Every finding on record at Excelcare at Wilmington LLC

Based on record review and interview, it was determined that for one (R1) out of nine residents reviewed for resident rights, the facility failed to initiate a PASARR (Pre-admission Screening and Resident Review) review when R1 was started on a new anti-psychotic medication. Findings include:7/5/23 - R1's PASARR determined that R1 required a PASARR level II without specialized services. 7/7/23 - R1 admitted to the facility with a diagnoses, including but was not limited to, bipolar disorder.1/19/24 - Delusional disorder was added to R1's diagnoses list as evidenced by dates on R1's facility facesheet.This diagnosis was not documented on R1's 7/5/23 PASARR evaluation.3/6/25 - C1 (psychiatrist) documented in R1's progress notes, .Patient on Zyprexa (olanzapine) for off-label use was discontinued.8/21/25 - C1 ordered Rexulti (an atypical anti-psychotic medication) 2mg (milligrams) by mouth at bedtime for delusional disorder.The facility failed to request a new PASARR evaluation when R1's behaviors significantly escalated and he began to exhibit delusional behavior, which required a new psychiatric medication.9/29/25 3:20 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Director of Operations), E4 (Regional Director of Clinical Services) and E5 (ADON).

Based on record review and Interview, it was determined that for two (R1 and R2) out of nine residents reviewed for resident rights, the facility failed to ensure the medical records were in accordance with professional standards by being accurate.1. Review of R1's clinical record revealed:7/7/23 - R1 was admitted to the facility with diagnoses, including bit was not limited to, bipolar disorder.8/29/25 11:45 AM - From reading the facility's investigation report, there was a heated interaction between R1 and R4 during a room change. 8/29/25 2:53 PM - E8 (LPN) documented in R1's progress notes, Incident note: Officer [name] responded to the facility and interviewed [R1]. No case number is being assigned at this time.8/29/25 - E8 (LPN) documented in R1's Behavior Monitoring Record under Psychotropic use target behavior: agitation. At the end of each shift note frequency- # of times behavior occurred. On 8/29/25 for dayshift, E8 documented 0 instances of agitated behavior.The facility failed to accurately document R1's behaviors on 8/29/25 dayshift. 9/22/25 3:29 PM - E5 (ADON) documented in R1's progress notes, Resident displayed aggressive behaviors both verbal and physical. Resident came out of his room towards a staff member who was standing in the nurse's station with a knife on his L (left) hand and started waving at the staff member. No triggers identified. Resident was unprovoked.9/22/25 - E7 (LPN) documented in R1's Behavior Monitoring Record under Psychotropic use target behavior: agitation. At the end of each shift note frequency- # of times behavior occurred. On 9/22/25 for dayshift, E7 documented 0 instances of agitated behavior.The facility failed to accurately document R1's behaviors on 9/22/25 dayshift. 9/26/25 10:45 AM - During a telephone interview, R4 stated that he was moving rooms on 8/29/25 before lunchtime, R1 came into his room as he was packing his belongings and was agitated and aggressive. R1 was telling him to get out of his room. R4 stated, [R1] backed me into the corner. R4 confirmed that he requested that the facility call the police on his behalf.2. Review of R2's clinical record revealed:9/10/25 - R2 was admitted to the facility with diagnoses, including but not limited to, stroke and aphasia (a language disorder that affects a person's ability to speak, understand, read and write). 9/10/25 - E6 (MD) ordered in R2's EMR, NPO (nothing per oral) diet, NPO texture, NPO consistency.9/11/25 3:37 AM - R2's EMR under the Tasks tab has documented a PO (per oral) intake of 120 mls (milliliters).9/13/25 1:41 AM - R2's EMR under the Tasks tab has documented a PO intake of 120 mls.9/15/25 1:47 AM - R2's EMR under the Tasks tab has documented a PO intake of 360 mls.9/15/25 4:30 AM - R2's EMR progress note documented, .The resident noted alert, oriented, open eyes equally, pupils' equal round and reactive to light, nonverbal, but able to responds (sic) to questions been asked via gestures (nodding) to indicate understanding.9/15/25 10:50 PM - R2's EMR progress note documented, Patient alert and responsive but nonverbal.9/16/25 3:10 PM - R2's EMR health status note documented, Patient alert and responsive but nonverbal.9/17/25 2:21 AM - R2's EMR under the Tasks tab has documented a PO intake of 120 mls.The facility failed to ensure that R2's medical record was accurately documented. On four separate occasions, staff documented that R2 was drinking fluids when R2 was ordered to be NPO. 9/19/25 1:26 PM - R2's EMR health status note documented, .Observed the patient lethargic and slow to respond.9/19/25 4:55 PM - E9 (physician assistant) documented in R2's EMR, .He [R2] is awake and aphasic, able to nod or shake head for certain questions appropriately.Physical exam: .Neuro: .Speech clear. Labs: refer to chart.The facility failed to ensure that R2's medical record was accurately documented according to professional standards. Within the body of the same note, the provide [E9] documented that R2 was aphasic and able to nod or shake head to questions and that R2's speech was clear. 9/29/25 1:47 PM - During an interview, E2 (DON) stated that the CNAs documentation on the Tasks regarding PO (per oral) input was erroneous. When a patient is NPO, that task should be resolved so the CNAs do not document any PO intake. E2 also stated, He [R2] could shake his head yes or no to questions.he was nonverbal. Had verbal aphasia. E2 also stated that R2 was only here nine days and did not have any lab work during that time. The facility failed to ensure that R2's medical record was accurately documented as the provider [E9] in his 9/19/25 note referenced Labs : refer to chart; however there were no recent lab results from the last nine days in R2's chart. 9/29/25 3:20 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Director of Operations), E4 (Regional Director of Clinical Services) and E5 (ADON).

