Every finding on record at Excelcare at Lewes LLC

Based on interview and record review, it was determined that for one (R173) out of two residents reviewed for hydration, the facility failed to ensure that R173 maintained proper hydration which resulted in harm, requiring hospitalization on 6/1/25 and 6/19/25 with diagnosis of acute kidney injury (AKI) and dehydration. Findings include:The BUN (blood urea nitrogen) lab test measures the amount of urea nitrogen in the blood. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidney . BUN levels also may vary according to the state of hydration, with increased levels seen in dehydration and decreased levels seen in overhydration. Mosby's Diagnostic and Laboratory Test Reference 2023. Review of R173's clinical record revealed: 4/25/25 - R173 was admitted to the facility with a diagnosis of acute lithium toxicity, AKI (acute kidney injury), acute metabolic encephalopathy and congestive heart failure (CHF).4/28/25 - A care plan documented that R173 had potential for alteration in nutrition due to dementia and Parkinson's disease with the following interventions: assist at meals as needed, encourage oral fluids to promote adequate hydration, and monitor for the need of other nutrition interventions. 4/28/25 - A nutrition progress note documented a nutrition assessment which recommended R173's fluid intake should be 1943-2098 mL/day. The assessment further identified R173 was at risk for dehydration and malnutrition. The progress note further mentions lab tests obtained on 4/26/25 which documented the following lab values: Sodium 140; BUN 29; creatinine 1.4; eGFR 53. 4/30/25 - An admission MDS documented that R173 required set up assistance of one staff for feeding and hydration and also documented that R173 was a BIMS of 1, indicating severely cognitively impaired. The daily totals obtained from CNA Task flow sheet and MAR for R173's fluid intake:5/1/25 - 1080 mL.5/2/25 - 840 mL.5/3/25 - 620 mL.5/4/25 - 1080 mL.5/5/25 - 1080 mL.5/6/25 - 720 mL.5/7/25 - 1680 mL.5/7/25 - A Malnutrition Risk Assessment documented that R173 was at risk for malnutrition related to severe dementia and hand shake (tremors). 5/8/25 - 1920 mL.5/9/25 - 1410 mL.5/10/25 - A physician's order documented encourage increased fluid intake of 240 mL per shift. 5/10/25 - 720 mL.5/11/25 - 840 mL.5/12/25 - A nutrition progress note documented R173's average fluid intake was 330 mL/day and recommended to discontinue prescribed hydration pass related to R173's diagnosis of CHF. The assessment documented to encourage oral fluid intake and determined a new fluid goal was 1635 - 1766 mL/day.The daily totals obtained from CNA Task flow sheet and MAR for R173's fluid intake:5/12/25 - 960 mL.5/13/25 - 1200 mL. 5/14/25 - 940 mL.5/15/25 - 1800 mL.5/16/25 - 1200 mL.5/17/25 - 720 mL.5/18/25 - 1320 mL.5/19/25 - 720 mL.5/20/25 - 840 mL.5/21/25 - 1000 mL.5/22/25 - 1320 mL.5/23/25 - 1200 mL.5/24/25 - 1080 mL.5/25/25 - 1080 mL.5/26/25 - 1200 mL.5/27/25 - 1080 mL.5/28/25 - 960 mL.5/29/25 - 930 mL.5/30/25 - 1080 mL.5/31/25 - 1080 mL.6/1/25 - 360 mL.6/1/25 11:00 AM - A transfer form documented that R173 was being sent to hospital post fall for evaluation. 6/1/25 - A hospital progress note documented that R173 presented to the emergency department related to frequent falls, hypotension, and confusion. R173 was admitted with diagnosis of AKI and dehydration, requiring further work up.6/4/25 - R173 was readmitted to the facility.6/10/25 - A nursing progress note documented R173 had low oral intake and will discuss adding R173 to the assist to feeding list.The facility lacked evidence of resident being added to the feeding list or the assessment regarding the need. The daily totals obtained from CNA Task flow sheet and MAR for R173's fluid intake:6/11/25 - 1320 mL.6/12/25 - 1040 mL.6/13/25 1:00 AM - A physician's progress note documented that R173 was seen following two unwitnessed falls. The progress note lacked evidence of assessment of hydration status, fluid intake, or interventions to encourage hydration. 6/13/25 - 840 mL.6/14/25 - 1200 mL.6/15/25 - 720 mL.6/16/25 - 780 mL. 6/16/25 - A progress note documented R173 was having lethargy.6/17/25 - 1160 mL.6/18/25 - 1140 mL.6/18/25 - A progress note documented R173 was having increased confusion, agitation, restlessness, and continues with poor intake.6/19/25 - 720 mL.6/19/25 1:48 PM - A laboratory results report documented that R173 had the following lab values: BUN level of 62 mg/dL, creatinine 1.70 mg/dL, hemoglobin 7.6 g/dL and hematocrit 23.3.6/19/25 2:35 PM - A progress note documented that lab results were called to provider and documented R173 would be seen by MD. The progress note documented R173 was noted to have increased shortness of breath, increased falls, and increased confusion/agitation/anxiety.6/19/25 4:21 PM - A nursing progress note documented that R173 was sent to the hospital for further evaluation.6/19/25 4:24 PM - A hospital progress note documented that R173 had lab values of BUN of 62 mg/dL and creatinine 1.7 mg/dL upon arrival to emergency department. The progress note further documented R173 was being admitted with diagnosis of AKI, hypotension, and anemia with a plan to fluid resuscitation via IV fluids and avoid nephrotoxic medications.2/17/26 11:15 AM - During an interview, E16 (Dietician) stated resident's will have a nutrition evaluation at admission and quarterly thereafter and the dietician is expected to review intake, weights, labs and hydration status. E16 stated that additional fluids or supplements can be ordered if fluid goals are not being met and if resident is not consistently meeting goals the expectation is to discuss with the provider. E16 also stated that a resident having a diagnosis of AKI would be someone that would be closely monitored to prevent from reoccurring. 2/18/26 11:45 AM - During an interview, E13 (CNA) stated that if a resident is not drinking well the staff is expected to encourage fluids, monitor intake and notify the nurse if the resident is not meeting fluids goals during their shift. 2/18/26 12:00 PM - During an interview, E14 (LPN) stated that R173 was not a good drinker and staff would encourage him to drink. E14 stated that R173 would drink if staff would sit and encourage him to drink, but did say at times he would refuse to drink and push the cup away. E14 stated that R173 having poor intake was reported to the Nurse Manager and the process is for the Nurse Manager to report goals not met to the provider. E14 could not verify if the Nurse Manager reported R173 not meeting fluid goals was reported at that time and stated she did not see any progress notes documenting that. 2/18/26 12:15 PM - During an interview, E17 (Unit Manager) stated the expectation is for the provider to be notified if a resident is not meeting fluid goals and to be evaluated by the provider and dietician for interventions related to hydration. Despite nursing documenting R173's decreased intake and change in mentation, the facility failed to increase monitoring, implement approaches to increase hydration and consult with the physician about decreased intake.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on interview and record review, it was determined that for one (R3) out of one resident reviewed for dialysis, the facility failed to ensure that the provider was consulted when R3 refused dialysis services. Findings include:Review of R3's clinical record revealed:12/18/25 - R3 was admitted to the facility.12/26/25 - A physician's order documented R3 dialysis appointment Monday, Wednesday and Friday transport via stretcher. 2/9/26 11:30 AM - A progress note documented that R3 left for dialysis. 2/9/26 - A dialysis communication form documented that R3 attended dialysis but refused treatment and R3 was returned to facility without interventions. 2/12/26 1:01 PM - During an interview, E20 (LPN) stated dialysis center called the facility to notify them that R3 did not receive dialysis on 2/9/26. E20 stated she did not write a progress note documenting that R3 did not receive dialysis and stated the Nurse Manager was notified that R3 did not receive dialysis.2/12/26 1:15 PM - During an interview, E17 (UM) stated that R3 went to dialysis on 2/9/26 and was not aware R3 did not receive dialysis.2/12/26 1:30 PM - During an interview, E21 (NP) stated that neither the nurse nor the dialysis center notified her that R3 did not receive dialysis on 2/9/26 and that the expectation would be to notify her. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review, interview and review of physician orders it was determined that for one (R11) out of six residents' sampled for unnecessary medication review the facility failed to ensure that R11's blood pressure medication was held when vital signs were below ordered parameters. Findings include:The facility policy on medication administration last updated 5/1/25 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Review of R11's clinical record revealed:9/22/25 - A physicians' order was written for R11 to receive metoprolol daily for blood pressure; hold for systolic blood pressure (SBP) less than 130 or hear rate (HR) less than 60. October 2025 - R11 was administered metoprolol with below ordered parameters on the following dates:10/7 with a SBP of 11810/28 with a SBP of 125. November 2025 - R11 was administered metoprolol with below ordered parameters on the following dates:11/24 with a HR of 52.12/7/25 - An MRR irregularity report documented, metoprolol is not always held as required by the physician's order. The report lacked evidence of review by R11's attending and was signed by E27 (LPN). December 2025 - R11 was administered metoprolol with below ordered parameters on the following dates:12/3 with a SBP of 12312/10 with a SBP of 12612/12 with a HR of 5812/16 with a SBP of 11312/20 with a SBP of 12112/24 with a SBP of 126 and HR of 5612/26 with a SBP of 127.January 2026 - R11 was administered metoprolol with below ordered parameters on the following dates:1/3 with a SBP of 1101/4 with a SBP of 1141/5 with a SBP of 1141/6 with a SBP of 1091/10 with a SBP of 1261/11 with a SBP of 1161/13 with a SBP of 1161/17 with a SBP of 1171/18 with a SBP of 107 and a HR of 541/19 with a SBP of 1031/22 with a SBP of 1191/30 with a SBP of 116. February 2026 - R11 was administered metoprolol with below ordered parameters on the following dates:2/1 with a SBP of 1292/2 with a SBP of 1252/4 with a SBP of 121 and HR of 592/7/26 - An MRR irregularity report documented metoprolol not always held consider discontinuing. MRR was signed by E26 (NP) on 2/11/26 who documented that the metoprolol was discontinued. 2/9/26 - R11's physician's order for metoprolol was discontinued. 2/13/26 11:08 AM - During an interview E50 (LPN) one nurses who administered R11's metoprolol in February and January confirmed the finding that R11 received their metoprolol when vital signs did not meet ordered parameters. E50 stated, If the one vital sign is good [within parameters] then I give the medication based on that. 2/13/26 11:19 AM - During an interview E26 (NP) confirmed that R11's metoprolol was to be held for either parameter and that she was unaware that R11 was administered the metoprolol outside of parameters. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on record review and interview, it was determined that for one (R41) of one resident reviewed for grievances, the facility failed to ensure prompt resolution of a grievance regarding missing dentures. Findings include:5/14/25 - A facility provided grievance form completed by E14 (LPN) documented that FM1 reported R41's top dentures were missing. E14 conducted a room sweep and documented that the 11:00 PM - 7:00 AM shift would complete a second room sweep. The concern was reported to the Director of Nursing.5/14/25 - A grievance documented that E28 (Former Social Worker) was in receipt of the grievance and reported receiving an email from the Director of Nursing requesting that E28 contact FM1. On 5/16/25 during that contact, FM1 was informed that if the resident was approved for Medicaid and no longer Medicaid-pending, Medicaid would replace the dentures. FM1 stated the resident had transferred from another facility and was already approved in Delaware. The family agreed to wait until E28 verified Medicaid status with the Business Office. A discussion with the Business Office was scheduled for 5/19/25.5/19/25 through 7/28/25 - A record review did not reveal documented investigative findings, corrective actions, or grievance closure following the scheduled Business Office discussion.7/28/25 at 11:49 AM - A facility provided email thread documented E15 (Social Worker) emailed the dentist requesting enrollment for R41 and indicated the resident needed to be fitted for dentures.7/29/25 at 10:35 AM - The dentist responded requesting confirmation that E29 (Former Business Office Manager) was the resident's representative payee.8/11/25 at 1:45 PM - The dentist notified E15 that R41 did not qualify for the dental program. FM1 was informed that the resident did not qualify due to lack of income required for program eligibility.2/18/26 at 1:45 PM - During an interview, E15 reviewed the grievance documentation and confirmed the facility's grievance process includes receipt of the grievance, forwarding it to the appropriate unit or manager to search for the missing item, and, if not located, forwarding the matter to the Nursing Home Administrator. E15 was unable to explain the extended timeframe and stated uncertainty as to why a meeting with E29 was required before proceeding with denture replacement. E15 further stated the events that occurred during her absence. 2/18/26 at 1:53 PM - During a joint interview with E12 (Current Business Office Manager) and E15 it was revealed and confirmed by E12 that the facility could have obtained dental services on a fee-for-service basis and was not required to wait for Medicaid eligibility determination to proceed. E12 further confirmed the resident did not qualify for the dental program because program eligibility required income, which R41 did not have.Record review indicated resolution of the denture replacement did not occur until January 2026, approximately eight months after the grievance was initiated.The facility was unable to demonstrate a grievance was promptly resolved or managed in accordance with its stated grievance process.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on interview and record review for one (R56) out of two residents reviewed for catheter use, the facility failed to refer R56 to urology timely while having an ongoing urinary catheter issue. Findings include: Review of R56's clinical record revealed:10/24/23 - R56 was admitted to the facility.11/6/23 - A care plan documented R56 had a foley catheter related to neurogenic bladder with the following interventions: resident had a 18F with a 30 mL balloon, position catheter bag and tubing below level of the bladder; monitor intake and output per facility policy; monitor for signs and symptoms of discomfort on urination and frequency; monitor for signs and symptoms of UTI and report to physician; monitor and document for pain or discomfort related to catheter. 2/25/25 - A progress note documented R56 returned from an appointment and foley catheter was found to be out, with balloon intact. The progress note documented that foley catheter insertion was attempted and unsuccessful at this time, due to resistance. The provider was notified and recommendation to leave foley catheter out and bladder scan every 8 hours for residual urine. 2/26/25 - A progress note documented that foley catheter re-insertion was successful.3/1/25 - A progress note documented that R56 had large amount of bleeding and blood clots noted from penis. The on-call provider was notified and labs and urine culture ordered. 3/2/25 6:03 AM - A progress note documented that R56 presented with excessive bleeding and clots around urinary catheter and was sent to hospital for evaluation. 3/2/25 9:51 AM - A diagnostic report for CT results documented the tip of the catheter is seen in the penile urethra with distended balloon just proximal to the tip. 3/2/25 3:54 PM - A progress note documented that R56 returned from hospital. 3/5/25 12:00 AM - A physician's progress documented that R56 was recently seen and examined by urology with foley catheter change. The diagnoses, assessment, and plan section documented that R56 will follow up with urology.11/3/25 10:31 AM - A visit summary report documented that R56 was seen by urology. 