left lateral malleolus was developed. Approaches included keep pressure off area(s) as able. Review of the 9/14/15 TAR lacked a signature signifying that Marathon liquid was applied as ordered. The 9/15/15 Weekly Skin Check noted pressure area unopened on the L lateral malleolus. The 9/19/15 TAR lacked evidence of Ensure and Prostat being given as ordered on the 7 AM to 3 PM shift (2 doses Ensure, one dose Prostat). The 9/22/15 Weekly Skin Check noted dark area on the L lateral malleolus. The facility did not complete the next Weekly Wound Progress Note until 9/23/15, 12 days later, instead of weekly, as per the care plan and facility policy. The 9/23/15 Weekly Wound Progress note stated to continue with Marathon liquid per MD order, offload heels as tolerated, continue on low air loss mattress and that the DTI measured 1.0 cm by 0.5 cm with no depth. The following observations/interviews were made: - 9/17/15 at 8:22 AM - lying on bed on back sleeping, both heels directly on mattress, not offloaded. - 9/17/15 approximately 9:15 AM - lying on back, head of bed at 45 degrees, heels directly on mattress, not offloaded. - 9/17/15 at 11:35 AM - lying in bed on back, heels in direct contact with mattress with left side of foot in contact with the bolster part of the mattress and both great toes are pressed up against the bed's footboard. - 9/22/15 at 4:23 PM - lying in bed slightly turned to left side, head of bed raised at 45 degrees, both feet on pillow with the left malleolus in direct contact with the pillow; observed moving right foot. - 9/23/15 at 8:39 AM - observed both feet with E22 (LPN); has pillow under lower legs, but heels are in direct contact with mattress, E22 confirmed heels were not offloaded and stated yesterday he had two pillows to offload. -9/23/15 approximately 11:00 AM - in an interview with E23 (RN/WCC) when asked why the weekly wound progress note was not done from 9/11/15 until 9/23/15, E23 stated she was on vacation last week and someone was supposed to be assigned to do it. -9/23/15 approximately 1:00 PM - observed E3 (ADON) and E23 in R62's room; spoke with them regarding the lack of offloading of the heels. E3 stated that there was no need to offload R62's heels as he was on a low air loss mattress. During an interview on 9/23/15 at approximately 2:30 PM, findings were reviewed with E2 (DON), E3, and E16 (Regional Nurse Consultant). E2 stated that the DTI was caused by R62's shoes, that they found it because they were checking the resident's skin and they developed interventions right away. E3 stated that a low air loss mattress was offloading and she had been a wound care nurse previously. E2 then shared the facility's Unavoidable Pressure Ulcer Quality Improvement Tool, dated 9/7/15. This tool stated the following: - R62's risk factors included impaired/decreased mobility and decreased functional ability, and Resident refusal of some aspects of care or treatment. - The following interventions were initiated to address the resident's risk factors prior to development of a pressure ulcer: T&R, pressure reducing mattress, 2 person assist in bed; - Narrative Summary: appears that resident shoes caused alteration to ankle. Alteration very consistent with where shoes pressed. No shoes to be worn currently, non skid socks, Tx and low air loss mattress. E2 provided R62's shoes for observation to the surveyor. They were Air Monarch sneakers. The inner lining on the left lateral sneakers was observed with a soft cushioned lining. Although R62 was identified as being at risk for developing pressure ulcers, the facility failed to consistently follow a turning and positioning schedule for this resident who required assistance from staff for bed mobility and they failed to offload his heels according to the care plan. There was no evidence that R62 refused these interventions for the two weeks prior to identification of the DTI. Despite the care plan approach for daily observations of skin by direct care staff, R62's PU was not identified until it was a DTI in evolution. The facility failed to complete weekly, accurate skin checks, they failed to administer supplements as ordered, and they failed to complete a Weekly Wound Progress Note. Additionally, the facility failed to correctly offload the left lateral malleolus after the DTI was identified. Findings were reviewed with E1 (ED), E2 and E3 (ADON) on 9/23/15 during the exit conference at approximately 4:20 PM.

Based on clinical record reviews, interviews, and review of facility documentation, it was determined that the facility failed to ensure that 2 (R7 and R12) out of 34 Stage 2 sampled residents, who were incontinent of bladder received the appropriate treatment and services to prevent UTIs and to restore as much normal bladder function as possible. For R12, the facility failed to: - assess R12's urinary status twice, upon admission and readmission; - Failed to develop a care plan that identified potential causes for a UTI after R12's hospitalization ; - Failed to implement a 3 day voiding diary on admission, readmission, and when there was a decline in R12's urinary status; - Failed to comprehensively assess R12's bladder incontinence on admission and after the 8/12/15 quarterly MDS revealed a decline in bladder function; - Failed to identify that R12's bladder function was not recorded by the CNA's 6 times in July; - Failed to identify, reassess and respond to R12's increase in urinary incontinence for approximately five (5) months (May 14, 2015 through September 17, 2015). For R7, the facility failed to: - accurately and comprehensively assess R7's urinary continence status upon admission; - Failed to complete a 3-day voiding diary; - Failed to develop an individualized toileting plan; - Failed to identify a progressive decline in R7's urinary status; - Failed to act accordingly and attempt to restore as much normal bladder function; - Failed to reassess R7's urinary status that progressed to always incontinent. Findings include: The facility policy entitled Bladder Elimination Assessment, revised 6/30/06, stated, Purpose To ensure that each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services through an interdisciplinary approach, to achieve or maintain as much normal urinary function as possible, and avoid urinary tract infections . 