Based on observations, interviews, record review, policy review, and review of the facility's investigations, the facility failed to ensure four of five residents reviewed for abuse prevention (Resident (R) 8, R183, R184, and R286) out of 28 sampled residents were free from abuse from other residents. R184 verbally abused R183 when attempting to take R183's walker believing it was his. R8 slapped R286 when attempting to take a magazine away from R286. The verbal and physical abuse from R183 and R286 created the potential for fear, pain, and injury to R184 and R8. Findings include: Review of the facility's policy titled Abuse/Neglect - Exploitation Mistreatment and Misappropriation of Property Prevention, dated 06/15/24, read, in part, Residents of this facility shall be protected from occurrences of abuse, exploitation, misappropriation of property, mistreatment or neglect. 1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R183 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbances, major depressive disorder, anxiety disorder, and schizoaffective disorder. Review of the readmission Minimum Data Set (MDS) located under the MDS tab of the EMR, with an assessment reference date (ARD) of 12/05/24, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R183 was severely cognitively impaired. Behaviors during the assessment period noted verbal behavioral symptoms occurred 1-3 days and other behavioral symptoms not directed at others occurred 1-3 days. Review of R183's Care Plan, located under the Care Plan tab in the EMR, initiated 09/16/24, identified The resident has a potential to be verbally aggressive as evidenced by screaming, yelling or cursing at others. Review of the admission Record located under the Profile tab in the EMR revealed R184 was admitted on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing. R184 discharged home on [DATE] as planned following rehabilitation. Review of the admission MDS with an ARD of 02/21/25 revealed a BIMS score of 14 out of 15 which indicated R184 was cognitively intact. Review of the facility's investigation, dated 03/03/25, provided by the Administrator, revealed On 2124/25 [02/24/25] at approximatety [approximately] 12:40PM [R183] was ambutating [ambulating] down the hattway [hallway] when he attempted to take the rotting [rolling] watker [walker] that was sitting in the doorway of [R184's room] in front of [R184] who was sitting in her room in her wheetchair. [wheelchair]. [R183] had one end of the rotting [rolling] watker [walker] and [R184] grabbed the other end of the watker [walker] and totd [told] [R183] that the walker belonged to her. [R183] then cursed at [R184] and totd [told] her that it betonged [belonged] to him. The Nurse [Licensed Practical Nurse, LPN4] and [Certified Nursing Assistant. CNA1] noted the exchange occurring with [R183] and were heading towards the residents and immediatety [immediately] separated the residents and redirected [R183] back to his room. No physical contact bewveen [between] the residents occurred. The safety of att [all] other residents was ensured. [R183] was ptaced [placed] on 30-minute safety checks post incident. [R183] was referred to [Behavioral Health Hospital] on 02/24/25 for further evatuation [evaluation]. [R184] was moved from room [current room] to [room further away from R183]. Changes made to the CP [care plan]: [R183] ptaced [placed] on 30-minute safety checks and transfered [transferred] to [Behavioral Health Hospital] on 2/25/25 lot [for] turlher [further] evaluation. PsychandSW [Psychiatrist and Social Worker] to continue to fotlow [follow]. During an interview on 03/11/25 at 11:16 AM, the Director of Nurses (DON) and Administrator confirmed the verbal abuse by R183 to R184. The DON stated, R184 was not afraid. No physical contact occurred. R183 thought the walker was his and started to take it from R184's doorway. R184 pulled it back, let go, and laughed at R183. R183 cursed at R184 claiming the walker was his. R183 was sent to a behavioral health hospital because his agitation had been increasing, he was trying to hoard wheelchairs, walkers, and the weight chair. His meds will be evaluated. He will return. Review of the R183's Progress Notes located under the Clinical tab in the EMR revealed a Behavior Note dated 02/04/25 which read, Patient observed agitated and aggressive this morning. He was Collecting all the wheelchair claiming that they are his and nobody can use them without buying them from Him. He was also observed confronting staff