2/18/2026 9:35 AM - During an interview, E30 (LPN) stated that R56 was difficult to replace the urinary catheter and recalls staff having ongoing difficulty changing. E30 stated that R56 was recommended to follow up with urology and have catheter changes done with them due to the increased difficulty. 2/18/2026 10:03 AM - During an interview, E31 (LPN) stated that R56 had multiple catheters dislodged in the year 2025 and stated that R56 was difficult catheter to change. E31 stated that R56's catheter would leak often and would require staff to change it. E31 stated the expectation would be for staff nurses to attempt to change the catheter and if unsuccessful they would be referred out.2/18/2026 12:11 PM - During an interview, E14 (LPN) stated the expectation is to get residents scheduled with outside providers as soon as possible. E14 confirmed that R56 did not see urology until 11/3/25.The facility failed to refer R56 to an outside provider timely. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review and interview it was determined that the facility failed to ensure accuracy of resident records for one (R41) out of six residents reviewed for falls when R41's fall incident report contained inaccurate information regarding an injury. Findings include:Review of R41's clinical record revealed; 12/15/25 1:09 PM - A progress note in R41's clinical record documented, At 1235, while this writer was at the meds cart giving out afternoon med, heard a bomb sound behind in the dining area, immediately turned and saw patient lying face down on the floor. Immediately assessed patient and a hematoma noted on patient forehead . 12/15/25 - The incident report for R41's fall documented, No injuries observed at time of incident in the injuries observed at time of incident section. 2/18/26 12:03 PM - During an interview E40 (R--) confirmed the finding and stated, they did write it in the other section. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. 02/09/2026 9:14 AM Sussex Hall nutrition refrigerator contained three (3) opened cartons of thickened water that were incorrectly dated to reflect the date of disposal as per manufacture recommendations. One container was dated February 3, 2026 and the other two cartons were dated January 31, 2026. The manufacturer's instructions on the cartons state that once opend, any remaining product should be discarded after four (4) days. 02/09/2026 10:08 AM Henelopen Hall Nutrition Refrigerator contained 1 carton of Thickened water that wereincorrectly dated

Based on record review and interview, it was determined that for one (R41) of one resident reviewed for grievance, the facility failed to promptly to initiate the replacement of lost dentures within three days after notification of loss.Findings include:5/14/25 - A facility-provided grievance form documented that FM1 reported R41's top dentures were missing. E14 (LPN) completed a room sweep and documented that the 11:00 PM - 7:00 AM shift would complete a second room sweep. The concern was reported to the Director of Nursing. The grievance included a note that a meeting with the Business Office to explore Medicaid eligibility for denture replacement.2/18/26 at 1:45 PM - During an interview, E15 stated she was unable to explain the extended timeframe for replacement of the dentures and was unsure why a meeting with the Business Office was required prior to proceeding with replacement. E15 further stated the events that occurred while she was on leave from the facility.2/18/26 at 1:53 PM - During a joint interview with E12 (Current Business Office Manager) and E15 (Social Worker), E12 confirmed the facility could have obtained dental services on a fee-for-service basis and was not required to wait for Medicaid eligibility determination prior to replacing the dentures.The facility failed to initiate the replacement of the lost dentures within three days of notification and did not document extenuating circumstances that would justify delay.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on record review and interview, it was determined that for three (R11, R14 and R15) out of six residents reviewed for unnecessary medication review, the facility failed to ensure for the medication regimen review (MRR) that irregularities identified were reviewed by the attending/designee. Findings include:A facility policy titled, Pharmacy Services – Drug Regimen Review, dated 5/1/25, documented, . the pharmacist will report any irregularities to the attending physician, the facility's medical director and the director of nursing . The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it . 1. Review of R15's clinical record revealed: 8/26/25 – R15 was admitted to the facility with a diagnosis including, but not limited to, hypothyroidism. 12/8/25 – A medication regimen review for R15 documented that charting omissions are noted for levothyroxine for 11/21/25. A nursing comment documented, Omitted? Not sure why, and was signed by E27 (UM). There was a lack of an attending or designee signature on the aforementioned medication regimen review document. 2/16/26 2:44 PM – During an interview, E26 (NP) stated that when the MRR is submitted to the facility, some of the recommendations can be added by the nurses. However, if the medication or frequency changes, they give it to the provider. The UM or DON gets the medication review and then gives it to us, the provider, to review. The surveyor noted the following irregularity: Charting omissions are noted for levothyroxine on 11/21/25. E26 stated that she would need to know that information. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON). 2. Review of R11's clinical record revealed: 6/20/25 - An MRR completed for R11 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 9/14/25 - An MRR completed for R11 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 10/19/25 - An MRR completed for R11 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 12/7/25 - An MRR completed for R11 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 1/14/26 - An MRR completed for R11 identified an irregularity. The MRR lacked evidence of review from an attending E4 (ADON) signed the comments section. 2/13/26 2:10 PM - During an interview with E4 (ADON) it was confirmed that all MRR's with irregularities were not reviewed by providers. 3. Review of R14's clinical record revealed: 4/6/25 - An MRR completed for R14 identified and irregularity. The MRR lacked evidence of review from an attending E4 (ADON) signed the comments section. 6/8/25 - An MRR completed for R14 identified an irregularity. The MRR lacked evidence of review from an attending E4 (ADON) signed the comments section. 10/16/25 - An MRR completed for R14 identified an irregularity. The MRR lacked evidence of review from an attending. 11/9/25 - An MRR completed for R14 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 12/7/25 - An MRR completed for R14 identified an irregularity. The MRR lacked evidence of review from an attending E27 (LPN) signed the comments section. 2/16/26 12:10 PM - During an interview E26 (NP) confirmed the findings, E26 reported that providers do not review all MRR's with documented irregularities, providers review irregularities after a referral from the nurses. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review and interview it was determined that for one (R11) out of six residents reviewed for unnecessary medication review the facility failed to ensure that an ordered as needed psychotropic medication extended beyond 14 days had a documented rationale and duration. Findings include:Cross refer F756The facility policy on Psychotropic drug use last updated 5/1/25 indicated PRN orders for psychotropic drugs are limited to fourteen days. Except if the attending physicians or prescribing practitioner believes that it is appropriate for the PRN order to be extended, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.Review of R11's clinical record revealed:1/22/25 - R11 was admitted to the facility with multiple diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety. 10/15/25 - A significant change MDS assessment documented that R11 was cognitively impaired and receiving psychotropic medications. R11 exhibited physical behaviors 4 - 6 days in a seven-day period. 10/16/25 11:32 - A progress note in R11's clinical record documented, Hospice nurse was in to visit. New [physicians] orders received from hospice for Lorazepam 6 hours PRN [for] anxiety/agitation. NP concurs with said orders hospice.10/16/25 - A physician's order was written for R11 to receive Lorazepam 0.5 MG every six hours as needed for anxiety. This order was extended on 10/23/25. The clinical record lacked evidence of a rationale for the extension.10/19/25 - An MRR for R11 documented A duration must be specified for PRN psychoactive [psychotropic] medications. First order is limited to only fourteen days, but if the rationale documented by the prescriber to continue order .Please update Lorazepam per CMS regulations. Note: There is no exception to this regulation for hospice patients. The MRR lacked evidence of review by an attending provider E27 (LPN) signed the comments section. 10/23/25 - A physician's order was written for R11 to receive Lorazepam 0.5 MG every six hours as needed for anxiety. This order was discontinued on 11/6/25.11/12/25 - A physician's order was written for R11 to receive Lorazepam 0.5 MG every six hours as needed for anxiety. This order was discontinued on 12/30/25.12/10/25 - A quarterly MDS assessment documented that R11 was severely cognitively impaired and receiving psychotropic medications. R11 exhibited physical behaviors daily in a seven-day period. 12/29/25 - A physician's order was written for R11 to receive one Lorazepam 0.5 MG every six hours as needed for anxiety. The order was extended 1/2/26. The clinical record lacked evidence of a rationale for the extension.1/2/26 - A physician's order was written for R11 to receive one Lorazepam 0.5 MG every six hours as needed for anxiety. This order was extended 1/22/26. The clinical record lacked evidence of a rationale for the extension.1/14/26 - An MRR for R11 documented A duration must be specified for PRN psychoactive [psychotropic] medications. First order is limited to only fourteen days, but if the rationale documented by the prescriber to continue order .Please update Lorazepam per CMS regulations. Note: There is no exception to this regulation for hospice patients. The MRR lacked evidence of review by an attending E4 (ADON) signed the comments section This is not a first order for this patient. 1/22/26 - A physician's order was written for R11 to receive one Lorazepam 0.5 MG every six hours as needed for anxiety. This order is listed as indefinite with no indicated duration. The clinical record lacked evidence of a rationale for the extension.1/22/26 - A psychiatric follow up note in R11's clinical record documented a rationale for extending provider 11's Lorazepam. The note did not contain a duration/end date. 2/13/26 11:19 AM - During an interview E22 (RN) stated that she was unaware of documented rationale to extend R11's order for Lorazepam or a duration. E22 stated the psychiatric team had discussed the residents continued anxious behavior. 2/13/26 11:52 AM - E1 (NHA) confirmed that the facility lacked evidence of rationale for extension of R11's Lorazepam except for the 1/22/26 psychiatric note.2/13/26 2:10 PM - During an interview E4 (ADON) confirmed review of the 1/14/26 MRR and that it was not given to a provider because the order was not new.2/16/26 12:08 PM - During an interview E26 (NP) confirmed the finding, E26 reported that R11's Lorazepam was reordered without duration and rationale because he's on hospice. E26 was unable to recall reviewing the MRR that addressed the extension of R11's Lorazepam. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on interviews, record review and review of other facility documentation it was determined that for one (R174) out of three residents sampled for discharge, the facility failed to ensure a referral for home health care services was completed prior to discharge. R174 was discharged to home on 8/12/25. R174's home health services did not begin until 8/20/25 eight days after discharge from the facility. Findings include:A facility policy titled Notice Requirements before Transfer/Discharge dated 5/1/25 documented The facility will provide sufficient preparation and orientation to residents to ensure an orderly transfer or discharge from the facility.A review of R174's clinical record revealed:7/28/25 - R174 was admitted to the facility with the following diagnoses: aortic valve replacement, aortic regurgitation, and congestive heart failure.8/11/25 - A review of R174's discharge summary documented, Discharge summary and post-discharge plan for home health aide, home health RN/LPN, occupational and physical therapy.8/12/25 - R174 was discharged to home with a family member.9/30/25 9:40 AM - A review of a complaint to the Division documented, [R174] was discharged to a family member's home without a home health care agency referral. Further review of the complaint documented that R174 had been in the home for one week and had not received any physical or occupational therapy and had not received a wellness check from a nurse.2/16/26 11:00 AM - During an interview, E15 (SW) reported, I would need to check if a referral was made for [R174].2/16/26 12:17 PM - During an interview, E15 confirmed R174's referral for home health and therapy services was not requested until 8/15/25. E15 then stated, [R174's] referral for home health care was opened for recommended services on 8/20/25.2/16/26 1:48 PM - During an interview, E35 (DT) reported, [R174] already had therapy equipment at home. E35 confirmed and stated, Physical therapy and occupational therapy were recommended for [R174]. E35 then reported, Typically, recommendations are communicated to social services to set up home care.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on record review and interviews, it was determined for three (R6, R17 and R43) out of sixty-seven sampled residents, the facility failed to ensure the MDS was accurate. Findings include:1.Review of R6's clinical record revealed:12/16/25 - R6 was admitted to the facility.12/20/25 - An MDS assessment documented that R6 had an infection of the foot.2/18/26 9:30 AM - During an interview, E33 (MDS Coordinator) and E34 (MDS Coordinator) confirmed that R6 was marked for an infection of the foot on the MDS assessment and stated they are coded with infection of the foot related to a fungal infection documented by the podiatrist. 2. Review of R17's clinical record revealed:1/8/26 - R17 was admitted to the facility.1/15/26 - An MDS assessment documented that R17 had an infection of the foot.2/18/26 9:30 AM - During an interview, E33 (MDS Coordinator) and E34 (MDS Coordinator) confirmed that R17 was marked for an infection of the foot on the MDS assessment and stated they are coded with infection of the foot related to a fungal infection documented by the podiatrist. 3. Review of R143's clinical record revealed:9/21/25 - R143 was admitted to the facility.11/11/25 - A quarterly MDS assessment documented that R143 had an infection of the foot. 2/18/26 9:30 AM - During an interview, E33 (MDS Coordinator) and E34 (MDS Coordinator) confirmed that R143 was marked for an infection of the foot on the MDS assessment and stated they are coded with infection of the foot related to a fungal infection documented by the podiatrist. The facility failed to ensure the MDS was accurate for R6, R17 and R143.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on interview and record review, it was determined that for four (R2, R9, R22, R41 and R46) out of forty-nine sampled residents the facility failed to revise the residents care plans to reflect their individualized needs. Additionally, it was determined that for R2 the facility failed to ensure that the resident and the resident representative were involved in developing the care plan. Findings include:1. Review of R2's clinical record revealed: 11/15/24 – R2 was admitted to the facility. 11/4/25 – A Brief Interview for Mental Status (BIMS) evaluation documented R2 with a score of 15 out of 15, showing an intact cognitive status. 2/9/26 9:27 AM – During an interview, R2 stated that he did not recall having quarterly care plan meetings since his admission. 