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 .If the resident is not recommended for a retraining program an appropriate care plan will be developed for that resident .Procedure .2. If resident is determined to be incontinent on the Admission Nursing Assessment, the nurse will gather more specific information by completing the Bladder Incontinence Assessment form .and begin a 3-Day Bowel and Bladder Flow Sheet .The nurse will review the data from the Bladder Incontinence Assessment and 3-Day Bowel/Bladder Flow Sheet to determine if the resident is a candidate for a re-training program. If it is determined that the resident is an appropriate candidate for a retraining program, the resident will be referred to the Restorative Program. 4. If the resident is not a candidate for a re-training program ., care planning for the resident should take into account the individual findings of the assessments. 5. Re-assessment should occur with any significant change, annually or as deemed necessary . 1. In R12's thinned records, a hospital progress note, dated 5/9/15, stated, Pt admitted with UTI and AMS . Interagency Nursing Communication Record completed by the hospital and dated 5/14/15, listed R12 with [DIAGNOSES REDACTED]. R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's documents for the month of May revealed the following: Data Collection Tool, dated 5/14/15, completed on admission, noted the resident to be lethargic, with poor decision making, and the area of bladder function was blank. Physician's Admission H&P, dated 5/15/15, stated R12 had a history of [REDACTED]. A four page Bladder Incontinence Assessment, undated, was blank, except for R12's first and last name, the attending physician, and the room number. R12's assessment had no information regarding the resident's current status, bladder status, potential causes of incontinence, exams, summary (part of the assessment done after review of the Bladder Incontinence Assessment and the 3-Day B&B Flow Sheet are completed) and whether R12 was a candidate for a retraining program. There was lack of evidence in the clinical record that upon admission a bladder assessment and a 3-Day B/B Flow Sheet (3-Day voiding diary) was done. NN's from 5/15/15 through 5/17/15 documented that R12 was on daily skilled nursing services S/P UTI, alert with confusion, able to make needs known, incontinent of B&B, and bladder training N/A. The admission MDS assessment, dated 5/21/15, stated R12 was moderately impaired (decisions poor; cues/supervision required). The same MDS stated R12 was a one person, extensive assist for transfers and toilet use, and she was frequently incontinent. The MDS listed R12 with a [DIAGNOSES REDACTED]. The CAA Summary, dated 5/21/15, triggered ADLs Functional Status/Rehabilitation Potential as a potential problem area and it was checked off to proceed with care planning. The CAA Summary Report, dated 5/21/15, stated, She was admitted s/p hospitalization for change in mental status, UTI .She has a hx of .UTIs . The CAA Summary also triggered for urinary incontinence as a potential problem area and it was checked off to proceed with care planning. The CAA Summary Report stated, She was admitted s/p UTI. She has B/B incontinence. She is at risk for further UTI and skin breakdown. NN's from 5/22/15 through 5/23/15 documented that R12 was on daily skilled nursing services S/P UTI, alert with confusion, able to make needs known, incontinent of B&B, and bladder training N/A. Although R12 came into the facility with a [DIAGNOSES REDACTED]. Approaches included: incontinence care as needed after each episode of incontinence; monitor for increased episodes of incontinence; and one person assistance with toileting. A care plan approach was yellowed out (discontinued) that stated, Toilet/check/change resident upon rising in AM, before & after meals, at bedtime and every 2 hours during the night. Handwritten and undated was an approach to Check and change q round and PRN. It is unclear when the approach to check and change q round (usually every 2 hours) and PRN was implemented, as it was undated. Physician's Progress note, dated 5/26/15, stated was asked to see R12 secondary to drowsiness and wrote to check a urine culture. Review of the May MAR indicated [REDACTED]. On 5/30/15 another order was written for R12 to start an antibiotic for 7 days. Document review for the month of June revealed the following: Physician's Progress note, dated 6/1/15, stated the chief complaint of the visit was for a UTI, which developed in the facility, and that R12 was to continue [MEDICATION NAME] (antibiotic/ABT) for UTI. Review of the June MAR indicated [REDACTED]. Document review for the month of July revealed the following: Review of the Bowel and Bladder Detailed Entry Reports (completed by CNAs) from 7/1/15 through 7/31/15, lacked evidence that the toileting schedule was being followed, Documentation was only completed once per shift. Additionally, there were various responses such as; checking and changing pads during rounds, and resident asked to be toileted - used bathroom/bedpan. This report also revealed the following: - 7/2/15 from 2:09 AM to 10:00 PM (no evidence R12 was toileted for about 20 hours); - 7/3/15 from 7:27 AM to 10:57 PM (no evidence R12 was toileted for over 15 hours); - 7/4/15 from 10:59 PM to 7/5/15 1:23 PM (no evidence R12 was toileted for over 13 hours); - 7/20/15 from 1:04 PM to 7/21/15 12:17 AM (no evidence R12 was toileted for over 11 hours); and - 7/27/15 from 10:17 PM to 7/28/15 2:04 PM (no evidence R12 was toileted for over 15 hours). An SBAR Communication Form, dated 7/12/15, stated, R12 had a decreased level of consciousness, increased confusion or disorientation, decreased mobility, needs more assistance with ADLs, weakness (general), rapid breathing .Transfer to the hospital (non-emergency) .Resident didn't eat dinner secondary to N/V with decreased LOC, increased HR and temp .yet continues with change in MS, increased temp . A physician's orders [REDACTED]. The Hospital H&P, dated 7/12/15, stated R12 was admitted for AMS, her niece noticed the change of mental status at the facility. At that time R12 had a temperature of 101.5 (fever) and was hypoxic. R12 had similar symptoms with a previous UTI, so the facility