when they attempted to use the Hoyer lift. Patient was also attempting to get into other patient rooms to retrieve their [NAME] chair claiming it belongs to him. when redirected by staff he attempted to use his cane to hit staff. Patient was redirected to a calm environment, and was also offered a snack but was not effective. MD was notified. Order was obtained for Ativan gel I mg [milligram] PRN [as needed] Q [every] 8 hours. During an interview on 03/13/25 at 11:30 AM, the Social Services Director (SSD) stated, We're able to utilize the services of the behavioral health hospital to help with medication management when R183 starts escalating. In his dementia, he will think everything around him is his and he starts hoarding. He will resist cares, medication, food at those times. The behavioral health hospital works with his dementia and schizophrenia and medications. The resident's responsible person is involved and was in agreement to the transfer. Resident is not physically aggressive. He is expected to return, staff will continue with close supervision. The psychiatrist will following him in the facility as well. 2. R8 was originally admitted to the facility on [DATE] following a hospitalization to treat metabolic encephalopathy. R8's other diagnoses include anxiety, dementia, depression, and atrial fibrillation. Review of R8's EMR revealed R8 quarterly MDS with ARD of 03/04/25 indicated a BIMS of five out of 15 which indicated serve cognitive impairment. Review of the facility provided Incident/Accident log, revealed a resident-to-resident incident involving R8 and R286. Review of R8's Progress Note, dated 03/05/25 at 1:29PM read, Resident to resident abuse. While in Dining Room this resident (the aggressor) approached fellow resident in attempt to take her magazine from her, they began to yell and this resident slapped fellow resident's left side of face with open hand. Review of the facility's investigation of the resident-to-resident incident revealed an interview with R286 dated 03/05/25 at 1:52PM.indicated, R286 stated she was sitting in at the dining room table by myself when the lady (R8) walked up to me and grabbed my magazine. I said you can't come up taking other people's stuff, then she hit me. An interview was attempted with R286 on 03/13/25 at 11:37AM but the resident was not able to offer any information regarding the incident between her and R8. During an interview with R8's resident representative (RR1) on 03/10/25 at 12:43PM, she confirmed that she was notified of the incident that occurred on 03/05/25. She added that she has been surprised at R8's behavior, but did advise that there has been a cognitive decline due to the dementia diagnosis. During an interview on 03/11/25 at 9:03AM LPN1 she stated that outside of the incident on 03/05/25, R8 had not shown aggression towards other residents but could be combative during care. During an interview with Certified Nursing Assistant (CNA)3 on 03/13/25 at 11:40AM, she confirmed that she was present in the dining room at the time of the incident and stated, R8 had just been redirected by another aide, because she was trying to get at the hole punch on the nurses' station. R8 then approached R286, who was reading a magazine, and R8 attempted to take it from her. They began to speak to incoherently yell at each other and before staff could separate the two, R8 reached back and slapped R286. CNA3 continued, advising the residents were separated and assessed. CNA3 also confirmed that neither resident was injured and notification to resident representative and physician was made. CNA3 was asked if R8 had showed any signs of aggression towards other residents prior to this incident and she stated that she had not and she was very surprised by the incident. Interview with the DON was interviewed on 03/13/25 at 9:18AM, and she confirmed that the incident was investigated and reported to the State Agency (SA) per the facility's abuse reporting policy. She added that local law enforcement was also contacted. The DON also advised that the investigation concluded that the incident did occur, and the facility responded by adding additional monitoring for R8. The DON was asked how she was ensuring the ongoing safety of the facility's residents and the DON stated that R8 had shown no physical aggression towards others since her admission to the facility in November and since the incident on 03/05/25. She added that R8 is monitored and followed by their psych services, and they are monitoring R8 closely.