2/10/26 – A review of R2's electronic chart documented a care conference meeting on 11/29/24, where R2 was present and no further meetings afterwards. Furthermore, the electronic chart for R2 documented a care plan completed on 3/10/25, 5/21/25 and 12/2/25. 2/16/26 8:50 AM – During an interview, E15 (SW) confirmed that R2's last care conference meeting was 11/29/24 and that there were no care conference meetings in 2025. There was a lack of evidence that R2 was involved in developing a care plan for 3/10/25, 5/21/25 and 12/2/25. 2. Review of R9's clinical record revealed: 3/17/23 - A physician's order was written for R9 to wear a right palm protector at all times, as tolerated, may use rolled gauze [wash cloth] if replacement unavailable. 12/8/25 - Reviews to R9's care plan for potential for further contractures related to impaired mobility and existing contractures was completed, the palm guard/replacement was listed as an intervention. The care plan lacked evidence of any potential refusals from R9 to wear the palm guard or a replacement such as a rolled washcloth or gauze. 2/9/26 10:00 AM - R9 was observed without a palm guard or replacement. R9 answered no when offered a palm guard/replacement. E19 (LPN) stated he usually refuses. 2/11/26 12:10 PM - R9 was observed without a palm guard or replacement. 2/16/26 1:13 PM - R9 was observed without a palm guard or replacement. R9 answered no when offered a palm guard/replacement. 2/16/26 1:17 PM - During an interview E18(CNA) confirmed that R9's palm guard/replacement was not in place and stated, I haven't seen the palm guard recently, but we use a washcloth then, he takes it out or sometimes says no. 2/16/26 1:25 PM - During an interview E23 (LPN) stated he gets the washcloth I have not seen the palm guard he takes them out. E22(RN) then immediately confirmed that R9's care plan for a palm guard should have been updated to reflect the residents' potential refusals. 3. Review of R22's clinical record revealed: 9/16/25 - A quarterly MDS assessment documented that R22 was cognitively impaired and dependent for bathing. 12/15/25 Annual MDS assessment documented that R22 was cognitively impaired and dependent for bathing. 12/29/25 - A review of R22's care plan for self-care deficit was completed. The care plan documented that R22 required set up assistance for bathing. 12/15/25 Annual MDS assessment documented that R22 was cognitively impaired and dependent for bathing. 2/12/26 2:28 PM - During an interview E24(CNA) confirmed that R22 was dependent for bathing and occasionally refuses care. E24 stated, She needs me to pretty much do everything now for her now. She hasn't been able to without help in a while. 2/12/26 2:28 PM - During an interview E3 (DON) confirmed the finding and stated she would revise R22's care plan to include the R22's dependence for bathing. 4. Review of R41's clinical record revealed: 11/3/25 - A quarterly MDS assessment documented that R41 was cognitively impaired and dependent for bathing. 11/17/25 - R41's care plan for self-care deficit was reviewed by the facility and indicated that R41 required one person to assist them with bathing. The care plan lacked documentation of R41's dependance for bathing. 2/18/26 12:19 PM - During an interview E4 (ADON) confirmed the facility failed to ensure that R41's self-care deficit care plan was revised to reflect residents' dependence for bathing. 5. Review of R46's clinical record revealed: 10/27/25 R46's behavior care plan for safety hazard to others as evidenced by resident is combative during care, attempts to hit staff with bed remote and call bell was created. 1/13/26 - A quarterly MDS assessment documented that R46 was cognitively impaired and had physical behaviors four to six times in a seven-day period. 1/13/26 - An incident report was submitted to the State Agency that alleged R46 aggressed another resident during an altercation when R46 swung a television remote and hit another resident. 1/19/26 - A five day follow up to the previous incident report was submitted that documented, care plans were reviewed. 2/12/26 - Review of R46's behavior care plans lacked evidence of revision to include R46's new behavior of an attempt to hit residents. 2/12/26 1:37 PM - During an interview E3 (DON) confirmed that the facility failed to revise R46's behavioral care plan to include the new potential for resident-to-resident altercations. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on observation, interview, and record review, it was determined that for one (R131) out of one resident reviewed for ADL (Activities of Daily Living), the facility failed to provide ADL care for dependent residents. Findings include Review of R131's clinical record revealed:3/12/25 - R131 was admitted to the facility with a diagnosis of stroke infarction, affecting the right side.12/3/25 - A quarterly MDS assessment documented that R131 was dependent on staff for bathing and dressing.12/15/25 - A review of R131's care plan for ADL's documented that the resident is dependent for ADL care. The care plan did not include a refusal of nail care. 2/9/26 9:00 AM - An observation revealed that R131's left and right hands had long fingernails, and there was black debris under the fingernails of his right hand.2/10/26 10:00 AM - An observation revealed that R131's left and right hands had long fingernails, and there was black debris under the fingernails of his right hand. 2/11/26 12:51 PM - During an interview, E10 (CNA) stated that when she gives a bath, she washes the resident and does hair and nails. R131's bath days are Mondays and Thursdays. 2/11/26-1:00 PM - During an interview, E5 (UM) confirmed that the 3:00 PM to 11:00 PM shift documented that R131 received his bath, R131's left and right hands had long fingernails and that his fingernails on the right hand had black debris underneath.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review and interview it was determined that the facility failed to the ensure the Medical Director fulfilled his/her responsibility of ensuring implementation of the Drug Regimen Review policy to be consist with current professional standards of care regarding provider documentation in response to identified irregularities. Findings include: Cross refer F756The facility job description for responsibilities of the medical director indicated, Provider Supervision and &Consultation: Provide guidance and education to physicians, nurse practitioners, and physician assistants regarding best practices in long-term care. Policy Development & Implementation: Ensure compliance with federal, state, and local healthcare regulations, including CMS and CDC guidelines.The facility policy on Drug Regimen Review last updated 5/1/25 indicated, The attending physician must document in the residents medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it.2/18/26 8:52 AM - During an interview E2 (ROD) confirmed that the facility's Medical Director was not ensuring provider compliance with the drug regimen review policy. E2 stated, Our DON position reviews them and then notifies the provider, but we will be changing that.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on observation, interview and record review it was determined that for one (R183) out one resident sampled for respiratory care, the facility failed to provide professional standards of practice. Findings include:A review of R183's clinical record revealed:1/31/26 - R183 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure.2/7/26 - An initial MDS documented that R183 was moderately impaired BIMS 11.2/10/26 - A physician's order for R183 documented place nebulizer face mask after each use in a plastic bag.2/15/26 - A review of the treatment administration record lacked evidence of an order directing that the mask and tubing be stored in a protective plastic bag when not in use.2/9/26 at 11:35 AM - An observation revealed that R183's oxygen tubing was on the floor, and not in a protective plastic bag. The nebulizer face mask was on the bedside table and not in a protective plastic bag.2/10/26 at 9:00 AM - An observation revealed that R183's oxygen tubing was on the floor and not in a protective plastic bag. The nebulizer face mask was on the bedside table and not in a protective plastic bag.2/10/26 AM 10:30 AM - During an interview, E5 (LPN) confirmed that oxygen tubing and a nebulizer face mask are required to be stored in a protective plastic bag when not in use. E5 immediately placed the oxygen tubing and mini neb into a protective plastic bag.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on record review and interview, it was determined that for one (R141) out of one resident reviewed for pain, the facility failed to provide pain management according to professional standards of practice Findings include:Review of R141's clinical record revealed:[DATE] - R141 was admitted to the facility with a diagnosis of spondylopathy cervical region and muscle weaknessXXX[DATE] - A quarterly MDS assessment documented that R141was alert and oriented. Additionally, the MDS documented that R141 had painXXX[DATE] - A baseline care plan was initiated for potential for pain and actual for spinal stenosis of the cervical region, mobility impairment, spondylopathy, and chronic pain syndromeXXX[DATE] - A progress note revealed R141 had a surgical cervical fusionXXX[DATE] - A physician's order for oxycodone 5 mg, take 2 tablets by mouth as needed for pain for 14 days. The order was discontinued [DATE]XXX[DATE] - A physician's order was reissued for Oxycodone 2 tablets 5mg by mouth for chronic pain as needed for painXXX[DATE] 4:40 AM - A review of R141's MAR (Medication Administration Record) revealed oxycodone 5mg, take 2 tablets by mouth, was not givenXXX[DATE] 7:10 AM - A progress note documented E3 (DON) was called to R141's room, R141 was complaining of neck pain, and the pain level was 7 of 0-10 pain scale. The nurse practitioner was made aware, and a new order was received to give Oxycodone 2 tabs 5 mg by mouthXXX[DATE] 9:45 AM -During an interview, R141 stated experiencing significant pain throughout the night and specifically requested her prescribed oxycodone for pain and was told by E7 (RN) they did not have it. [DATE] 4:40 AM - A late entry progress note by E7 (RN) documented not given. E7 called the provider for an order for Oxycodone 5mg 2 tabs by mouth so they can pull the medication out of the Pyxix but was unsuccessful. [DATE] 9:32 AM - An interview with E7 confirmed the prescription expired for R141's oxycodone on [DATE] and failed to get a new order to use back-up pain medication at the facility to treat R141's pain. [DATE] 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review, interview and review of other facility documentation, it was determined that for one (R3) out of one sampled residents reviewed for dialysis, the facility failed to monitor R3's dialysis catheter and failed to complete R3's before (pre) and after (post) dialysis assessments. Findings include: Review of R3's clinical record revealed:12/18/25 - R3 was admitted to the facility.12/19/25 - A care plan documented R3 needs dialysis related to renal failure with the following interventions: encourage resident to go for scheduled dialysis appointments; monitor/document/report any sign and symptoms of infection to the access site: redness, swelling, warmth or drainage; monitor/document/report signs and symptoms of renal insufficiency: change in level of consciousness, changes in skin turgor, change in heart or lung sounds; monitor/document/report signs and symptoms of the following: bleeding, hemorrhage, bacteremia or septic shock.12/25/25 - An admission MDS documented that R3 was receiving hemodialysis and dependent for ADL's. 12/26/25 - A physician's order documented R3 dialysis appointment Monday, Wednesday and Friday transport via stretcher. 2/12/26 - A review of physician's order lacked evidence of an order to assess R3's dialysis catheter. 2/12/26 1:01 PM - During an interview, E20 (LPN) stated the expectation is for the nurse to complete a pre and post dialysis assessment on R3, including assessment of the dialysis catheter. E20 confirmed pre and post assessments should be completed and documented in a progress note in the medical record. 2/12/26 - A review of the progress notes and assessments in R3's medical record lacked evidence of pre and post dialysis assessments. A review of the dialysis assessment revealed an assessment of the dialysis port or catheter is included. 2/12/26 1:15 PM - During an interview, E17 (UM) confirmed the expectation is to assess R3 before and after dialysis and the progress notes lacked evidence of those assessments being completed.2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on observation, interview and record review, it was determined that for two (R2 and R56) out of 2 sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include:A facility policy and procedure titled, Dental Services, dated 5/1/25, documented, It is the policy of the facility to accommodate needed dental services, including routine dental services; to ensure the facility provides the assistance needed or requested to obtain these services. The facility will, if necessary or if requested, assist the resident: a. Making appointments . 1. Review of R2's clinical record revealed: 11/15/24 – R2 was admitted to the facility. 11/25/24 – A care plan was initiated for R2 with broken/carious teeth, including interventions to coordinate dental care and transportation as needed. 11/4/25 – The annual MDS assessment documented that R2 was cognitively intact and had obvious or likely cavity or broken natural teeth. 2/9/26 9:28 AM – During an observation and interview, R2 stated that they have had broken teeth and has told the facility that he wanted them pulled since he was admitted . R2 stated he has not seen a dentist since arriving at the facility. An observation was made of missing teeth, broken teeth on the bottom right, and miscolored teeth and gums. 2/16/26 9:25 AM – During an interview, E5 (UM) stated that if a resident has a broken tooth, abscess, or dental pain, the Nurse Practitioner would assess them if medication is needed, then let the social worker know to see if they are part of the facility's dental program. If they are not part of the program, then they can schedule the resident to go outside the facility. 2/16/26 10:08 AM – During an interview, E15 (SW) explained that if a resident is interested in the facility's dental program, they can request information from anyone, specifically mentioning her or the business office. The request is then sent via fax to the dental program. E15 confirmed that R2 was not enrolled in the facility's dental program and had no dentist appointment. 2/17/26 – An oral cavity assessment for R2 documented that he had some natural teeth lost and has broken, loose, or carious teeth. There was a lack of evidence of any routine dental consultation since 11/15/24. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON). 2. Review of R56's clinical record revealed: 10/24/23 - R56 was admitted to the facility. 11/6/23 - A care plan documented that R56 had dental health problems related to poor oral hygiene with broken carious teeth with the following interventions: coordinate arrangements for dental care; diet as ordered; monitor, document, report any oral dental problems needing attention; provide mouth care as per ADL personal hygiene. 10/9/24 - A progress note documented R56 had a new patient dental exam. 2/09/2026 11:37 AM - During an interview, R56 stated he had not seen the dentist and was interested in a cleaning. 2/16/26 2:45 PM - During an interview, E15 (SW) stated when a resident verbalizes they are interested in dental services she will send the documents over to the dental office. E15 stated that caseworkers for insurance provider are responsible to offer services to the residents and she just sends the paperwork over to dental office. E15 provided a list of resident's receiving dental services and confirmed that R56 was not on the list to receive services and did not have an appointment on 10/1/25 or 11/24/25 when the dentist was at the facility. 2/16/26 3:00 PM - During an interview, E32 (Unit Clerk) stated she was responsible to set up transportation if the resident utilizes an outside dental provider. E32 confirmed that R56 does not have an outside provider for dental. The facility failed to assist R56 in obtaining routine dental care since 10/9/24. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD) and E3 (DON).