was concerned and sent her for an evaluation. She was treated for [REDACTED]. The document also stated that R12 had a UTI and PNA, an elevated white blood cell count (indicative of an infection), and AMS that was likely due to infection. A Hospital Discharge Summary, dated 7/15/15, stated that R12 was admitted because of AMS, she was initially treated for [REDACTED]. The Data Collection Tool, dated 7/15/15, completed on readmission from the hospital, listed UTI and PNA as current [DIAGNOSES REDACTED]. A Bladder Incontinence Assessment, dated 7/15/15, stated R12 was confused, wheelchair bound and she needed extensive assistance for ADLs. The assessment listed that R12 had no apparent voiding pattern, unable to determine onset of incontinence, had multiple daily episodes of little or no control and her perception of need to void was absent. R12's assessment had no information regarding the resident's potential causes of incontinence, exams, summary (part of the assessment done after review of the Bladder Incontinence Assessment and the 3-Day B&B Flow Sheet are completed) and whether R12 was a candidate for a retraining program. The Physician's Admission H&P, dated 7/15/15, stated, .S/P UTI [MEDICAL CONDITION] .(sic.). NN's from 7/15/15 through 7/17/15 revealed: - 7/15/15 at 10:00 PM, Received .at 7:15 PM .Has a dx of UTI, PNA .Incontinent of B&B . - R12 was alert with confusion, able to verbalize needs, incontinent of B&B, requires assist X1 for ADLs and transfers and continues on ABT for PNA and UTI. Physician's Progress Admit Note, dated 7/16/15, stated S/P hospitalization secondary to change of mental status and fever. The plan listed was to complete the ABT for her PNA and UTI. A 3-Day B/B Flow Sheet was done from 7/16/15 through 7/18/15, the front of the document was filled out, but the back portion was not, it did not capture or identify any episodes of urinary incontinence. There was no evidence that data was analyzed in order to develop an individualized toileting schedule for R12. Review of the July MAR indicated [REDACTED]. Document review for the month of August revealed the following: The Data Collection Tool, dated 8/10/15, completed as a quarterly assessment, listed UTI . and PNA as current [DIAGNOSES REDACTED]. A Bladder Incontinence Assessment, dated 8/10/15, stated R12 was confused, wheelchair bound and needed extensive assistance for ADLs and unable to determine onset of incontinence. R12's assessment had no information regarding the resident's current status, bladder status, potential causes of incontinence, exams, summary (part of the assessment done after review of the Bladder Incontinence Assessment and the 3-Day B&B Flow Sheet are completed - stated, Resident is incontinent of bowel and bladder) and whether R12 was a candidate for a retraining program. R12's Quarterly MDS assessment, dated 8/12/15, stated R12 was severely impaired for decision making and continued to be a one person, extensive assist for transfers and toilet use. R12 was now coded as always incontinent, and she was not on a toileting program. This is a decline in continence from the 5/21/15 MDS when R12 was frequently incontinent. The same MDS listed R12 with a [DIAGNOSES REDACTED]. Although the urinary incontinence care plan had a handwritten note on the bottom of the page that it was reviewed and revised on 8/14/15, the facility failed to capture that R12 had two UTI's, one of which she was hospitalized for [REDACTED]. The facility failed to revise the care plan and failed to incorporate new interventions. Review of the clinical record revealed that an undated CNA resident care card (Kardex) indicated that R12 was incontinent of bladder and needed one person assist. There was no evidence that a 3 day voiding diary was completed and analyzed in order to establish an individualized toileting schedule for R12. Review of the electronic Resident Bowel and Bladder by Shift Chart, completed by CNAs that capture if the resident is continent or incontinent of bladder, for May 2015 through September 2015 revealed the following: - 5/14/15 through 5/31/15 consisted of a total of 52 shifts during which R12 was incontinent on 37 out of the 52 shifts (71%); - 6/1/15 through 6/30/15 consisted of a total of 90 shifts during which R12 was incontinent on 69 out of the 90 shifts (77%); - 7/1/14 through 7/31/14 consisted of a total of 83 shifts during which R12 was incontinent on 73 out of the 83 shifts (88%). In the month of July, R12 was hospitalized from [DATE] to 7/15/15. In addition there were 6 shifts (7/2/15; 7/3/15; 7/5/15; 7/6/15; 7/20/15; 7/28/15) that lacked evidence that R12 was toileted or incontinence care was given, two of those shifts were after R12's hospitalization for a UTI. - 8/1/15 through 8/31/15 consisted of a total of 93 shifts during which R12 was incontinent on 84 out of the 93 shifts (90%). - 9/1/15 through 9/17/15 consisted of a total of 51 shifts during which R12 was incontinent on 46 out of the 51 shifts (90%). The following information was obtained by interviews with facility employees: - 9/21/15 at 11:25 AM E18 (RN) stated it was facility practice for the receiving nurse to fill out assessment forms which included the Bladder Incontinence Assessment on new residents and ones returning from the hospital that were out for > a day. The CNAs were responsible for doing the 3-Day B/B Flow Sheet, once completed, they gave it to the charge nurse (UM). E18 further stated that the nurses do not evaluate the 3-day voiding dairy, they are only responsible to complete the front of the assessment. E18 stated if a resident was on a toileting program, then Caretracker would let the CNAs know. - 9/21/15 at 11:32 AM E19 (CNA) stated that everytime we toilet someone, we have to chart it in Caretracker. When residents first arrive, a 3-day voiding diary is completed and chart Y (yes) or N (no) to capture if they are continent or incontinent. E19 stated this charting is done on paper, not on Caretracker, then once the front is completed, it is given to the medication nurse, then the medication nurse gives to the supervisor (UM). E19 stated the 3-day voiding diary showed what the resident really needed or how often they needed toileted. E19 stated that Caretracker does not capture when to toilet someone, we are verbally told in