Based on record review, interviews, and facility policy review, the facility failed to ensure residents were free from physical abuse from: 1. one resident (Resident (R) 95) who demonstrated repeated acts of physical violence towards multiple other residents to include residents R24 and R109; and 2. R128's wandering behavior resulted in a resident-to-resident abuse between R128 and R6. The facility's Administrator was informed on [DATE] at 3:40 PM that Immediate Jeopardy (IJ) existed at F600-K Freedom from Abuse and Neglect when the facility failed to implement effective interventions to ensure residents were free from abuse from R95. The facility provided an acceptable removal plan for the Immediate Jeopardy on [DATE] at 12:21 AM. The survey team validated that the Immediate Jeopardy was removed on [DATE] at 1:45 PM. The removal was validated by observations, interviews, record review, and review of training records. The removal plan included training for all disciplines recognizing signs and symptoms of abuse and neglect, along with reporting and preventing abuse and neglect. All residents with known behaviors were reviewed and care plans were reviewed for effectiveness. Abuse policies were reviewed and updated to include resident to resident interactions. After removal of the Immediate Jeopardy, the deficiency remained at an E scope and severity for pattern with a potential for more than minimal harm. Findings include: 1. a. Review of R95's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, irritability and anger, delusional disorders, and anxiety disorder. Review of R95's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Further review revealed R95 had physical behavior symptoms directed at others. Review of R95's Care Plan, located under the Care Plan tab of the EMR and dated [DATE], revealed The resident has the potential to be physically aggressive related to poor impulse control as evidenced by swinging fist at others. Interventions in place were to calmly explain or reinforce why behavior was inappropriate or unacceptable. Intervene as necessary to protect the rights and safety of others. Provide programs of activities that were of interest and accommodated the resident's status. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Registered Nurse (RN) 2, dated [DATE] at 1:46 AM, indicated R95 was combative and verbally aggressive toward staff who were unable to redirect him. R95 became verbally aggressive toward both of his roommates waking them both up. Staff were unsuccessful at redirecting R95 out of the room and R95 attempted to hit staff. Staff offered snacks but R95 refused and wheeled (himself) to a different unit. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Assistant Director of Nursing (ADON), dated [DATE] at 3:15 AM (one and a half hours later) indicated R95 was found in R24's room swinging his arms at R24. R95 told staff he hit R24 in the face. Coffee was provided to R95 as requested which calmed him down for a short period of time but R95 became more aggressive and difficult to redirect by the staff. The physician was notified and R95 was sent out to the emergency room (ER). Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN9, dated [DATE] at 1:09 PM, indicated R95 returned from the ER at 9:00 AM and was moved to another unit and the Psychiatrist (PSYD) reviewed R95's medications and there was a new order for Ativan (anti-anxiety medication) 0.5mg (milligram) tab one dose and for Ativan IM (intramuscular) 1mg every six hours PRN (as needed). During an interview on [DATE] at 5:39 AM, RN2 stated R95 was combative and noncompliant towards both staff and other residents. She stated staff tried redirection, keeping him by the nurse's station, offering fluids, snacks, and general safety checks every two hours. RN2 stated R95 was moved to another unit after hitting R24 in the face but she was unsure of any changes to his care plan for aggressive behaviors. During an interview on [DATE] at 9:24 AM, RN7 stated R95 was very aggressive, and staff tried calming him down and were aware of some things that worked such as offering coffee or Pepsi. RN7 stated was not aware of changes made to his plan of care when he was readmitted . During an interview on [DATE] at 10:17 AM, the Social Services Director (SSD) 1 stated R95 was very authoritative, and thought he was the boss. SSD1 stated it was best for them to walk away and reapproach later. She stated the interdisciplinary team (IDT) met a lot to discuss him and tried to have consistent staff provide care since he liked consistency. b. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Licensed Practical Nurse (LPN) 1, dated [DATE] at 1:26 AM, indicated R95 was exhibiting very aggressive behaviors and went into a female residents' room and was touching their feet and both residents yelled at R95 to get out of the room. R95 got up off his wheelchair and sat down on one of the female resident's wheelchairs. R95 could not be redirected and started kicking and punching at female staff members. A male nurse from another unit came and picked R95 up and placed him in his own wheelchair and he eventually self-propelled to another unit. No change in plan of care. During an interview on [DATE] at 10:58 AM, LPN1 stated R95 was very aggressive and argumentative to staff, but he was much more aggressive towards other residents at the facility. She stated staff tried to keep him away from other residents and he was moved to other areas of the facility, but staff were unable to redirect him during the 11:00 PM to 7:00 AM shift. LPN1 stated staff tried to stay out of his range. LPN1 stated they would provide fluids, and sometimes he accepted but there was a skeleton crew at nighttime which made it more difficult to redirect or intervene. On [DATE], she stated she remembered R95 very inappropriate and calling out racial names and attempting to hit staff before he went into a female resident's room and was touching their feet c. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated [DATE] at 7:53 PM, indicated R95 became physically aggressive throwing punches and kicking at staff and struck R109 on the arm. No change in plan of care. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated [DATE] at 3:38 AM, indicated R95 continued with behaviors and wandering in and out of female resident rooms and calling two female aides [derogatory language]. R95's roommate complained that R95 kept purposely running into his bed with his wheelchair to wake him up. At 3:45 AM, R95 continued being aggressive and kicked a nurse in the leg twice and hit her in the face. During an interview on [DATE] at 10:58 AM, LPN1 stated that on [DATE], R95 was in the hallway in his wheelchair and when R109 passed by and attempted to speak to R95, R95 punched R109 in the face. LPN1 stated she witnessed R95 hit R109 in the face.LPN1 stated a few days later, on [DATE], R95 could not be redirected and went into another room of female residents. and while attempting to redirect R95, he kicked her in the knees multiple times and punched her in the face. She stated R95's medications were changed, and he was moved off her unit to another unit, but she was unsure what, if any additional changes in his plan of care were put into place after these incidents. d. Review of a Nurse's Note, located under the Notes tab in the EMR and written by the ADON and dated [DATE] at 1:46 PM, indicated the IDT team met and requested a room change and another psychological evaluation to be completed for R95. The resident was moved to another unit. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN10, dated [DATE] at 4:25 PM, indicated at 4:25 PM, a psychological evaluation was completed on R95. Medications were reviewed and new orders for Depakote (mood stabilizer) 125mg BID (twice a day) one day, Ativan 0.5 mg tab BID and discontinue mirtazapine (anti-depressant medication). On [DATE], a new order for Depakote 250 mg QD (once a day). During an interview on [DATE] at 2:00 PM, the Administrator stated there were no psychological evaluations completed on R95, but the PSYD completed a medication review. e. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN7, dated [DATE] at 5:53 AM, indicated R95 was physically aggressive throwing punches, kicking at staff and attempting to hit a fell ow resident, but staff intervened and redirected the resident away from the other resident. R95 continued to be aggressive and attempted to hit any staff that passed by. The staff's attempts to redirect were unsuccessful. R95 had another room change and was moved to a different unit. No other changes in the plan of care. During an interview on [DATE] at 9:24 AM, RN7 stated she did not remember who the resident was that R95 tried to hit on [DATE], but that R95 had multiple behaviors during that time. She stated R95 was sitting in his wheelchair and tried to punch the nurse and the staff were attempting to calm him down, but he could not be redirected. RN7 stated he was kicking at staff who tried offering him coffee or snacks, but he continued to refuse that along with his medications f. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN1, dated [DATE] at 10:28 PM, indicated R95 was being resistive to care, and staff attempted to provide reassurance to R95 who appeared to calm down. However, after care was provided R95 punched a nurse on the cheek and struck another nurse in the left eye. R95 was sent out to the ER for further evaluation. He came back to the facility on [DATE] at 1:27 AM. At 11:10 AM, the physician gave an order for one time Ativan 0.5mg by mouth. No other changes in the plan of care. During an interview on [DATE] at 4:25 PM, RN1 stated R95 would wander the halls and staff tried to redirect by offering coffee or food. But she was unsure if there were specific interventions on R95's care plan that listed things staff should do to effectively redirect or engage him. During the incident that occurred on [DATE], she stated R95 punched one of the nurses in the head and she called 911 and she thought R95 was transported to ER. RN1 stated when he returned, he was moved to another unit, but she was unsure if there were any changes made to his plan of care. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN5, dated [DATE] at 2:37 PM, indicated R95 continued to be agitated and running into other residents with his wheelchair and kicking door of nurse's station. Re-direction unsuccessful but staff continued to re-direct. Review of a Nurse's Note, located under the Notes tab in the EMR and written by the Director of Nursing (DON), dated [DATE] at 1:18 PM, indicated the IDT team met and R95 medications were reviewed and there was a new order to discontinue Lorazepam (anti-anxiety medication) and start Ativan gel. During an interview on [DATE] at 9:24 AM, ADON stated R95 could be very aggressive, and at times redirected. The ADON stated they sent him out to the ER to get him psychiatric treatment, but the ER would send him right back to the facility. She stated they tried to address his aggressive and violent behavior by moving him to other rooms but that was only effective for a short period of time. She stated that the facility was not protective of other residents since R95 was able to physically assault other residents on multiple occasions She stated his behavior only stopped due to his physical decline. During an interview on [DATE] at 10:36 AM, the PSYD stated he was at the facility every Thursday seeing residents. He stated when he made rounds, he physically saw each resident and reviewed their medical record along with their medications. He stated R95 had