Based on record review and interview it was determined that for one (R11) out of six residents reviewed for unnecessary medication review the facility failed to ensure that the resident was free from unnecessary medications. Findings include: Review of R11's clinical record revealed: 9/23/25 - A physician's order was written for R11 to receive Metoprolol, a blood pressure medication one time a day for hypertension, hold for systolic blood pressure greater than 130 or heart rate less than sixty. October 2025 - Review of R11's MAR revealed that nineteen out of thirty-one doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. November 2025 - Review of R11's MAR revealed that twenty-five out of thirty doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. December 2025 - Review of R11's MAR revealed that eleven out of thirty-one doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. January 2026 - Review of R11's MAR revealed that nine out of thirty-one doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. 2/9/26 - A physician's order was written to discontinue R11's Metoprolol. 2/16/26 12:08 PM - During an interview E26 (NP) confirmed the finding, E26 reported, I discontinued the medication in February because with low blood pressure it was no longer appropriate. E26 was not made aware of the frequency that R11's Metoprolol was held and stated, If I would have been notified of the holds, I would have discontinued it at that time. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on interview, record review and review of other documentation as indicated, it was determined that for one (R2) out of seven residents reviewed for abuse the facility failed to ensure residents were free from abuse. R2 was found on the floor of his room, with R1 standing over him, and sent to ER for a head injury. This failure resulted in physical harm (R2) and psychosocial harm as the reasonable person would be adversely affected by being attacked in their home. Findings include:Cross refer F609 and F740.Review of R1's and R2's record revealed:7/1/25 - R2 was admitted to the facility.7/28/25 - R1 was admitted to the facility.8/12/25 - A care plan was initiated for R1 documenting socially inappropriate behavior as evidenced by verbal aggression toward staff and other residents. Interventions included ensuring safety, reminding the resident that behavior was inappropriate, and attempting to redirect with activities or preferred snacks.10/15/25 - A quarterly MDS assessment documented that R2 had a BIMS score of 7 indicating severe cognitive impairment and required the assistance of one staff for most ADLs.10/21/25 10:45 PM - A progress note documented that R1 was having increased agitation and that redirection was unsuccessful. R1 was described as persistently aggressive, pushing staff, and barricading the door with items while physically holding the door shut. The on-call provider was notified and R1 was sent to the ER.10/22/25 2:18 AM - A progress note documented that R1 returned from the ER with no new orders.10/22/25 8:45 PM - A progress note documented that R1 was extremely agitated and anxious, was pacing hallways, combative with staff, exit seeking, and banging on doors. Staff were advised to call the on-call provider if behaviors continued.10/23/25 1:00 AM - A provider note documented that R1 was evaluated for follow-up after the ER visit for aggressive behaviors and that no new orders were issued.10/26/25 6:00 AM - A progress note documented that R1 was arguing loudly with roommate R2. Staff reported that behaviors between the two residents had markedly increased within the last week, and that both residents became overly fixated and verbally assertive or aggressive, requiring separation and staff redirection to calm.10/28/25 - A quarterly MDS assessment documented that R1 had a BIMS score of 4 indicating severe cognitive impairment and demonstrated physical aggression toward others, verbal aggression, and other behavioral symptoms during the review period. The MDS documented that R1 was not receiving psychological therapy services.10/29/25 7:45 AM - A progress note documented that R1 was confused and became aggressive with staff, pushing and grabbing, refusing vital signs, and stating he would call 911 because of his roommate. R1 was documented as walking room to room without a shirt until 3:00 AM.10/29/25 at 10:14 AM, a progress note documented that R1 was arguing with the nurse and was frantic, hiding and collecting trash in the room.10/30/25 11:21 AM - A behavior charting progress note documented that R1 remained out of his room to avoid arguments with R2.10/30/25 6:22 PM - A progress note documented that R1 was verbally aggressive with staff.11/1/25 3:02 PM - A behavior charting progress note documented that R1 was pacing up and down the hallways, asking for a way out, and required redirection to the dining room.Despite repeated documentation from 10/21/25 through 11/1/25 of R1's escalating agitation, aggression, exit-seeking, and continual conflict with his roommate, the facility did not revise R1's care plan, reassess the risk posed by the roommate pairing, increase supervision, obtain behavioral health services, or implement interventions to prevent foreseeable harm.11/2/25 6:58 PM - A facility incident report documented that R2 was found on the floor after an unwitnessed resident-to-resident altercation. R2 was noted to have a contusion to the back of the head and required transport to the hospital for evaluation.11/2/25 7:25 PM - A nursing progress note documented that R1 was heard yelling down the hallway. Staff observed R1 standing over R2, who was on the floor following the altercation.11/2/25 9:01 PM - A hospital progress note documented R2 had a contusion to the back of the head and strain of neck muscle.11/2/25 10:50 PM - R2 was readmitted to the facility post hospital evaluation with diagnosis of head injury and strain of neck muscle.11/3/25 7:00 AM- A progress note documented that one-to-one (1:1) supervision was initiated for R1.11/3/25 8:09 AM - A hospital x-ray report documented that R2 had a scapholunate ligament (ligament in wrist) injury suspected to left wrist.11/3/25 2:09 PM - A progress note documented that the IDT team discussed the 11/2/25 incident and confirmed that R1 was placed on 1:1 supervision starting at 7:00 AM.11/3/25 4:00 PM - A room change form documented that R1 was moved to another room due to the 11/2/25 incident.11/3/25 4:14 PM - A progress note documented that the ADON (E3) consulted with the NP (psych) regarding R1's behavioral changes. The facility lacked evidence that a psych consult actually occurred.11/4/25 5:09 PM - An electronic training text message documented: Staff must promptly recognize and report roommate conflict for resident safety. ID signs of conflict inc. dementia-related behaviors, report concerns to DON or NHA ASAP, and use approved interventions: redirect, de-escalation. Social Work Support, increased monitoring, or room changes when safety cannot be maintained.11/7/25 9:45 AM - E9 (CNA) stated during an interview that R1 had been having increasing behaviors and confirmed that on 11/2/25, R1 hit R2, causing R2 to fall and sustain a head injury that required transport to the ER. E9 stated that the behaviors leading up to the event had been ongoing and that staff had difficulty redirecting R1.11/7/25 11:43 AM - E6 (CNA) stated during an interview that R1 and R2 had verbal conflict prior to the incident on 11/2/25. E6 stated that R1 pushed R2 on the floor during the incident and R2 had to be sent to the ER for evaluation.11/7/25 1:53 PM - R2 stated during an interview that R1 told him that he [R2] could no longer live in their room cause the other bed belonged to his wife. R2 stated that R1 threatened to kill him [R2] if he did not move out of the room. R2 stated he was scared of R1 and was glad he no longer shares a room with him. R2 also stated that he was scared for his wife to come visit the facility because he would not want R1 around his wife. R2 stated that if R1 was still living in the room he would be skeptical and feel the need to keep something in his hand for protection and also stated if R1 was in the dining room he would not eat there at the same time and leave.11/12/25 10:00 AM - E7 (CNA) stated during an interview that behaviors between R1 and R2 had been escalating and that staff had been unable to redirect R1 during the aforementioned time period.11/12/25 2:30 PM - E9 (CNA) and E14 (CNA) stated during an interview R1 and R2 were good friends until mid October 2025, when R2 was diagnosed with Covid and had to move into a different room. R1 was very confused during this time and started showing behaviors towards R2.11/12/25 2:35 PM - E12 (LPN) stated during an interview when R2 was moved for isolation, R1 became increasingly confused and thought the other bed in their room was for his wife. E12 stated that R1 and R2 had multiple verbal altercations during this time. E12 confirmed that altercations were only verbal until 11/2/25.11/12/25 2:45 PM - E15 (LPN) stated during an interview that R1 and R2 were having verbal altercations between 10/21/25 and 11/1/25. E15 stated the process is to notify the social worker when verbal and physical altercations occur and E15 stated the facility usually moves a resident if altercations become physical. E15 stated that during this time she did not notify the social worker of the verbal altercations or feel that R1 needed to be moved.11/12/25 3:00 PM - E4 (SW) stated during an interview that she was not informed of any verbal altercations prior to the 11/2/25 incident and confirmed once the incident occurred R1 was moved from the shared room.11/13/25 10:56 AM - E7 stated during an interview that R1 was moved to a different room after the physical altercation on 11/2/25. E7 stated that R1 was vocal about his concerns regarding R1 and anytime he was near R2 would make statements saying there is the man [R1] who pushed me down and he is too close to me.The facility failed to recognize escalating verbal altercations between R1 and R2, with lack of interventions the verbal altercations became physical on 11/2/25. The physical altercation resulted physical abuse, R2 requiring hospitalization for injuries sustained and feelings of psychosocial harm. R2 had feelings of fear related to R1 related to being attacked in his own home.The facility had in-service training via electronic communication that started on 11/4/25 and was completed on 11/5/25. Additionally, the facility completed an in-person education that was initiated on 11/4/25 and provided signature sheets for all staff who completed. A roommate evaluation was completed on six residents with potential conflict and was concluded on 11/6/25 per documentation. Based on the review of the facility's investigation, documented response, completion of training via electronic communication and in-person, resident interviews and evaluation, implementation of R1 on 1:1 supervision, and staff interviews, the incidents related to E1 and E2 were determined to be past non-compliance. The plan of correction was initiated on 11/4/25 and completed on 11/5/25. 11/14/25 3:15 PM - Findings were reviewed with E1 (Corporate NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on record review and interview, it was determined that the facility failed to provide pain management according to professional standards of practice for one (R97) out of three residents sampled for pain. R97 was not provided pain medication causing unrelieved pain for approximately six hours resulting in harm. Findings include: November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant. April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. Review of the facility's Policy and Procedure titled: Pain Management Program, effective date 4/1/20, stated, . Purpose: Promote recognition and intervention to manage pain at the individual's goal or tolerance level to promote the highest quality of life practible (sic) . The goal of the interdisciplinary team is to promptly identify pain and develop an effective individualized Pain Management Plan . When a resident arrives at a center, a licensed nurse completes a comprehensive assessment of the resident using the nursing assessment form. When the nurse determines the need to look further into the resident's condition related to pain a comprehensive Pain Evaluation enables the licensed nurse to gather information regarding location, onset, and duration; Pain intensity and description . Controlled Pain Management Program is a static program that has been developed and tested to meet the resident's needs, and that manages (controls) the resident's pain when implemented properly . Cross refer F656. Cross refer F842. Review of R97's clinical record revealed: 3/10/22 - R97 was admitted to the facility with a diagnosis of Spinal Stenosis (a condition that painfully compresses the nerves to the lower back and legs) 3/10/22 - A comprehensive pain assessment revealed the resident had pain in the last five days, occurring frequently, and it was affecting her sleep and day to day activities. The comprehensive pain assessment lacked the location, type of pain (acute or chronic), and non pharmacological and pharmacological interventions. 3/10/22 - A baseline care plan initiated for chronic pain related to Spinal Stenosis (lower back pain) had a goal of 0 out of 10 pain (using scale of 0 being no pain and 10 being the worst possible pain). Interventions included to evaluate for the presence/ absence of chest pain, but failed to include interventions specific to pain with spinal stenosis. 3/10/22 - A baseline care plan initiated for potential for pain related to impaired mobility with a goal of pain to be controlled to an acceptable level of 0 out of 10. Interventions included: assess for and address pain prior to, during and after treatments; administer pain medications as ordered; report and document complaints of pain and/or nonverbal signs of pain; reposition as needed for comfort. 3/15/22 - An admission MDS assessment documented that R97 was alert and oriented. Additionally, the MDS documented R97 had pain, frequently, limiting day to day activities, pain scale 8 (very severe) out of 10. The MDS triggered the CAA (Care Area Assessment) for pain and triggered to initiate a care plan. 4/4/22 - A Physicians order for Acetaminophen tablet 500 mg give 1 tablet by mouth every 6 hours as needed for pain/discomfort. Gabapentin 300 mg by mouth every 8 hours for low back pain. 4/5/22 - A review of Physician's orders revealed an order for Voltaren Gel 1% (pain relieving cream) apply to low back topically four times a day for low back pain. 4/22/22 - A Physicians order for Oxycodone (an opioid pain medication sometimes called a narcotic; used to treat moderate to severe pain) tablet 15 mg give 1 tablet by mouth every 6 hours for pain. 4/28/22 - A Physicians order revealed an acceptable pain level for R97 of 0 out of 10 every shift. 5/26/22 8:29 PM - Review of progress notes revealed a PRN (as needed) Tramadol (pain reliever) was adminsitered for a pain level 8 out of 10. 5/27/22 12:00 AM - Review of MAR (Medication Administration Record) revealed Oxycodone 15 mg was not given, a code of 7 (meaning sleeping) for reason. 5/27/22 1:12 AM - A progress note revealed PRN administration of Tramadol was effective. 5/27/22 1:50 AM - Review of the Individual Controlled Substance record for R97 revealed routine Oxycodone 15 mg was unavailable and one dose (three 5 mg tablets) was removed from the emergency box. 5/27/22 2:15 AM - A progress note documented that Oxycodone 15 mg (12 AM dose) was not administered. R97 had prn pain med earlier and is currently asleep. The MAR documented a code of 7. 5/27/22 6:00 AM - Review of the MAR revealed the 6:00 AM dose of Oxycodone 15mg was administered from the Emergency box. 5/27/22 12:15 PM - Review of the Individual Controlled Substance record for R97's routine Oxycodone 15 mg was unavailable and one dose (three 5 mg tablets) from the emergency box was removed. This left no more back up doses in the emergency box. 5/27/22 5:35 PM - Review of the MAR documented PRN Tramadol was administered with a pain score of 8 out of 10. 5/27/22 6:00 PM - Review of the MAR for Oxycodone revealed a code of 5 which signified Hold/ See progress notes. 5/27/22 6:19 PM - A progress note documented Oxycodone not administered due to waiting for delivery from the pharmacy. 5/27/22 6:30 PM - A Physician's Order was written to hold Oxycodone 5mg (incorrect dose) one dose for chronic pain. The facility failed to ensure the resident's routine Oxycodone was acquired, thus, the resident was not administered her medication at 6:00 PM. In addition, the facility failed to obtain an accurate order from E25 (MD) to hold the Oxycodone 15 mg. 5/27/22 9:32 PM - A progress note documented a post (after) pain assessment scale of 5 out of 10 from the PRN Tramadol dose at 5:35 PM. 5/27/22 10:57 PM - Acetaminophen (used to treat mild pain and fever) was administered for a pain level of 10 out of 10. 5/27/22 11:12 PM - Review of the MAR documented that PRN Tramadol was given for a pain level of 10 out of 10. 5/27/22 Untimed - Review of the MAR documented that R97 verbalized a pain level of 10 out of 10 during the night shift assessment. 5/28/22 12:00 AM - Review of the MAR for Oxycodone documented a code of 9 or Other/See Progress Notes. 5/28/22 1:12 AM - A progress note documented a post assessment pain score of 10 out of 10 after administration of Acetaminophen and Tramadol. Despite R97's pain being at 10 out of 10, the facility failed to consult the attending physician for alternative pain relief and failed to obtain Oxycodone from a pharmacy. 5/28/22 1:46 AM - A progress note documented (Oxycodone) En route from pharmacy. 5/28/22 4:45 AM - Review of the MAR documented Oxycodone 15 mg was administered ten hours and forty five minutes after the dose oxycodone. 5/28/22 6:00 AM - Review of the MAR documented that routine Oxycodone 15 mg was administered, despite being administered one hour and fifteen minutes before. 5/28/22 Untimed - Review of the MAR shift pain assessment documented that R97 verbalized a pain level of 8 out of 10. 1/30/23 10:30 AM - An interview with E5 (RN) revealed that the facility was unable to obtain Oxycodone on 5/27/22 and she was advised by the off going shift to give Oxycodone as soon as it was available. 1/30/23 11:40 AM - Review of findings with E2 (DON) confirmed that the facility ran out of the Oxycodone on 5/27/22 and should have consulted the on call provider regarding the ineffective pain medication administered in the absence of Oxycodone. At this time, E2 (DON) confirmed that the facility failed to provide medication to control R97's pain resulting in six hours of severe uncontrolled pain rated at a level of 10 out of 10. 2/1/23 - Beginning at 1:45 PM - Findings were reviewed with E1 (NHA), E2 and E4 (Corporate) during the Exit Conference.