report if someone is on a toileting program. Caretracker does not show the amount of times it was charted in, instead an event is highlighted in yellow to alert you that an event was not charted. E19 stated, for example, once Bladder Activity is charted on, the alert light goes off. With regard to R12, E19 stated she was not on a toileting program and R12 verbalized when she needed to go. R12 was incontinent at times and stated when she wanted to go to the bathroom, but when checked she was already wet. - 9/22/15 at 9:43 AM E20 (RN,UM) stated once the Interagency document was received, the UM entered all the orders. Medication nurses were responsible for all the assessments, including the Bladder Incontinence Sheet and the the 3-day voiding dairy. E20 stated, if the resident was known to be incontinent by either the Interagency document, family interview, or upon checking the resident and finding them to be wet, the unit nurse would initiate the 3-day voiding diary. When asked who reviewed the dairy, E20 stated she was unsure, she had never been given the document to review in the year she has been there. Once reviewed, a care plan toileting program was initiated by the IDT team, compromised of the MDS coordinator, DON, and ADON. E20 then stated that the Kardex was updated in the daily clinical meetings for the CNAs to know the plan. She was unsure if Caretracker was reflective of what was in the Kardex. - 9/22/15 at 10:30 AM E21 (LPN) stated when a resident first arrives, the unit nurses are responsible for full head to toe assessments and they had to fill out the Bladder Incontinence Sheet to determine if the resident was incontinent or continent. E21 stated that CNAs were responsible for completion of the 3-day voiding diary and hourly checks were done for those 3 days. E21 stated that once the form was completed, it was determined if the resident was continent or incontinent. When asked who analyzed the data, E21 stated, I don't know, I know that the MDS office does something with it. When the back of the form was shown to E21, she stated she was unfamiliar with the back of the 3-day voiding dairy. E21 had been employed at the facility for over a year. - 9/22/15 at 11:12 AM E2 (DON) stated the expectation was that on admission, a 3-day voiding dairy was done to determine bladder patterning. If a resident was continent, a voiding dairy was not necessary. It was expected that the Admission Data Collection Tool was filled out and at midnight, on the day of admission, a voiding diary was initiated. Upon completion of the dairy, in the clinical daily meetings, the IDT team would implement an individualized care plan. E2 stated the IDT team was comprised of the MDS coordinator, therapy department, DON, ADON, nursing supervisors (including relief supervisors), and CNA's. E2 stated once a care plan was initiated, this was communicated to staff via the 24 hour report, that was read everyday by the nurses and the Kardex was updated for the CNAs. E2 stated Caretracker does not prompt the CNAs when to complete a task, such as toileting, but the CNAs were able to document multiple times during a shift. He also stated that CNAs were not documenting after every care provided, rather they were only charting once per shift. E2 stated that management was working on point of care (electronic system) charting instead of end of shift charting. No additional information was provided to the surveyor before the exit. - The facility failed to complete a 3-day voiding diary upon R12's admission to the facility on [DATE]. - R12 developed 2 UTIs while in the facility and was hospitalized for [REDACTED]. - R12 declined from frequently incontinent on the 5/21/15 admission MDS to always incontinent on the 8/12/15 quarterly MDS. - There was a lack of documentation showing that R12 was toileted or given incontinence care for 6 shifts. - The facility failed to thoroughly complete the Bladder Incontinence Assessment twice, on R12's admission and readmission from the hospital. - The facility failed to revise the care plan when R12 returned from the hospital. - The facility failed to develop and implement an individualized toileting plan based on a voiding dairy. - The facility failed to re-assess the resident's continence status. R12 progressively declined in urinary continence. 2. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's admission Data Collection Tool, dated 6/3/15, stated R7 was alert and oriented to person and place, his short and long term memory was intact, and he was incontinent of bladder and used pads or briefs. A Bladder Incontinence Assessment, dated 6/3/15, was incomplete. It failed to identify contributing factors/[DIAGNOSES REDACTED]. The section Bladder Status on page 1 was blank, except for a notation that the buttocks had some redness. Page 2 of the assessment (identifies any abnormal laboratory values which may be potential causes of incontinence and identifies diagnostic exams performed) was blank. Page 3 of the assessment, which was to be completed after review of Bladder Incontinence Assessment and the 3 Day B&B Flow Sheet to determine whether the resident was recommended for a retraining program, was blank. The Summary portion of the assessment (page 3) stated after review of the Bladder Incontinence Assessment and the 3-Day Bowel and Bladder Flow Sheet; a determination was to be made whether the resident was a candidate for a retraining program. Page 4, the Bladder Retraining Progress Notes, dated 6/3/15 stated, Alert and Oriented x 2 (to person and place); Resident stated sometimes he has accidents Resident incontinent of bladder (occasionally) wears pull-ups and adult diapers (per resident). No c/o pain during urination. Soft nondistended abdomen. R7's clinical record revealed that although a 3-Day Bowel & Bladder Flow Sheet (voiding diary) was dated to start at 12 midnight on 6/3/15 (should have been dated 6/4/15), it was not completed. The facility failed to ensure that a voiding diary was completed and they failed to develop an individualized toileting plan based on the voiding diary for R7. An interim care plan, dated 6/3/15, for the problem of incontinence included the following approaches, If incontinent start B&B pattering (sic); If incontinence is total check q 2hrs and render good peri care as