some behaviors and was on every Thursday list to be seen. anytime there was physical altercation the residents' medications were reviewed and adjusted and he followed-up within a week He stated R95 was a chronic patient, but he did not document that anywhere in the EMR because he kept his own notes. During an interview on [DATE] at 10:36 AM, the DON stated R95's behavior depended on the day. She stated staff tried redirecting him. She stated they offered him coffee or activities of his choice like football, which he liked. The DON stated there were some staff he really took to, so they tried assigning those staff to provide his care. She stated they tried finding the right room/unit in the facility and PSYD made several medication adjustments. During an interview on [DATE] at 10:08 AM, the Administrator stated staff attempted to address R95's aggressive behaviors by sending him out to the ER in hopes the hospital would send him for psychiatric treatment. But she stated they would send him back to the facility. She stated staff tried redirection, offering coffee, putting on football. But R95's aggression was out of control no matter what staff did. Further review of the Care Plan revealed no updates to the care plan since it was implemented on [DATE] despite R95's multiple abusive behaviors towards other residents. One intervention, not documented on the care plan, was to transfer R95 to different units of the facility where the abusive behaviors continued. 2. Review of R6's Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R6's MDS with an ARD of [DATE], revealed a BIMS score of ten out of 15 which indicated moderate cognitive impairment. R6 was independent with ambulation and was documented as wandering for one to three days of the assessment period. Review of R6's Care Plan located in the EMR under the Care Plan tab, dated [DATE], indicated Resident is/has potential to be verbally aggressive r/t [related to] Dementia. Interventions were revised [DATE], STOP sign initiated at the door. Review of R128's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted initially to the facility on [DATE]. Diagnoses included dementia with behavioral disturbances, restlessness and agitation, schizoaffective disorder, mood disorder, and generalized anxiety. Review of R128's MDS with an ARD of [DATE] revealed a BIMS score of 99 which indicated severe cognitive impairment. R128 required one person supervision for ambulation and was documented as wandering daily. R128 expired on [DATE]. Review of R128's Care Plan, located in the EMR under the Care Plan tab, dated [DATE], indicated resident had Socially inappropriate behavior: inappropriate touching AEB [as evidence by]: touching other's hair and/or rubbing others' head. Interventions were revised on [DATE] to include, Intervene and redirect when inappropriate behavior is observed. Review of the Investigation Report of resident-to-resident physical abuse provided by the facility, dated [DATE], revealed on [DATE] at 12:10 PM, RN10 and CNA9 heard R6 yelling for help and immediately responded to the resident. R128 was observed by CNA9 trying to grab and swing at R6, and R6 was trying to push the resident out of her room. CNA9 separated the residents. RN4 documented that R6 told the nurse that R128 had come into her room, and she told him to get out, but R128 continued and then grabbed her on the shoulder. R6 then told RN10 that R128 hit her on the left side of her face, but not hard. R128 sustained a small skin tear to the left upper arm, right forearm, and chest. R6 had no visible injuries. R128 was difficult to redirect. Upon the facility becoming aware of the incident on [DATE], the facility placed a stop sign on R6's room doorway to redirect R128 away from her room. During an interview on [DATE] at 10:10 AM, CNA9 stated that she could not recall the incident but did recall R128 wandered up and down the hallway with his walker and was difficult to redirect. She stated that he did not like to stand still and would wander into other residents' rooms. She stated R6 preferred to stay in her room and could be easily agitated when someone tried to come in. During an interview on [DATE] at 10:45 AM, ADON stated that R128 was a wanderer and had behaviors with touching other people. During an interview on [DATE] at 12:50 PM, RN10 stated that R128 had entered R6's room and she only saw that R6 had pushed R128. She stated that R128 was a wanderer and liked to get into the personal space of other residents. She stated that he had not shown signs of aggressive behavior, but due to his constant shadowing of other residents and getting into their space, the other residents would become upset and that would lead to altercations. She stated they continued to try new interventions such as one on one, keeping him in the dining room with activities, and adjustments to his medication. During an additional interview on [DATE] at 1:33 PM, the ADON stated the facility had used stop signs to keep him from visiting other resident rooms and had also tried to keep him engaged. Further review of R6's Care Plan located in the EMR under the Care Plan tab, revealed interventions were revised on [DATE] to place STOP sign initiated at the door. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated [DATE] and [DATE], revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed appropriate corrective action should be done once abuse was identified and the care plans should be revised. 26446 15879