Based on record review and interview, it was determined that for one (R1) out of three residents sampled for medication errors, the facility failed to ensure that medications were administered in accordance with the 5 rights of medication administration, causing a significant medication error that resulted in an emergent transfer to the hospital and intubation. Findings include: According to Medline Plus (last updated 1/12/20), medication administration includes the following components: right medicine; right dose; right patient; right time; right route; right documentation; right reason; and right response. Review of the facility General Dose Preparation and Medication Administration policy (revised on 1/1/13) documented the following: .4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1.1 Verify each time a mediation is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 5.1 Identify the resident per Facility Policy . 11/16/2012 - R1 was admitted to the facility. 11/18/19 - A care plan documented, Resident prefers not to wear ID (identification) name band. 6/16/20 - The annual MDS documented that R1 had a BIMS score of 99, signifying that R1 was unable to complete the interview. It also confirmed the following active Diagnoses: [REDACTED]. 8/23/20 at 10:15 AM - R1's vital signs were recorded: Temperature: 97.7; blood pressure (BP): 130/68; pulse: 78; respirations: 18; pulse oximetry: 97% on room air. 8/23/20 at 10:30 AM - R1's vital signs were recorded: BP: 88/52 (low); pulse: 74; respirations: 18. 8/23/20 at 10:30 AM - A nursing note written by E4 (RN Supervisor) documented, (provider group name) on call notified of resident receiving incorrect medications. New orders received for resident to have vital signs every 15 minutes for 12 hours and monitor resident for any changes in functional/neuro status. Resident is awake and at her baseline neurologically and functionally. Currently out in the common area sitting at a table with activities. Daughter-in-law made aware of the situation and plan of care. 8/23/20 at 10:45 AM - R1's vital signs were recorded: low BP: 84/42; pulse: 74; respirations: 17; pulse oximeter: 96% on room air. 8/23/20 at 11:04 AM - A nursing note written by E6 (RN Preceptor) confirmed that R1 has had a decrease in blood pressure to 84/42. Remains alert and awake and in no other distress. Returned to bed with staff assist x2 (times two) and supervisor notified. 8/23/20 at 11:17 AM - A nursing note written by E4 (RN Supervisor) stated that R1 had a drop in her systolic blood pressure (top number of BP) with vital signs check. Placed in a supine position (lying on back) and I was notified. On call (provider group name) was notified and order received to send resident to the ED (Emergency Department) for further treatment. 911 was notified. (Name of ED staff) in the ED was given report. Daughter-in-law was notified. 8/23/20 at 11:17 AM - The Resident Transfer Form documented the following: ED transfer [MEDICAL CONDITION]; Resident was hypotensive; abnormal vital signs; No devices or special treatments (being used). 8/23/20 at 11:17 AM - R1 left the facility. BP upon departure was 128/72 with pulse oximeter at 96% on room air. 8/23/20 at 11:32 AM - The Facility Event Report documented that a medication variance was identified on 8/23/2020 at 10:10 AM pertaining to an incorrect medication and incorrect resident, as follows: Resident received incorrect medications prescribed for another resident. On call PA issued orders for vital signs every 15 minutes for 12 hours and to monitor resident for any changes in functional/neuro status. This report further documented that R1 was awake and at her baseline neurologically and functionally. 8/23/20 (untimed) - An employee Statement signed by E2 (DON), E4 (RN Supervisor) and E5 (RN Orientee) documented that the medications for R2 ([MEDICATION NAME], Klonopin and Tylenol) were placed in a pill bag and crushed and added to pudding, per order. E6 (Preceptor) pointed out R2 to E5 (RN orientee) and described R2 as wearing her hair in a bun and leaning forward. E5 went to R1, who was sitting at a closer table also was leaning forward and wearing her hair in a bun. Before E6 could intervene, E5 administered R2's medications to R1. 8/23/20 (untimed) - A statement by E5 (RN Orientee) documented that Preceptor pointed to resident and stated resident had her hair in a bun and leaning forward. I walked toward a resident with bun in hair and leaning forward and gave resident her medication without any problems. My preceptor was reviewing process and looked over and came over and notified me that it was not R2 (intended resident). 8/24/20 (untimed) - An employee Statement prepared by E7 (RN) documented that when emergency personnel arrived at approximately 11:00 AM, R 1 was sleeping in bed, arousable to verbal and tactile stimulation, resisted blood pressure cuff and muttered leave me alone Pt had eyes open, appeared sleepy but remained arousable. Review of hospital records documented: 8/23/20 at approximately 2:30 PM - R1 was intubated. 8/23/20 at 5:42 PM - Nursing Procedure: Communication documented the following: Patient was given another patient's morning medications, including [MEDICATION NAME] 100 mg, [MEDICATION NAME] 1 mg and [MEDICATION NAME] ([MEDICATION NAME]) 4mg. Spoke with Poison Center Coincidentally, the patient is already on an antipsychotic and thus is not naïve to such medications . Subsequent call made after facility confirmed that R1 is not 'chronically on benzodiazepines.' Poison Center states to provide supportive care and intubation to protect airway per MD. 8/24/20 - Admission Information from the hospital where R1 was transferred documented the following: (R1) was brought to the emergency room because of altered mental status . Per emergency room (ER) report, patient was given oral medication which includes 100 mg of [MEDICATION NAME], 1 mg [MEDICATION NAME], 4 mg [MEDICATION NAME] . ER attending had decision to emergently intubate the patient for airway protection and prevent respiratory arrest. 8/24/20 - A History and Physical Report documented the following Impressions: acute [MEDICAL CONDITION] secondary to medication overdose, intubated and on mechanical ventilation; medication overdose incidental; acute kidney injury; [MEDICAL CONDITION] mild; advanced dementia noncommunicative; history of [MEDICAL CONDITION]; history of [MEDICAL CONDITION]; history of hypertension. 8/24/20 (untimed) - R1 was extubated. 8/26/20 - The Hospital Course contained in the discharge documentation that the patient was intubated . due to acute [MEDICAL CONDITION] secondary to medication overdose unintentional. Patient also had acute kidney injury, urinary tract infection and also treated for [REDACTED]. The Discharge [DIAGNOSES REDACTED]. Accidental medication overdose causing [MEDICAL CONDITION] and [MEDICAL CONDITION] requiring intubation. Now back to baseline. Will return to SNF. 2. Aspiration pneumonia; 3. Acute [MEDICAL CONDITION] requiring intubation. Resolved. Did well post extubation on 8/24/20; 4. Urinary tract infection; 5. Acute [MEDICAL CONDITION], on top of [MEDICAL CONDITION]. Resolved no back to baseline; 6. Acute Kidney Injury, resolving; 7. Elevated transaminase level, resolving. 8/25/20 at 11:55 AM - An interview with E2 (DON), E3 (VP of Operations), and E4 (RN Supervisor) confirmed that R1 was intubated at the hospital for airway protection. R1 was intubated on 8/23/20 and extubated on 8/24/20. E3 confirmed that R1 does not typically take the medications that were administered to R1 in error. 8/25/20 at approximately 1:45 PM - Interview with E1 (NHA) acknowledged that the medication error occurred due to resident identifier not being used. E1 stated that some residents or their responsible parties choose to not have the resident wear an identifier bracelet. This decision was documented in the care plan. E1 also confirmed that if a resident was not wearing an identifier that nurses must sign off in the EMAR that they acknowledge this fact. E1 further confirmed that he reported E5 (RN Orientee) to the Division of Professional Regulation as a result of the medication error. 8/25/20 at approximately 2:25 PM - During an interview, E2 (DON) clarified several vital signs for the surveyor and stated that she often reminded her staff of the importance to slow down and not multi-task. She stated that the facility's investigation was initiated immediately. E2 confirmed that E5 resigned and no longer worked at the facility. 8/26/20 (untimed) - R1 returned to facility. 8/26/20 at 2:30 PM - An email from E1 (NHA) confirmed that there was a picture of each resident in the EMAR, regardless of whether the resident had an identifier bracelet. E1 further confirmed that approximately 40% of all residents have an identifier bracelet and this preference was discussed at the resident's care plan meeting. 8/26/20 at 4:18 PM - An email from E2 (DON) supplied the following materials: Timeline of interventions following the medication error on 8/23/20; Process Improvement education for medication administration during orientation; medication event checklist, medication administration competency checklist, Resident Identification policy (revised 8/24/20); Process Improvement: medication administration and nursing orientation; orientation schedule; nurse orientee evaluation; facility orientation evaluation; and a poster depicting the 5 rights of medication administration. As a result of the failure to ensure that medications were administered in accordance with the 5 rights of medication administration, the facility failed to prevent a significant medication error. Findings were reviewed with E1 (NHA), E2 (DON), E3 (Regional Director of Clinical Operations), E8 (Managing Partner), E9 (Regional Director of Operation) at the exit conference on August 28, 2020, beginning at 10:30 AM.