needed; Toilet before and after meals and at hs and q 4 hrs during the night until my B&B assessment is completed or per my request for toileting; Pads/Briefs/Urinal/bedpan/bedside Commode as needed. The physician's H&P, dated 6/5/15, did not identify any urinary problems. The electronic Bowel and Bladder Detailed Entry Report, completed by CNAs, from 6/4/15 through 6/10/15, lacked evidence that R7 was being toileted according to the interim incontinence care plan. Review of the report revealed entries were completed only once per shift and included varied responses, such as, Toileted per toileting plan; Checking and Changing Pads during rounds; Resident toileted self. There was no evidence that the facility followed the interim plan of care for incontinence. The 6/10/15 admission MDS assessment stated R7's daily decision making skills were severely impaired and he required extensive assist of one staff for transfers and toilet use. This MDS assessment also stated R7 was frequently incontinent during the assessment period (6/4/15 through 6/10/15) and there was no trial of a toileting program. On 6/12/15 a urinary incontinence care plan was developed. Approaches included: incontinence care as needed after each episode of incontinence; monitor for increased episodes of incontinence; and requires the assistance of 1 person for toileting. The approach Toilet/check/change resident upon rising in AM, before & after meals, at bedtime and every 2 hours during the night was yellowed out (indicating it was discontinued) and written in was Check and change q round and PRN. It is unclear when the approach to check and change q round (usually every 2 hours) and PRN was implemented, as it was undated. Review of the electronic Resident Bowel and Bladder by Shift Chart, completed by CNAs revealed the following: - 6/4/15 through 6/30/15 consisted of a total of 81 shifts (3 shifts per day) during which R7 was incontinent on 44 out of the 81 shifts (54.3%). - 7/1/15 through 7/31/15 consisted of a total of 93 shifts during which R7 was incontinent on 59 out of the 93 shifts (63.4%). - 8/1/15 through 8/31/15 consisted of a total of 93 shifts during which R7 was incontinent on 69 out of the 93 shifts (74.1%). - 9/1/15 through 9/17/15 (through the 12 AM to 7:30 AM shift) consisted of a total of 49 shifts during which R7 was incontinent on 48 out of the 49 shifts (97.9%). According to the 6/12/15 urinary incontinence care plan, the facility was to monitor for increased episodes of incontinence. Despite progressive decline of R7's urinary incontinence from 6/4/15 through 9/17/15 there was no evidence the facility identified the decline and/or re-assessed the resident. The electronic Bowel and Bladder Detailed Entry Report, completed by CNAs, from 8/27/15 through 9/2/15, lacked evidence that R7 was being toileted according to any scheduled toileting plan. Review of the report revealed entries were completed only once per shift and again had varied responses, such as, Toileted per toileting plan; Checking and Changing Pads during rounds; Resident toileted self. A quarterly MDS assessment, dated 9/2/15, stated R7's daily decision making skills were severely impaired and he required extensive assist of one staff for transfers and toilet use. The 9/2/15 MDS assessment stated R7 was always incontinent during the assessment period (8/27/15 through 9/2/15) and there was no trial of a toileting program. This was a decline from the 6/10/15 MDS assessment, when R7 was frequently incontinent. On 9/17/15 at 11:40 AM during an interview with R7, he stated that he knows when he needs to use the bathroom to urinate, but at times has some accidents. On 9/17/15 at approximately 3:00 PM, E11 (CNA) was interviewed. E11 stated that she has worked with R7 for approximately 3 to 4 weeks since he transferred to the 700 wing. E11 stated R7 was able to stand, pivot and transfer with one (1) person assist and was a one (1) person assist for toileting. E11 stated that she toilets R7 before meals and then once in the afternoon. E11 stated the resident was not on a scheduled toileting program (as part of the plan of care), this was just what she does as a routine with her residents. E11 stated that R7 will use the bathroom to urinate, that he may be wet at times, but he will still urinate into the toilet. On 9/21/15 at approximately 10:45 AM, E13 (LPN) was interviewed. E13 stated that the medication nurse assigned to the room is responsible for completing the nursing admission assessment (Data Collection Tool) when a new resident is admitted . E13 stated that the Bladder Incontinence Assessment is completed as part of the admission assessment, and the 11:00 PM to 7:00 AM shift starts a 3-Day Bowel & Bladder Flow Sheet on all residents who have incontinence. When the diary is completed, the nurse on duty reviews it and determines if the resident is appropriate for a toileting plan. E13 stated that specific times (hours) are not used and CNAs are told to check residents at least every two (2) hours and to assist them to the bathroom or check to see if they are wet. On 9/21/15 at 11:10 AM, E8 (CNA) was interviewed. When asked how does a CNA know what care a resident needs, she stated they get report from the nurse and check the yellow sheet (Kardex). She stated if a resident is on a toileting plan, the nurse lets them know, but there are no specific times told to them by the nurse, nor is it noted in the Caretracker system. E8 stated if she is told a resident is on a toileting plan it means check and take to the bathroom every two (2) hours and make sure they are not wet. E8 stated that CNAs can document more than once a shift in Caretracker and they are supposed to enter the activity completed each time they leave a resident's room. On 9/22/15 at approximately 11:15 AM, E14 (LPN) was interviewed. E14 stated that the medication nurse assigned to the room completes the nursing admission assessment, which includes the Data Collection Tool and the Bladder Incontinence Assessment. E14 stated the resident and/or family are interviewed regarding the resident's urinary continence status. She stated a 3-Day Bowel & Bladder Flow Sheet is started by the 11 PM to 7 AM shift for all residents with incontinence. E14 stated that when completed, the 3-day diary gets handed in