Based on observations, interview, record reviews, and facility policy review, the facility failed to ensure four out of four isolation carts were fully stocked with the supplies needed to promote infection control, Resident (R) 30 did not consume a pill dropped on the ground, and staff utilized proper hand hygiene after wiping R116's nose of 41 sampled residents. Findings include: 1. During an observation on 02/26/24 at 10:30 AM, room [ROOM NUMBER] had signage on the door showing that the room was an isolation room and isolation carts were outside the door. The signage included contact precautions and droplet precautions and indicated a face shield, or goggles were to be donned (put on) when entering the room. During an observation on 02/26/24 at 10:30 AM, there were no face shields or goggles noted to be on the isolation cart of room [ROOM NUMBER]. Observation further revealed when Licensed Practical Nurse (LPN) 4, who was also the unit manager, went to get a face shield from the other three isolation carts, she could not find any on the other carts. Observation further revealed LPN4 had to go to central supply to get the face shields and put them on all the carts. During an interview on 02/26/24 at 10:35 AM, LPN4 revealed it was okay to go into an isolation room if you had glasses on as long as your eyes were covered. During an interview on 02/26/24 at 10:35 AM Certified Nursing Assistant (CNA) 8 revealed she did not know the facility had face shields to use but she had glasses on when she went into room [ROOM NUMBER]. During observation on 02/26/24 at 12:15 PM, the isolation cart outside room [ROOM NUMBER] did not have any gloves in it. During an interview on 02/26/24 at 12:17 PM, in the hallway by room [ROOM NUMBER], the Housekeeping Director (HSKPD) revealed there were no gloves in the isolation cart. The HSKPD revealed she was responsible for restocking the linens and bags and if she had gloves on her cart, she would restock them as well. The HSKPD further revealed the CNAs and nurses would restock the gloves and masks. During an interview on 02/28/24 at 8:51 AM, LPN4 revealed the isolation carts should have had gowns, N95 masks, face shields, red bio bags, yellow bio bags, vinegar bags, trash bags, gloves, and hand sanitizer stored on them. Interview with LPN4 further revealed after looking in the isolation cart outside room [ROOM NUMBER] there were no gloves in it, and she went and got some for the cart. During an interview on 02/28/24 at 8:55 AM, LPN4 revealed the isolation cart outside of room [ROOM NUMBER] did not have any N95 masks in it. LPN4 revealed the isolation carts should be fully stocked and supplies should be fully available to help stop the spread of whatever was going around. LPN4 revealed she did not know why the face shields were not on the isolation cart and she was not sure where the system failed. LPN4 revealed she monitored the supplies by making rounds and it was everyone's responsibility to make sure the isolation carts were stocked. During an interview on 02/28/24 at 10:11 AM, the Infection Preventionist/Staff Development (IP/SD) revealed she made rounds to ensure staff used PPE appropriately and to make sure the isolation carts were stocked. IP/SD further revealed sometimes she would just visualize the isolation carts and not actually open them to make sure they were stocked. IP/SD further revealed she and the unit manager were ultimately responsible for the carts to be stocked. IP/SD revealed each isolation cart should have been stocked with face shields especially if a resident was on droplet precautions. IP/SD revealed the staff should have had the supplies available right then when they needed them. The IP/SD revealed glasses did not stop the spread of germs and that was why face shields were utilized. During an interview on 02/28/24 at 1:45 PM, the Director of Nursing (DON) revealed there was not just one particular person responsible for stocking the isolation cart daily and that included opening the isolation carts and looking inside for supply stock. During an interview on 03/01/24 at 8:18 AM, the Administrator revealed isolation carts were to be stocked and sanitized by housekeeping. The Administrator further revealed that the unit manager and the nurses were to make sure the isolation carts stayed stocked. The Administrator revealed she also made rounds on the unit and randomly would inspect the isolation carts. The Administrator revealed it was not a good idea to gown up with the PPE and then have to go get supply. She revealed it was an infection control issue. The Administrator further revealed that housekeeping would stock the carts with gloves, gowns, booties, face shields, yellow bags, and red bags when they went to the floor. 2. During medication pass observation on 02/27/24 at 9:46 AM, Licensed Practical Nurse (LPN) 5 gathered R30's medication and went to the sunroom where R30 was sitting by himself. LPN5 handed R30 a cup of medications, and while taking pills out one by one, one pill dropped onto the floor. After the pill dropped on the floor, R30 picked up the pill and placed it in his mouth without LPN5 intervening. Review of R30's Face Sheet, provided by the facility, revealed R30 was admitted to the facility on [DATE] with diagnoses that included hypertension, seizure, anemia, and overactive bladder. During an interview on 02/29/24 at 3:45 PM, LPN5 confirmed that she should have intervened when R30 dropped his medication on the floor, and discarded that one, and obtained another one. 3. During an observation on 02/26/24 at 10:30 AM Certified Nursing Assistant (CNA) 7, wiped R116's right nostril that had yellowish unknown substance coming out of it with a Kleenex. After CNA7 wiped R116's nose, CNA7 did not wash her hands and/or sanitize her hands. Review of R116's Face Sheet, provided by the facility, revealed R116 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, anxiety, and major depressive disorder (MDD). During an interview on 02/28/24 at 6:00 PM, the DON stated that if a pill fell on to the floor during medication pass, she would have expected the nurse to pick it up, identify the medication, discard that current medication, and get the resident another pill. The DON stated in addition, if a staff member was providing care to a resident, such as wiping a resident's nose, then she would have expected afterwards that staff washed their hands and/or used hand sanitizer. Review of the facility's policy titled, Infection Prevention and Control Program, dated 4/1/20, 11/1/21. 