Based on observations, interviews, a review of a clinical record and relevant facility documents, it was determined that the facility failed to provide adequate staff supervision, ensure that all doors in the secured Lewes Unit were alarmed, and/or that the magnetic door lock system on the Unit had a back-up system/plan in the event of a power failure. One (R2) of 7 sampled residents who had made attempts to leave the Unit; eloped on 10/2/15 from the secure unit, was found outside (Temperature 56 F) in the rain, taken to the emergency room , admitted for treatment of [REDACTED]. This deficiency is past noncompliance and was corrected on 10/5/15. Findings include: R3's clinical record indicated the following: 8/7/15 at 20:00 (8 PM) - MAR showed that R2 received an as needed medication - Ativan 1 mg. for exit seeking and restless behaviors. 8/13/15 at 19:55 (7:55 PM) - nursing- Resident seen by nurse and other staff, getting up from chair and running toward exit doors. Staff attempted to catch resident, but were unable to stop his/her before he/she exited doors. Resident followed and redirected by 2 staff with positive effect. No further attempts noted. Wanderguard placed on left ankle. 8/13/15 at 21:04 (9:04 PM) - nursing - New orders for wanderguard at all times; check placement every shift. 8/13/15 - Observation Reports- Quarterly Assessment - Risk of Elopement/Wandering Review document completed by nursing indicated the following (These are yes or no answers with some comments): Is the resident cognitively impaired with poor decision-making skills? - yes. Has the resident expressed a desire to go home, packed belongings to go home or stayed near exit? - yes. Is the wandering behavior a pattern, goal-directed or routine tied to the resident's past (i.e. worked 3rd shift, taking long walks or seeking someone they cannot find)? - No. Is the resident at risk for elopement/wandering at this time? If yes, explain why. - yes, redirected and returned to unit. Care plan for focus/problem area cognitive loss- impaired cognition related to Dementia as evidenced by hoarding (initiated- 7/29/11). Interventions include but are not limited to: monitor for changes, explain each activity or care procedure, gently redirect activities when resident makes inappropriate actions. The intervention establish a routine/provide consistent caregivers was initiated - 10/4/14. A new intervention added 8/13/15 wanderguard at all times. Check placement every shift. There was no specific care plan focus/problem area developed for elopement risk. Staff were utilizing the behavior/intervention monthly flow record sheets to monitor and document on hoarding behaviors, inappropriate sexual behaviors, and other behaviors. These behaviors were charted on every shift but there was no flow record sheet implemented to track and trend exit seeking behaviors. 8/14/15 at 3:08 AM - nursing progress note- Resident has been awake and wandering halls all of this shift. Stating I've got to go home. I'm having a baby tonight. Noted to attempt to open the exit doors numerous times this shift, easily redirected. At one point this shift, noted that resident had removed wanderguard from her ankle and was carrying it in her hand. Wanderguard replaced. 8/15/15 to 8/27/15 - nursing progress note- no exit seeking behaviors, however, on 8/18/15 at 2:30 PM, R2 was observed to be ambulating around the Unit and later observed close to an exit door talking to another resident. 8/31/15 at 22:45 (10:45 PM)-MAR showed that the nurse had documented that R2 received an as needed medication- Ativan 0.5 mg (order is for 1 mg) for anxiety and exit seeking behaviors. 9/12/15 - Observation Report- Quarterly Assessment - Risk of Elopement/Wandering Review sheets completed by nursing documented the following (These are yes or no answers with some comments): Is the resident cognitively impaired with poor decision-making skills? - yes. Has the resident expressed a desire to go home, packed belongings to go home or stayed near exit? - yes. Is the wandering behavior a pattern, goal-directed or routine tied to the resident's past (i.e. worked 3rd shift, taking long walks or seeking someone they cannot find)? - yes. Is the resident at risk for elopement/wandering at this time? If yes, explain why. - yes, the resident says is leaving or has to go home several times a week. MDS completed 9/21/15 documented the following: BIMS score - 03 - means R2 is severely cognitively impaired Signs and Symptoms of Delirium - fluctuates (comes, and goes, changes in severity) Inattention - has difficulty focusing attention, easily distracted, out of touch or difficulty following what staff said. Disorganized thinking - rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. 9/25/15 at 22:45 (10:45 PM) MAR indicated that R2 received an as needed medication - Ativan 1 mg. The nurse documented that the medication was given for anxiety and exit seeking behaviors. The nursing progress notes - showed there were no entries at all for the entire month of September 2015, despite the administration of medications for exit seeking behaviors. This was confirmed in an interview with E3 (ADON) on 5/5/16 and with E4 (RNAC) on 5/6/16 at 9:10 AM. 10/2/15 nursing - At 6:05AM went to give medications to the resident's roommate and saw that R2 was not in his/her bed. Checked the bathroom. At 6:08 AM talked to the CNAs and asked if they had seen R2. The response was no. Started checking other rooms at 6:10 AM. At 6:20 AM, notified the other nurse that the resident was missing. Continued the search. At 6:25 AM, the other nurse let the Supervisor know that the resident was missing and a code orange was called. At 6:32 AM, I found out that the exit door on Lighthouse when I pushed it the door opened and the alarm went off. I immediately ran down the hallway to the other exit door and the door opened and it does not have an alarm. At 6:34 AM, immediately let the supervisor know that this door was not secure. Immediately had staff search outside. The doors on the Unit were not checked for at least 20 minutes after the search began. A written statement not dated documented the following: E10 (CNA) found the resident after searching the neighborhood around 7:05AM. The resident was on a front porch. The resident was wearing a long cotton night gown, socks and shoes. E10 gave the resident her jacket and helped the resident into the car. The resident was able to walk to the car and the resident told E10 that R 2 was cold. Arrived back at the nursing facility around 7:14 AM. Nurses and aides responded immediately and removed wet clothing and wrapped the resident in blankets. The facility Event Report started on 10/2/15 at 6:25 AM and completed at 9:28 AM showed that when the resident was brought back to the facility by E10, the resident was answering to her name, wet clothing removed, warm blankets and oxygen applied, vital signs taken, incontinence care provided and 911 called. Resident was cold to touch. Axillary temperature was 97.1, pulse 100 and unable to get a blood pressure. Transferred to the emergency room for evaluation and treatment. Hospital Emergency Flow Sheet Record reflected that on 10/2/15 the following vital signs were taken: 7:53AM - blood pressure (BP) -99/55, pulse (P) 99, respirations (R) 20, rectal temperature (T.) 92.9. Normal rectal T 99.6 F. Received immediate treatments which included but were not limited to: warming blanket, warmed-up saline infusion bolus and warmed bladder irrigation. 8:19 AM - 8:45 AM vital signs were closely monitored. R2's rectal T. ranged from 93.2 to 93.4 9:00 AM to 11:00 AM rectal T. range was 95 to 98.6. Hospital History & Physical records from 10/2/15 documented the following: Presenting Chief Complaint: Found outside in the rain from nursing home, presented with hypothermia, shivering and leg cramps. After aggressive treatment with heating blankets, warmed-up saline infusion bolus and warmed-up bladder irrigation patient's initial core temperature of 92 degrees Fahrenheit (F) went up to 95 degrees F. The patient was admitted to acute care inpatient level of care with further treatment for [REDACTED]. In addition, the patient received intravenous antibiotics for an acute urinary tract infection. 10/5/15 Hospital Discharge Documentation indicated the following: Discharge [DIAGNOSES REDACTED]. Post Incident documents: 10/2/15 (after the elopement incident) - E8's (CNA) written statement documented that she redirected the resident back to the bathroom in his/her room around 2:30 AM. R2 had stated to the staff person that she was going to have a baby. R2 was outside of room 354 (near the North Exit door) which had the magnetized lock system but no audible alarm at the time of the incident. E8 said she did watch the resident walk back to the other hallway but did not see R2 go into the room. !0/2/15 - facility's timeline of the elopement event showed that E8 had seen R2 at the nurse's station then walking toward his/her room around 4:00 AM- 5:00 AM. The facility did not have a consistent informal or formal system of how often visual checks were to be done for residents on the Lewes Unit at the time of the elopement. 10/2/15 Facility timeline documented that the Administrator checked the distance of where the resident was found by staff. The distance was 0.28 of a mile. The facility inspection and/or invoice records regarding the fire, security and alarm system were reviewed during the on-site survey ending 5/6/16. The magnetic door locks and/or alarms on the Lewes Unit were checked on 5/3/16 and again on 5/5/16. 5/3/16 at 10:40 AM interview with E11 UM-RN confirmed that the exit door by room 314 & 315 had always had an alarm and she showed the surveyor that the door was locked by pushing on it. It requires a key to disalarm and the nurse that works this hallway has the key. E11 had not been on staff at the facility at the time of the elopement. 5/3/16 at 10:50 AM interview and tour- E5, the Maintenance Director showed the surveyors the power supply area where the equipment malfunction occurred on 10/2/15. There was a loose wire at the power supply panel that had been repaired according to E5. 5/3/16 interview at approximately 11:10 AM, E1, the Administrator stated that on 10/2/15 when it was discovered that R2 was missing, staff also noted that the magnetic doors to the outside of the facility on the end of each hallway (Lewes Unit) were not locked. The alarm sounded when tested by staff on the South exit door (near rooms 314 & 315) that was unlocked. There was never an alarm on the North exit door which goes directly outside to the community neighborhood. Lewes is a secure Unit with a wanderguard system at the front double doors but no wanderguard system was ever installed at the South and North exit doors. The facility's security/fire/alarm system company had been out on 10/1/15 to investigate Lewes doors and also to install 2 horn strobe lights in place of the 2 bad ones found on inspection. Replaced dual relay for door release in the power supply and installed horns/strobes (part of the fire alarm system). All systems were tested and working at the time of departure. 10/2/15, invoice documented that the security/fire/alarm company came out - found 2 doors in the Lewes Unit had no power to the magnetic locks. Found a loose wire in the power supply terminal. Re-connected the wire and the power was restored to the doors. tested power supply battery back-up. Batteries were low and were replaced. One invoice documented battery at 10%. This was confirmed with E5 and the security/fire/alarm company owner (E12) during a telephone interview on 5/5/16 at 1 PM. Reviewed inspection reports both by the Fire Marshall and from the facility's company from 1/15/15 through 10/6/15. These reports showed the following; There were multiple deficiencies identified and comments regarding the various systems, however, there was no documentation regarding work done (maintenance work) on the systems except as stated above and as part of the facility's plan of correction mentioned below. The doors, locks, gates and alarms were tested by E5 at least weekly based on documents. The facility Policy and Procedure to locate missing residents (revised 8/29/14) in effect at the time of the elopement was reviewed during the survey. There were no specific timelines for notifications in the policy except to notify the police after 15 minutes of the search. The police were notified at 6:35 AM on 10/2/15, the search started at 6:08 AM. Walkie talkies were to be distributed to the UM/Charge Nurse and any staff working the perimeter of the building. E10 did not communicate to other staff via walkie talkie when she found the resident. The findings were discussed at exit on 5/6/16 at 2:15 PM - 2:55 PM with E1(NHA), E3 and E2(DON) (by telephone). The facility implemented the following plan of correction: On 10/2/15 (7:05 AM) - R2 found by facility staff, received immediate care, 911 called and resident transported to the hospital. 10/2/2015 -stationed staff by doors found to be unlocked (de-magnetized), security company called immediately (on-site by 10:00 AM). An Emergency door alarm was installed on the only unalarmed door in the Lewes Unit by facility maintenance staff. The security/alarm company inspection of the Lewes Unit was done. Immediate repairs made to power supply terminal which had a loose wire. Batteries low (at 10%) in power supply back-up which were replaced. tested all doors and keypads all functioning after repair. Audit was done of all residents with wanderguards and their care plans were reviewed Created a binder with paper back-up for each unit of all elopement risk residents, instead of a master and computer program. This will be audited weekly with updates as needed. Ordered audible alarms. Until installed every 15 minute checks on the doors remained in effect. Alarms installed on 10/5/15. 10/6/15 - all magnetic lock relays had a power failure notification pathway to be jumped to fire panel, permit submitted to Fire Marshall for approval. All wanderguards were placed on generator, post battery back-up as well as all magnetic locks.