to E2 or E3 (ADON), who then evaluate it and determine if the resident is appropriate for a retraining program. She stated if a toileting program is to be started it is communicated to the nursing supervisor, who then communicates it to the nurse, who then tells the CNAs. E14 stated there is no one resident on her assignment who is currently on a scheduled toileting plan and she has never had anyone on an actual scheduled toileting plan since she's worked at the facility. She stated she encourages the CNAs to take the residents to the bathroom frequently. On 9/22/15 at 11:30 AM, E2 was interviewed. E2 stated that if a resident has incontinence on admission to the facility, a 3-day diary is to be started at midnight and after completion it is reviewed and a care plan is developed. E2 stated review of the 3-day diary is done at Clinical Meeting, held daily, which is attended by the DON, ADON, MDS Coordinator, Nurse Supervisor and the therapy department. E2 stated that the nurses are to read the 24 hour report to check if a resident is being placed on a toileting plan and the CNAs are to check the Kardex. E2 stated the Caretracker system does not prompt the CNAs when to complete toileting, but they are able to enter documentation more than once a shift. E2 stated that the facility identified the CNAs were not documenting in Caretracker as they should be, meaning documenting each time after care was provided, and are only documenting once a shift. However, they (management) have not had time to fully act on this discovery. Findings were reviewed with E2 regarding R7's incontinence. E2 stated he would like the opportunity to review R7's chart on his own. No additional information was provided to the surveyor before the exit. The facility failed to accurately and comprehensively assess R7's urinary continence status upon admission, failed to complete a 3-Day Bowel & Bladder Flow Sheet, and failed to, based on voiding patterns, develop an individualized toileting plan in an attempt to restore as much normal bladder function as possible. Upon admission to the facility, R7 was frequently incontinent of bladder. R7 progressively declined, yet there was no evidence the facility identified the decline and acted accordingly. There was no evidence of any re-assessment and R7 progressed from frequently incontinent to being always incontinent. Findings were reviewed with E1 (ED), E2 and E3 (ADON) on 9/23/15 during the exit conference at approximately 4:20 PM.

Cross refer F248 Based on observations, record review and interviews, it was determined that the facility failed to ensure that one (R10) resident out of 34 Stage 2 sampled residents, with severely impaired cognition and a history of unwitnessed falls, received adequate supervision to prevent a fall with injury. R10's fall from a geri chair on 8/5/15 was unwitnessed and without adequate supervision which resulted in the resident sustaining a broken hip that required hospitalization . However, due to R10's high risk for surgery, her advanced age and dementia, surgery was not performed. R10 returned to the facility for palliative care for the broken hip. Additionally, the facility failed to ensure that 4 (501, 502, 605, and 606) out of 31 rooms were free from accident hazards. Findings include: The facility's Fall Management Program (Revised 10/27/11) stated, .To provide a systemic review (sic) the resident to determine risk for falls and develop appropriate interventions . 3.1 Definitions: A fall is any sudden, unintentional change in position that causes an individual to land at a lower level on an object, the floor or ground. Falls include: Found on floor, Slides to floor unassisted .3.2 .1. Fall Risk Factors .a. Intrinsic Risk Factor (internal) included, History of previous falls. b.Inactivity, boredom . 1. Review of R10's clinical record revealed that on 12/1/14 at 3:00 PM, R10 was found on the floor in her room between her wheelchair and her geri-chair. R10 was placed back in her geri-chair via hoyer lift . R10 did not sustain an injury. According to R10's quarterly MDS assessment, dated 2/5/15, this resident had a [DIAGNOSES REDACTED]. 2/5/15- R10's fall risk assessment using a standardized quarterly Fall Risk Review Tool failed to identify the 12/1/14 fall under R10's history of falls. R10 was incorrectly given a score of 0 (no falls within the last 3 months). 2/12/15 - R10 was care planned (initiated 8/23/13) for Potential for injury related to being a fall risk due to decreased mobility, decreased cognition/lack of safety awareness, episodes of anxiety/behaviors, hx of falls, medication, adl decline. The stated goal was that R10 would have no injury related to falls. The Care plan approaches included: administer medication per order, ensure foot wear has non-skid soles, keep bed in lowest position safest for me, keep call bell in reach encourage to use prn, Therapy evaluation/screen/treat, toilet/incontinence care every round and prn, Transfer with 1 assist, mechanical lift (hoyer lift) x 2 assist, bed and chair alarms, hipsters, and fall mat. 3/20/15 - a physician's orders [REDACTED]. 4/29/15 at 4:15 PM incident report stated, Responding to Resident's calls for help from . Resident noted sitting on floor in front of her Geri-Chair. Resident was unable to describe or explain incident. There was no injury documented. The facility's incident report lacked evidence that a chair alarm and hipsters were in place as per R10's care plan. E2's (DON) written statement, dated 4/30/15, on the facility's investigation report stated that R10 was provided with a dycem on the geri-chair to prevent R10 from sliding. 4/30/15- dycem to geri-chair was added to R10's care plan. 5/7/15- The annual MDS assessment stated, R10's cognition remained severely impaired. R10 needed extensive assistance of staff for all ADLs. The MDS assessment only reflected R10's most recent fall of 4/29/15. R10's clinical record lacked evidence of a quarterly Fall Risk Review Tool assessment to determine R10's risk for falls, in conjunction with the annual MDS assessment. 5/13/15 at 5:00 PM - Incident Report stated, Resident noted sitting on floor in her room, in front of her recliner (geri-chair). Stated that she slide (sic) out of chair to the floor. R10 did not sustain injury. This report stated that R10 was provided with a new dycem - old dycem worn out. There was no evidence that the facility revised the care plan and identified the need for more appropriate interventions such as the need for adequate supervision to prevent the resident from sliding out of the chair and sustaining a fall with injury. 5/14/15 -E5's (OT) note stated, O.T. completed a f/u screen s/p fall out of her geri-chair. Pt. continues at her PLOF .with all cares .No dycem currently under resident in geri-chair, OT acquired and placed under resident as per care plan. No further skilled OT/PT interventions required at this time. It is unclear why the assistive device dycem was not in place. 8/5/15 - R10 had another unwitnessed fall while in her geri-chair. An incident report dated 8/5/15 at 6:45 PM stated, Resident found sitting on the floor in front of her chair (geri-chair), no signs and symptoms of injuries noted with initial evaluation. Resident complained of pain afterwards, X-rays obtained. X-Ray result dated 8/5/15 showed left femoral neck fracture (a hip fracture proven to be serious injuries in the elderly population that are associated with high mortality and significant morbidity in the geriatric population)- Medscape Drug, Diseases and Procedures reference on Femoral Neck Fracture Imaging updated 10/29/2013), http://emedicine.medscape.com/article/ 8-overview. R10 was sent to the hospital for evaluation and treatment with the family's consent. R10 was hospitalized from [DATE] - 8/10/15. According to the Hospital Discharge Summary, dated 8/10/15, R10's [DIAGNOSES REDACTED]. The hospital physician met with R10's family and explained the high risk of surgery considering her advanced age and dementia. R10's family agreed to provide palliative care for R10. 9/16/15 at approximately 10:15 AM - R10 was observed in her room, alone in her geri-chair, in a reclined position with her legs elevated and eyes closed. R10's room was approximately 8 rooms away from the nursing station. 9/17/15 at 10:55 AM - R10 was observed in her room alone in her padded geri-chair (halfway reclined with elevated legs) with her eyes closed. R10's call bell was laying on her lap, but was not clipped to her gown. R10 was mumbling with her eyes closed. Her left hand touched the call bell on her lap and the call bell slid onto the floor. The surveyor made E15 (CNA) aware that R10's call bell fell on to the floor. 9/21/15 at 3:20 PM- interview with E6 (LPN) related to the 8/5/15 fall, he stated that he could not remember if there was a dycem on the geri-chair. Also, R10 was left in her geri-chair in the hallway opposite the door of her room. The CNAs were busy moving residents from the dining room to other residents' rooms when the unwitnessed incident occurred. E6 stated that he was also busy passing medications at that time in the same hallway, but did not see how she fell . 9/21/15 at 3:30 PM- interview with E7 (CNA), she stated that R10 always tried to move herself down and out of the geri-chair and everybody (staff) knew that. If you (staff) catch her attempting to move down and get out of the geri-chair, she would quickly get herself back up. She also stated that R10 was very quick. According to E7, she saw R10 sitting on the floor in front of the geri-chair on 8/5/15 parked outside of another resident's room, across from R10's room. E7 stated on 8/5/15 the dycem was on the geri-chair. She also stated that on 8/5/15 she helped E6 put the resident back in the geri-chair manually and with E6, she also helped R10 back to bed. She gave R10 a bed bath and when turning R10 towards her, R10 started to complain of hip pain. R10's unwitnessed/unsupervised falls (3) dated 12/1/14, 4/29/15 and 5/13/15 occurred while R10 was in the geri-chair in her room without staff supervision. R10's last fall on 8/5/15 was also unwitnessed/unsupervised while in her geri-chair, which resulted in a left hip fracture. R10 returned to the facility after 4 days of hospitalization without surgical intervention and placed on palliative care for pain control for her fractured hip. The facility failed to adequately assess/evaluate R10's falls dated 12/1/14, 4/29/15 and 5/13/15 so appropriate interventions were developed to reduce R10's risk of injury from falls, and prevent falls. Findings were discussed with E2 (DON) and E16 (Regional Nurse Consultant) on 9/22/15 at approximately 3:00 PM. 2. Observations from stage 1 on 9/15/15 and during the environmental tour with E17 (Housekeeping Supervisor) on 9/21/15 from 2 PM to 2:40 PM revealed the following: -Observations were made on 9/15/15 at 11:26 AM and during the environmental tour with E17 on 9/21/15 of high, uncovered toilet bolts and loose and missing covers on the A/C unit of room 501. -Observations were made on 9/15/15 at 11:35 AM and during the environmental tour with E17 on 9/21/15 of high, uncovered toilet bolts in the bathroom of room 502. -An observation was made on 9/21/15 during the environmental tour with E17 of high, uncovered toilet bolts in the bathroom of room 605. -An observation was made on 9/21/15 during the environmental tour with E17 of high, uncovered toilet bolts in the bathroom of room 606. Findings were confirmed by E17 on 9/21/15 during the environmental tour between 2:00 and 2:40 PM. Findings were reviewed with E1 (ED) and E2 on 9/23/15 during the exit conference at approximately 4:30 PM.