Based on record review, interview and review of other facility documents, it was determined that the facility failed to ensure that two (R2 and R1) out of four (4) sampled residents were free of significant medication errors. R2's [MEDICAL CONDITION] (physical finding or changes in behavior that occur after abnormal electrical activity in the brain) medications were not administered for 15 out of 25 doses as ordered by the physician. R2 experienced [MEDICAL CONDITION] activity at the facility and was transported by 911 to the hospital. At the hospital it was determined R2 needed specialized care for the [MEDICAL CONDITION] and was emergently flown by helicopter to another hospital, out of state. R1 was administered an unusually high dose of [MEDICATION NAME] (helps decrease heart rate and control irregular heart beat) five times over a seven day period. R1 was consequently admitted to a hospital with [MEDICATION NAME] toxicity (too much [MEDICATION NAME] in the blood system that causes nausea, vomiting, decrease in appetite and decreased heart rate). Findings include: 1. R2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The following documentation was contained in the clinical record: 2/27/14- R2's admission order sheet listed various medications including Lacosamide (Erdosamide) (an anti-[MEDICAL CONDITION] medication) 100 milligrams (mg) one tablet by mouth twice daily for [MEDICAL CONDITION], Levetiracetam ([MEDICATION NAME]) (an anti-[MEDICAL CONDITION] medication)1000 mg by mouth daily for [MEDICAL CONDITION] and Levetiracetam 250 mg by mouth every Monday, Wednesday and Friday also for [MEDICAL CONDITION]. The manufacturer's website described Lacosamide as proven to reduce [MEDICAL CONDITION] when used in conjunction with other [MEDICAL CONDITION] medications such as Levetiracetam. The manufacturer then warns users of the medication not to"stop taking Lacosamide suddenly because it can cause serious problems and [MEDICAL CONDITION] that will not stop." 2/28/14 - A clinical note written at 12:25 AM documented R2's [MEDICAL TREATMENT] arrangements as Monday, Wednesday and Friday at 11:30 AM. 2/28/14- The 24 Hour Report Change in Condition form documented on each shift by nurses on each unit documented for R2 in the 7-3 time slot the following note "hold Lacosamide until arrives from pharmacy arrived received 9:00pm dose." In the 11-7 AM slot the following is documented "Lacosamide in narcotic drawer." There was not a physician's orders [REDACTED]. The pharmacy did not deliver Lacosamide for R2 until 3/2/14 and Lacosamide is not kept in the facility emergency medication or interim stock medication boxes. It is unclear how the medication was administered on 2/28/14 when it was not delivered until 3/2/14. It is also unclear how the facility planned to administer medication to manage R2's [MEDICAL CONDITION] disorder. The facility's "Medication Not Available" policy stated that when a medication is not available the nurse should first attempt to secure the medication from the starter box (a box supplied by pharmacy of unopened medications for use when medications are unavailable). If the medication is still not available the nurse should call the physician to determine if an alternative treatment plan is required. Lastly, the nurse should document the physician notification, and orders in the medical record. 2/2014- Medication Administration Record (MAR) indicated Lacosamide 100 mg one tablet by mouth twice daily for [MEDICAL CONDITION] was not given evidenced by circled initials; 2/27/14 - 9:00 PM 2/28/14 - 6:00 AM 2/28/14 - 9:00 PM There was no explanation of why the medication was not administered documented in the medical record and no evidence of physician notification. 2/2014- MAR indicated Levetiracetam 250 mg for [MEDICAL CONDITION] was not administered as indicated by no signature on MAR, no explanation of why the medication was not administered documented in the medical record and no evidence of physician notification; 2/28/14 - 9:00 AM 3/2/14- A physician's orders [REDACTED]." 3/2/14- R2's Controlled Substance Record, the form which indicated the number of Lacosamide tablets that were removed from the package revealed that only one tablet was removed (leaving 29/30 tablets quantity) during R2's admission at the facility indicating that is the only time and dose the medication was administered to R2. The blister pack (individualized packaging in which each pill/dose comes in a clear "blister" on a card with resident's label at top of the card) of Lacosamide also dated 3/2/14 by the pharmacy had one empty blister; the other 29 blisters were filled with the drug. 3/2014- MAR indicated Lacosamide 100 mg one tablet by mouth twice daily was not given as evidenced by circled initials on the following dates and times; 3/1/14 - 6:00 AM and 9:00 PM 3/2/14 - 6:00 AM 3/3/14 - 6:00 AM and 9:00 PM 3/4/14 - 6:00 AM and 9:00 PM 3/5/14 - 9:00 PM A total of "8" missed does out of "11" opportunities for medication administration. Documented reasoning for missed administration 3/3/14 "Resident at [MEDICAL TREATMENT], meds held", 3/4/14 "Lacosamide waiting from pharmacy", and 3/5/14 "Medication held [MEDICAL TREATMENT]." There is conflicting information between the MAR and the remaining number of pills in the blister pack. 3/2014- MAR indicated R2's Levetiracetam 250 mg by mouth every Monday, Wednesday, Friday, was not administered as evidenced by circled initials; 3/3/14 - 6:00 AM 3/2014 - MAR indicated R2's Levetiracetam 1000 mg by mouth daily appeared to not have been administered as evidenced by circled initials and documented on the back page of the MAR is the statement "meds held at [MEDICAL TREATMENT]."; 3/3/14 - 6:00 AM 3/6/14 -2:45 PM A nurse to physician communication progress note was written by E13, Registered Nurse (RN), the note documenting that R2 was experiencing tremors and increased blood pressure that began at 2:00pm. E13 then requested a provider visit specifically a medical doctor. 3/6/14- A facility subsequent visit exam was conducted by E17, physician, who, after examining R2, documented the following "has been having the problem for hours. The symptoms are severe. There has been a worsening since onset. I was asked to see the resident because of intermittent jerking motions. The resident has a history of stroke and [MEDICAL CONDITION] with prior [DIAGNOSES REDACTED] (long [MEDICATION NAME]). Plan: 911." 3/6/14- 3:15 PM A verbal order obtained and authorized by E17, to "send to emergency room for evaluation and treatment, [MEDICAL CONDITION] and hypertension". 3/6/14- R2 was sent to the hospital with a chief complaint of recurrent [MEDICAL CONDITION]. Hospital clinical record documented R2 "continued to seize at least over two hours probably closer to three. R2 was given anti-[MEDICAL CONDITION] medications and did not stop seizing, then was intubated (a tube placed in the throat for breathing). R2 was transferred to an out of state hospital to their neuro-intensive care unit for aggressive management prognosis guarded." 3/12/14 - At 12:00 PM an interview was conducted with E16, physician, who explained that while he was not the admitting physician, the intention of the medication was to be given as ordered even prior to [MEDICAL TREATMENT] stating "the Levetiracetam would be dialyzed (some of the medication would leave the resident's body during the [MEDICAL TREATMENT] process) leaving 750mg the extra 250mg was ordered on Monday, Wednesday and Friday was given to replace and meant to be administered before [MEDICAL TREATMENT]." 3/12/14- At 12:55 PM an interview was conducted with E3, a pharmacist, who confirmed that admission orders [REDACTED]. E3 explained that the Lacosamide was not sent with the delivery of medications because it is classified as a controlled substance. E3 stated that pharmacy protocol prohibits the acceptance of faxed admission orders [REDACTED]. The pharmacy will then send a prescription request form to the facility. E3 confirmed that the order was appropriately received for Lacosamide 100mg by mouth twice daily on 3/2/14 verbally by E3, and medication was dispensed on that date. Despite the dispensation on 3/2/14 at 9PM the facility failed to ensure R2 received 5 doses as required by the physician's orders [REDACTED]. 3/12/14-At 1:43 PM an interview with E6, RN unit manager was conducted. E6 explained that on 3/1/14 she was assigned as the nurse caring for R2 during the 3-11 PM shift. E6 discussed that during the medication pass she was unable to find the Levetiracetam, after looking in various drawers and was going to fax the pharmacy, but saw a form indicating the facility had the medication and eventually found the medication in the bottom of another drawer unopened. E6 described the protocol for unavailable medications as "The nurses should go to the doctor and the doctor should give another order to discontinue or typically hold and the nurse should call the pharmacy and find out when the med will be available. We use a local commercial pharmacy for our on-call. Any of our new orders faxed after 5PM will not come on the last run, after that fax to the on-call pharmacy.They call a courier to deliver medication." 3/12/14- At 3:10 PM an interview was conducted with E15, NP, who disclosed never actually being on site at the facility but rotating call and being on call for the facility the first weekend in March. E15 acknowledged making a call to the pharmacy on 3/2/14 to obtain R2's order for lacosamide and stated "because the resident did not come with a handwritten script" . E15 could not recall what nurse contacted her and stated "I know the nurse went over the past medical history of [REDACTED]." When asked about consent to the order to hold lacosamide until deliver, E15 stated "I don't recall a phone call about that but generally they will write such an order until a medication comes in." E15 denied being aware of the indications for Lacosamide and reported she was unfamiliar with the medication and that the nurse who requested the order did not disclose the indications for lacosamide at the time of the medication request. 3/12/14- At 3:28 PM an interview was conducted with E14, RN. E14 reported that R2 was assigned to her care during the 3-11 PM shifts on 3/3/14 and 3/5/14. E14 admitted ly did not administer R2's Lacosamide because "I just saw that this note on the chart said start when it comes, and I didn't see the medicine in the drawer." 3/12/14- At 3:34 PM an interview was conducted with E13, RN. On 3/6/14 E13 reported being told by a Certified Nurse's Aide, CNA, that R2 was having some "jerking movements" of the arms and legs. When E13 arrived to the room, R2 was no longer displaying the symptom. E13 reported she went to the physical therapy (PT) department and told them R2 would not be participating due to "jerking movements" earlier. E13 stated PT then came to perform PT at R2's bedside and observed R2 with "jerking movements". E13 stated at this time she was able to observe "intermittent eye and hand jerking" movements so she paged E17. E13 stated she then "reported the resident status to oncoming nurse and then E17 assessed R2 and determined R2 should be sent out emergently." 3/12/14- At 3:51 PM an interview was conducted with E2, Director of Nursing (DON). E2 stated "that when medications are not administered as ordered the staff should be contacting the physician to let them know it was held, and asking if the medication and times need changing based on the resident not being in the building." There is no evidence that R2 was out of the building at medication administration times of 6:00 AM and 9:00 PM . [MEDICAL TREATMENT] was scheduled at 11:30 AM. There is also no evidence that the physician was contacted to change the administration times. Following admission to the facility R2 did not receive prescribed [MEDICAL CONDITION] medications as ordered. Facility policy pertaining to unavailable medication was not followed. Available [MEDICAL CONDITION] medication, Levetiracetam was not administered as ordered. When Lacosamide became available it was not administered as ordered. R2 was emergently sent to the hospital for severe [MEDICAL CONDITION] activity and then flown to another out of state hospital for care on a specialty unit. 3/12/14 - 4:15 PM these findings were reviewed with E1, Administrator and E2, DON. 2. R1 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's policy titled Medication Orders documented that when there is any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. The following documentation was contained in the clinical record: 11/7/13- Order written by E8, Nurse Practitioner (NP) for [MEDICATION NAME] 0.125 mg (milligrams) to be administered daily for a [DIAGNOSES REDACTED]. 11/11/13- Lab result form documented R1's [MEDICATION NAME] level was 0.3 nanogram per milliliter(ng/ml) which is low. The physician hand wrote a note on the lab result that documented "for Afib rate OK no change" and there were no changes to the [MEDICATION NAME] order at that time. 11/27/13- Lab result form documented R1's [MEDICATION NAME] level was 1.4 ng/ml which was within the normal range. 1/17/14- Order written by E8, NP, for 125 mcg (same as 0.125 mg) of [MEDICATION NAME] to be administered daily. The medication was not to be administered if the resident had a heart rate of less than 60 beats per minute (bpm). 2/2014- Medication Administration Record (MAR) documented the 125 mcg of [MEDICATION NAME] for Afib was not administered due to a heart rate of less than 60 bpm on the following dates: 2/1/14 - 51 bpm 2/5/14 - 56 bpm 2/12/14 -51 bpm 2/12/14- Order written by E8 to discontinue the [MEDICATION NAME] secondary to a heart rate of 51 (low heart rate) and then start the [MEDICATION NAME] at 0.75 mg, (same as 750 mcg) daily. Despite the low heart rate this order increased the dose of [MEDICATION NAME]. 2/13/14- Nurse's note at 2:53 AM was written by E9, Licensed Practical Nurse (LPN), to discontinue [MEDICATION NAME] related to heart rate of 51 bpm and start [MEDICATION NAME] 750 mcg (same as 0.75 mg) to be administered daily unless R1's heart rate was less than 60 bpm. E9 failed to identify that the dose was an increased dose (rather than decreased) and failed to clarify the order. 2/2014- MAR documented the following: 2/13/14 - first dose of 0.75 mg [MEDICATION NAME] administered 2/14/14 - administered 2/15/14 - not administered heart rate 51 bpm 2/16/14 - administered 2/17/14 - not administered heart rate 52 bpm 2/18/14 - administered 2/19/14 - administered 2/13/14- Nurse's note written at 2:52 PM by E10, LPN, who documented R1 complained of nausea at 12:00 PM and was given [MEDICATION NAME] (anti-nausea medication) with some relief noted. 2/15/14- Nurse's note written at 7:19 a.m. by E11, Registered Nurse (RN), who documented R1 vomited liquid at 6:45 AM and was medicated with [MEDICATION NAME] for nausea. 2/16/14- Nurse's note written at 7:46 AM by E11, RN, who documented R1 complained of nausea at 6:00 AM and was medicated with [MEDICATION NAME]. 2/17/14- Nurse's note written at 6:18 PM by E12, LPN, who documented R1 stated that he felt nauseous since the weekend. E12 documented that she assessed R1's vital signs and documented his heart rate was 48 bpm. E12 also documented that the physician was notified and that new orders were received for blood work and a urinalysis to be completed the following day. The resident was placed on hydration monitoring (staff monitored fluid intake). 2/19/14- Nurse's note written at 11:06 AM by E7, LPN, documented that the [MEDICATION NAME] was discontinued secondary to nausea and vomiting. Blood tests for [MEDICATION NAME] level and other liver function tests were ordered. 2/19/14- Nurse's note written at 2:17 PM by E7, LPN, documented that R1's [MEDICATION NAME] level was 5.0 ng/ml (Toxic) and that the NP was notified and 911 was called to transport R1 to the hospital. 2/19/14- Physician's Progress note from the hospital documented that R1 was admitted with [MEDICATION NAME] toxicity. R1 had nausea, vomiting and [MEDICAL CONDITION] (heart rate less than 60 bpm). The [MEDICATION NAME] level at the hospital was 5.3 ng/ml (Toxic) and R1's electrocardiogram ((EKG) a test that checks for problems with electrical activity of the heart) showed changes that were consistent with [MEDICATION NAME] toxicity. The facility administered the high dose of [MEDICATION NAME] on 5 separate days and R1 experienced classic signs of [MEDICATION NAME] toxicity including nausea, vomiting and a decreased appetite, as documented in the nurse's notes. On 3/11/14 at approximately 10:40 AM an interview with E6, RN Unit Manager, confirmed that she had discovered the order for the [MEDICATION NAME] and immediately realized it was an unusually high dose and brought the concern to E8's, attention for clarification. E6 confirmed that the order was incorrectly written for a higher dose of [MEDICATION NAME] (changed from 125 mcg to 0.75 mg which is the same as 750 mcg). On 3/11/14 at approximately 11:15 AM an interview with E19, Staff Educator confirmed that there was no math competency section included on the Medication Administration test that is administered during new-hire orientation. On 3/11/14- at approximately 12:50 PM an interview with E2, Director of Nursing confirmed that there is no math test administered to staff nurses prior to hiring, during orientation or during annual education. On 3/11/14 at approximately 3:00 PM an interview with E18, RN Nurse Supervisor, confirmed that she had signed off the order for the [MEDICATION NAME] 0.75 mg. E18 stated that she had never considered that the order was written for the wrong dose of [MEDICATION NAME] and that she had "not worked with [MEDICATION NAME] very much." On 3/12/14 at approximately 12:55 PM an interview with E3, Pharmacist stated that the [MEDICATION NAME] was filled by the pharmacy on 2/12/14 for the 0.75 mg dose (same as 750 mcg). E3 also confirmed that the order was clarified with the facility on 2/19/14 (seven days after the [MEDICATION NAME] was delivered) because it was a "huge" dose. The pharmacy had packaged the daily doses of [MEDICATION NAME] as 3 tablets to be given together each day. The tablets were 250 mcg each (total of 750 mcg). The previous dose of [MEDICATION NAME] was administered as one tablet of 125 mcg. The facility failed to identify that R1's [MEDICATION NAME] order was incorrectly written for an unusually high dose before administering the medication on five separate days during a 7 day period. E8, documented on her order to change the dose of [MEDICATION NAME] due to a low heart rate of 51. This should have prompted the pharmacy to request a clarification of the order due to the increased dose rather than the expected decreased dose of [MEDICATION NAME]. R1 was consequently admitted to the hospital with [REDACTED]. Findings confirmed with E2, Director of Nursing on 3/12/14 at approximately 4:15 PM.