Based on record review, review of hospital records and interview, the facility failed to ensure that one (R1) out of 3 sampled residents was free from any significant medication errors. Interview with R1 on 1/30/13 at 8:15 AM revealed that after he took pills from a nurse on 12/18/12 a little while later he did not feel well. Following this, staff found R1 to have jerky movements of the upper and lower extremities. R1 was sent to the emergency room (ER). On 12/19/12 hospital documentation revealed an accu check of 11 at 12:07 AM. Hospital records also showed R1 was found to have [MEDICATION NAME] (a medication used to treat diabetics which causes cells in the pancreas to release insulin) in his blood despite the lack of a physician's order to receive this medication. Findings include: The interagency orders dated 12/12/12 from the acute care facility to the long term care (LTC) facility stated R1 was discharged to the LTC facility with [DIAGNOSES REDACTED]. On 12/12/12, R1 was admitted to the LTC facility for short term rehab. In the LTC facility he was being followed by E7 (Primary Care Physician) who had previously treated R1 and was familiar with his past medical history. After a six day stay at the LTC facility, R1 was sent to the emergency roiagnom on [DATE] for a change in his condition and [MEDICAL CONDITION] activity. An MDS (Minimum Data Set) was not completed for R1 as he had only been at the facility for six days. A review of R1's physicians order sheet (POS) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nurse's note dated 12/18/12 at 2100 stated, "At about 2015 (8:15PM) resident presented with involuntary jerky movements bilateral upper and lower extremities. Responded only to painful stimulus. 911 called. Resident transferred to hospital ER. Resident left unit at about 2020 (8:20PM) via stretcher accompanied by wife and sister. E7 (Primary Care Physician) notified of transfer. Report called into hospital ER". Review of facility incident report dated 1/3/13 revealed that E2 (Director of Nursing) received a phone call from E7 on 12/31/12 stating that R1's blood test from the hospital showed that resident had [MEDICATION NAME] (diabetes medication) in his system. Review of the hospital laboratory records dated 12/22/12 confirmed this finding. Also "critical tests results" from the hospital dated 12/19/12 at 12:07AM revealed an "accu check (blood sugar test) result of 11 and at 1:40 AM a result of 21 (normal range 80-120)". Review of R1's clinical records, POS and MAR from the facility revealed that he did not have a [DIAGNOSES REDACTED]. Interview on 1/30/12 with E2 (DON) stated, "there were no other residents on the 700 hall (R1 in room [ROOM NUMBER]) that were taking [MEDICATION NAME]". Upon review of all the POS's and MAR's by the surveyor for the residents that were on the 700 hall on 12/12/12, it was revealed that there were two (SS3 and SS4) residents that were prescribed and administered [MEDICATION NAME]. Interview on 1/30/13 at 10:45AM with E7 stated "I was suspicious that something may have happened. That he (R1) may have received the wrong medications. His (R1's) C-Peptide and Insulin levels were high which indicated that he (R1) may have gotten the [MEDICATION NAME] for 4-5 days". E7 also stated that there was no family history of diabetes. E7 also ordered the consult for an Endocrinologist. During an interview on 1/30/13 at 8:15 AM R1 stated, "I took pills from (name of nurse) (E5) around 6:00 (PM) and a little while later I didn't feel well. I don't remember anything after that". R1 stated that he did not remember how many pills or what they looked like. R1 also stated that he nor anyone in his family has diabetes. During an interview on 1/30/13 at 10:10 AM with R1's wife she stated, "E7 told me the week after Christmas about the hospital lab results ([MEDICATION NAME]). He (E7) had an idea when he (E7) was in the ER that this is what happened". R1's wife also stated that there are no family members that have diabetes. She said that she came to visit R1 on 12/18/12 at 8:15 PM and when she entered the room he (R1) was shaking violently and that he had never done that before. Interview on 1/31/13 with E5 (nurse) who was assigned to R1 on 12/18/12 stated that R1 was fine until around 7:30 PM when wife came in to visit and she came running into hallway asking for help. E5 went to the resident's room and found him to be having a [MEDICAL CONDITION]. E5 stated that R1 was not a diabetic and was not receiving [MEDICATION NAME]. Interview on 1/31/13 with E6 (nurse) who was there on 12/18/12 day shift stated that R1 was on [MEDICATION NAME] and a lot of BP (blood pressure) medications. She stated that she did not recall R1 being a diabetic and does not remember giving R1 any medications for diabetes. Review of the hospital discharge summary dated 1/6/13 stated, "History of Present Illness ...The patient had profound [DIAGNOSES REDACTED], blood sugar of 18 ...The patient came to the emergency room . He was resuscitated with D5 ([MEDICATION NAME]-sugar) on the way and then an [MEDICATION NAME] of D50 ([MEDICATION NAME]). The patient woke up but kept on relapsing back with hypoglycemic episodes. The patient showed some T-wave inversions. The patient was admitted to the hospital because of his [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and was admitted to the ICU (Intensive Care Unit)". Review of the hospital discharge summary dated 1/6/2013 revealed, "Hospital Course: According to problems: 1. Reason the blood studies back on. (R1) showed that his [DIAGNOSES REDACTED] did resolve after 24 hours of glucose administration. The patient 's blood showed high insulin levels, inappropriate for his situation. Also high C-peptide levels indicating endogenous insulin secretion". His [DIAGNOSES REDACTED]. There was no physician's order for [MEDICATION NAME]. Resident was discharged from the hospital on [DATE] to another long term care facility. Interview on 1/30/13 with E2 (Director of Nursing) revealed that when residents are discharged from the facility the staff takes their medication cards and removes the top which contains resident and medication information and staff shreds this part, then the medications are put in the hazardous waste container and picked up by Steri Cycle. This practice eliminated the possibility of anyone investigating what medications were in R1's medication cards. E2 also denied that there were any other residents on the hall on [MEDICATION NAME]. Interview on 1/31/13 at 10:30 AM with E8 who is the General Manager of the Pharmacy which supplies the medications to the facility revealed, their recommendation for medications of discharged residents, would be to send them back to the pharmacy to see if residents would be able to receive credit for them. It is not mandatory for the facility to send back the residents' medications. E8 was also questioned about the two residents (SS4 and SS5) that were receiving [MEDICATION NAME] and whose medications were on the same medication cart as R1. The pharmacy was not aware of any discrepancies occurring with these two residents and there were no additional requests for [MEDICATION NAME] to be filled by the facility for the month of December.