Based on record review, staff and family interviews and review of other medical records as indicated, it was determined that the facility failed to ensure that two (2) of twelve (12) residents reviewed (R1 and R4) received the care and services necessary to attain their highest practicable level of well-being. R1 was admitted to the facility following the surgical amputation of three toes on his right foot due to gangrene and necrosis. R1 was at risk for impaired healing of the right foot surgical incision due to [MEDICAL CONDITIONS]. For the first 4 and a half days that R1 was in the facility, the original bandage he arrived to the facility with remained on his right foot with no removal by facility staff or the attending physician/nurse practitioner to assess the status of the wound or to change the dressing. The first documented assessment by a facility nurse occurred nearly 5 days after R1 ' s admission and the nurse identified a " large black eschar / scab " at the incision site with the top half of R1 ' s foot noted to be " red and warm to touch " . Eschar is dead tissue and redness and warmth are possible indicators of infection. R1 was discharged from the facility the next day (six days after admission). It was later determined (within 2 days of discharge) by the surgeon who performed the original toe amputations that R1 had developed necrosis (death of tissue) at the incision site and a soft tissue infection ([MEDICAL CONDITION]) which required surgical intervention.In addition to the lack of wound assessments and dressing changes, the facility failed to evaluate why R1's pain was increasing and the causative factors contributing to a decline in his ability to walk. Then the facility discharged R1 without any medical evaluation of the surgical site although the day before a facility nurse had identified and documented eschar (dead tissue) of the incision along with redness and warmth. R4 had a urinary tract infection [MEDICAL CONDITION] with an antibiotic resistant organism diagnosed two days after his admission to the facility in June, 2011. Following antibiotic treatment, two repeat cultures performed in July, 2011 showed greater than 3 bacterial organisms. On the lab report for the second culture, a facility nurse and a Nurse Practitioner signed (nurse) and initialed (Nurse Practitioner) the laboratory report under a handwritten notation that " culture and sensitivity " results were awaited before new orders would be given. Actually, there were no antibiotic sensitivity results pending since the lab ' s routine practice was to request a repeat culture when there were more than 3 bacterial organisms in a urine specimen. Six days later, R4 had not been re-evaluated by the Nurse Practitioner and was still not receiving any antibiotic treatment for [REDACTED]. It was determined at the hospital that R4 was in septic shock with positive blood cultures (3 bacterial organisms), a positive urine culture (2 bacterial organisms, one of which was also in the blood), and other infection. Findings include: 1. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility documentation showed R1 to have a variable mental status mental status with confusion at times. Hospital documentation by the Nurse Practitioner who worked for the vascular surgeon (E9) indicated that as of 9/15/11 at 8:37 AM, R1 had a small amount of bruising along the incision which was described as continuing " to heal well " . R1 was admitted to the facility later that day. According to the Resident Admission assessment dated [DATE] and timed 6:40 PM completed by facility nurse E10, R1 had an amputation site of the right foot. E10 noted that the area was " wrapped " as documented in a nursing note timed 7 PM. In an interview on 10/20/11 at 9:44 AM with a state survey agency investigator, E10 confirmed that she did not change R1 ' s dressing or obtain orders for a dressing change. The Attending Physician (E4) completed a history and physical on 9/16/11 and documented that R1 had a bandage on his right foot and " refuses evaluation (of the right foot) at this time " . E4 wrote on the history and physical form that R1 had toe amputations due to gangrene and the plan was to provide " wound care " . Despite the above documentation that R1 was admitted with a bandaged amputation site of the foot, facility staff and the Attending Physician failed to ensure that there were orders for wound care. Facility staff caring for R1 on 9/16/11, 9/17/11, 9/18/11, and 9/19/11 also failed to question the lack of a dressing change order or request a dressing change order. Consequently, no dressing change was performed until approximately 3:30 AM on 9/20/11 (4 and a days after R1 ' s admission) when the dressing became soiled with feces as reported by nurse E11 in an interview with the surveyor on 12/1/11 at 2:25 PM. E11 did not document any assessment of the amputation site. Following the change of the soiled dressing on 9/20/11, the unit manager (E12) contacted the surgeon ' s nurse practitioner (E9) to obtain a dressing change order. This was R1 ' s 5th day in the facility. The order given by E9 was for a dry sterile dressing to be changed daily and as needed. Facility nurses changed R1 ' s dressing on 9/20/11 (3 PM to 11 PM shift) and 9/21/11 prior to R1 ' s discharge. On 9/20/11 at 11:20 PM nurse E15 documented that the blue sutures were intact and there was a " large black eschar / scab covering top half of foot red and warm to touch. No drainage " . The nurse who changed the dressing on 9/21/11 (E13) did not document any assessment. When interviewed by the surveyor on 12/6/11 at 2:50 PM, E13 recalled " necrotic tissue, dark tissue " at the site. E12 (unit manager) stated that she briefly looked at the wound when the last dressing change was performed and that the area definitely had eschar and the incision was " black, scabby " . R1 was discharged home with his wife on 9/21/11 at approximately 5:15 PM. According to hospital records, R1 arrived at the emergency room at 5:40 AM on 9/23/11 (36 hours after discharge from the facility) with severe pain of the right foot. In a history and physical dated 9/23/11, the surgeon (E14) documented that R1 had been in a nursing home where " apparently the wound has been neglected " and that the wound was found to have " a large irregular area of necrotic eschar, surrounded by inflammation " . E14 documented that R1 had " necrosis of an operative site secondary to neglect and possible poor vascular supply without hope of revascularization " . On 9/26/11 E14 performed a transtarsal metatarsal amputation " (removal of a portion of R1 ' s right foot). R1 ' s recent surgical amputation of 3 toes was documented on a " Preadmission Review " form and was known by the facility prior to R1 ' s arrival. The surgical date of 9/9/11 was listed on this form which was 6 days prior to R1 ' s admission to the facility. Hospital documentation on the " Interagency Nursing Communication Record " did not include wound care instructions. Orders were not requested of or provided by the Attending Physician (E4) or his Nurse Practitioners and consequently no dressing change or assessment of the surgical incision occurred until the dressing became soiled with feces 4 and a half days after R1 ' s admission. The facility ' s established " Admission and Readmission " policy and procedure was not followed for R1. The policy " to perform an admission / baseline assessment of the resident " was not followed as R1 ' s surgical wound of the foot was not assessed for over 4 days after admission. The policy " to identify significant needs, and initiate a plan of care " was not followed as facility staff and the attending physician / Nurse Practitioner failed to ensure that there were orders for changing the surgical site dressing and monitoring the status of R1 ' s surgical incision (e.g. assess for signs of impaired healing or infection). In addition to the lack of dressing change and nursing / medical assessment of the incision, Physical Therapy (PT) documentation indicated that R1 ' s pain increased and his functional status declined during his 6 days in the facility. According to the Physical Therapy Discharge Summary, R1 could ambulate 5 feet with a rolling walker with minimal assistance on 9/16/11 but was " unable to take a step without almost falling " and " unable to take a single step when discharged " 5 days later. When interviewed by the surveyor on 12/1/11 at 10:30 AM, the Physical Therapy Assistant (E8) who treated R1 and who had completed the PT Discharge Summary stated that R1 did not progress during PT and instead was going " backwards " everyday. E8 recalled that R1 was in " a lot of pain " and complained of significant pain each day which E8 explained limited R1 ' s activity. The clinical record lacked evidence that the possible reasons for increased pain of the right foot with a decline in ability to walk (such as inflammation or swelling) were evaluated during R1 ' s first 4 days in the facility. The Nurse Practitioner (E5) who wrote a note titled " discharge today " in R1 ' s clinical record on 9/21/11 (date of discharge) did not conduct an assessment of R1 ' s surgical incision. E5 wrote " toe dressing will be changed prior to discharge " but gave no indication in the note that she was aware that a large area of eschar with redness and warmth of the top of the foot was identified at the surgical site on 9/20/11. Neither the Nurse Practitioner (E5) nor the Attending Physician (E4) identified that R1 ' s white blood cell count had increased to 14.7 according to a 9/16/11 blood test compared to a pre-admission level of 10.4 on 9/12/11. Finally, in her 9/21/11 note in R1 ' s clinical record, Nurse Practitioner E5 documented that R1 currently had pain for which " extra [MEDICATION NAME] " was given. R1 was discharged from the facility on 9/21/11 at approximately 5:15 PM without having a medical evaluation of his surgical wound during his 6 day stay in the facility. During the 6 days he was in the facility, R1 failed to receive a dressing change to his incision for 4 days (9/16/11 through 9/19/11); developed increased pain which limited his activity during physical therapy; experienced a decline in his ability to walk (from walking 5 feet using a rolling walker with minimal assistance on 9/16/11 to not being able to take one step on 9/20/11); and developed eschar, redness and warmth of the surgical site. Following R1's discharge from the facility on 9/21/11 he was readmitted to the hospital on [DATE] for right foot metatarsal resection. The discharge summary dated 10/18/11 from this hospitalization under present illness the physician references the initial surgery of the right foot on 9/9/11. The physician stated R1 was discharged from the hospital in excellent condition and the incision was progressing well. "He was discharged to a nursing home and apparently his wound was neglected. Because his wife noted a fetid odor from the site, the foot was finally examined and he was found to have a large irregular area of necrotic eschar surrounded by inflammation." 2. R4 was admitted to the facility on [DATE] with dementia, [MEDICAL CONDITION], multiple pressure sores, an indwelling urinary catheter and a history of urinary tract infection with an antibiotic resistant organism (VRE). A urine culture collected on 6/18/11 with results reported on 6/22/11 revealed infection with [MEDICATION NAME] faecium (an antibiotic resistant organism) and [MEDICAL CONDITION]. R4 received the antibiotic Linezolid ([MEDICATION NAME]) to treat the [MEDICATION NAME] and [MEDICATION NAME] to treat the candida. A repeat urine culture was ordered to be performed in 4 weeks after the course of antibiotics was completed. The repeat urine culture was obtained on 7/22/11 with results on 7/25/11 indicating " mixed culture with greater than three organisms, please repeat. Organism- mixed coliforms, colony count greater than 100,000 cc " . Urinalysis results dated 7/26/11 for a specimen collected on 7/26/11 revealed a urinary tract infection with positive [MEDICATION NAME]; 3+ leukocytes; 50 - 100 white blood cells; and +4 bacteria (all indicators of a possible urinary tract infection " . A repeat culture was ordered via straight catheter on 7/25/11 with the 7/27/11 results again indicating " mixed culture with greater than three organisms, please repeat. Organism- mixed coliforms, colony count greater than 100,000 cc " . Handwritten on this lab result form was the statement signed by a facility nurse and dated 7/27/11 " Awaiting culture and sensitivity for new orders " . This statement was also initialed by Nurse Practitioner E5 on 7/27/11. When no culture and sensitivity results were found in the closed clinical record for R4, the surveyor asked E2, the DON, to determine if the results were available from the lab. On 12/7/11 at 11:45 AM E2 informed the surveyor that she had contacted the facility ' s lab representative and had been told that when there are mixed organisms, the specimen is considered contaminated and the only communication the lab will have with the facility will be the lab slip which instructs the facility to " please repeat " the test with another specimen. As explained by E2, this means that there was no sensitivity test pending on 7/27/11 for R4 when the nurse signed and Nurse Practitioner initialed that " new orders " were pending " culture and sensitivity results " . Based on this misunderstanding, on 7/27/11 no decision was made by the Nurse Practitioner (E5) regarding how to treat or further evaluate R4 ' s apparent urinary tract infection. On 8/2/11, nurse E16 documented that R4 had a blood pressure of 73/43 at 6 AM when his blood pressure was checked to determine if he should receive his high blood pressure medication ([MEDICATION NAME]). This blood pressure was significantly lower than R4 ' s usual blood pressure readings as documented on the MAR. On 12/6/11 at 11:15 AM, E16 stated to the surveyor that it was closer to 7 AM when she checked R4 ' s blood pressure and she stated that she thought the low blood pressure was because R4 was " really sleeping " and that he seemed his normal self to her. The next assessment of R4 occurred at 9 AM when the nurse on the next shift went to R4 ' s room and found R4 unresponsive to verbal and painful stimuli. The Attending Physician (E4) was present in the building and examined R4. E4 documented that R4 had a fever of 101.8 degrees Fahrenheit axillary; was non-responsive; and he (E4) suspected a stroke [MEDICAL CONDITION]. The paramedics arrived at the time of E4 ' s examination according to his note and R4 was transported to the hospital. According to the initial history and physical of R4 completed in the hospital on [DATE], R2 had an elevated white blood cell count of 23,000 and " [MEDICAL CONDITION] with septic shock. Source [MEDICAL CONDITION] is probably urinary tract infection " . R4 was later evaluated by an infectious disease specialist who documented that the urine culture performed in the hospital on [DATE] revealed two bacterial organisms- [DIAGNOSES REDACTED] pneumoniae and pseudomonas. One of these bacterial organisms ([DIAGNOSES REDACTED] pneumoniae) was also found in R4 ' s blood cultures from 8/2/11. Two additional bacterial organisms (MRSA and [MEDICATION NAME] faecalis) were found in R4 ' s 8/2/11 blood cultures but it was not clear what the source of these organisms was. R4 was not receiving antibiotic medication in the facility between 7/19/11 and 8/2/11 when he had an abnormal urinalysis and two urine cultures which were considered by the lab to be contaminated due to having more than 3 different bacterial organisms. A facility nurse and Nurse Practitioner (E5) who signed / initialed that culture and sensitivity results were pending on 7/27/11 were incorrect and consequently no treatment decision was made. Six days later R4 required hospitalization for unresponsiveness associated with a fever and decreased blood pressure. In the hospital, a bacterial organism present in R4 ' s urine on 8/2/11 ([DIAGNOSES REDACTED]) was also present in R4 ' s blood on that date.