5/2023, and 2/13/24, revealed the facility had established and maintained an infection prevention and control program to help prevent the development of and transmission of communicable diseases and infections. The policy revealed all staff would use personal protective equipment (PPE) according to facility policy. The policy revealed the IP [Infection Preventionist] was responsible for the oversight of the program and served as a consultant to the staff for implementation of isolation precautions. Review of facility's policy titled Hand Hygiene, dated 04/01/20, revealed All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom .Hand Hygiene Table . After handling items potentially contaminated with blood, body fluids, secretions, or excretions .Before preparing or handling medications .After sneezing, coughing, and/or blowing or wiping nose either soap and water or alcohol-based hand rub (ABHR is preferred). 25232

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one resident (Resident (R)106) out of a total sample of 41 residents was treated with dignity in toileting. Findings include: Review of R106's Face Sheet, located in the hard chart, revealed he was admitted to the facility on [DATE], from the hospital, with diagnoses of toxic encephalopathy (brain dysfunction) and sepsis (infection of the organs). Review of R106's admission Minimum Data Set (MDS) assessment located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 01/02/24, revealed R106 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated the resident had intact cognition. Review of this MDS revealed R106 was dependent on staff assistance of two for care. Review of the Bowel and Bladder section of this MDS revealed R106 was on a toileting program for bowel and bladder incontinence. Review of the admission comprehensive care plan, located in the EMR under the Care Plan tab, with an initiated date of 12/27/23 and revised on 01/04/24, revealed a care plan for incontinence of bowel and bladder. A toileting program was not one of the interventions. During an observation and interview on 02/26/24 at 11:00 AM, R106 stated he could tell when he needed to go to the bathroom but he wore a brief and the staff changed him. During an interview on 02/29/24 at 4:32 PM, R106 revealed it sucked to have to go in a brief. R106 further revealed that when he had asked staff to take him to the bathroom, the staff told him to just go in his brief. During an interview on 02/26/24 at 9:40 AM, Certified Nursing Assistant (CNA) 8, who was providing care to R106, stated R106 was not on a toileting program but was a check and change (the brief) every two to three hours. CNA confirmed R106 went to the bathroom in his brief. During an interview on 02/28/24 at 9:43 AM, Licensed Practical Nurse (LPN) 4 revealed that the CNA task page indicated R106 was on a toileting program before meals, bedtime, and as needed. LPN4 further revealed the CNAs changed R106's brief after urinating or having a bowel movement because staff used a [mechanical] lift to get him up out of bed. LPN4 confirmed that R106 was alert and oriented and could make his needs known including when he had to use the bathroom. During an interview on 02/29/24 at 3:00 PM, the Director of Nursing (DON) revealed a toileting program was supposed to promote quality of life for those residents requiring assistance to and from the bathroom. During an interview on 03/01/24 at 8:28 AM, the Administrator revealed it was not appropriate for staff to say just go in your brief when a resident asked to be toileted. The Administrator further revealed it was a dignity issue and not acceptable. During an interview on 03/01/24 at 9:01 AM, the DON revealed it was not acceptable for staff to say, just go in your brief and it was a dignity issue. Record review of the facility's policy titled, Promoting/Maintaining Resident Dignity, with a date of 04/01/20, revealed it was the practice of the facility to promote and protect residents' rights with respect and dignity in a manner that maintained or enhanced the resident's quality of life. The policy further revealed all staff involved in providing resident care was to promote resident dignity.

Based on record review, interview, and facility policy review, the facility failed to timely report to the state survey agency multiple incidents of abusive behavior of one resident (Resident (R) 95) out of a total sample of 41 residents. Findings include: Review of R95's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, irritability and anger, delusional disorders, and anxiety disorder. Review of R95's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/31/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Further review revealed R95 had physical behavior symptoms directed at others. Cross Reference: F600-Free from Abuse and Neglect. 1. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Licensed Practical Nurse (LPN) 1, dated 09/27/23 at 1:26 AM, indicated R95 was exhibiting aggressive behaviors and went into a female residents' room and was touching their feet and both residents yelled at R95 to get out of the room. R95 got up off his wheelchair and sat down on one of the female resident's wheelchairs. R95 could not be redirected and started kicking and punching at female staff members. 2. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated 10/19/23 at 7:53 PM, indicated R95 became physically aggressive throwing punches and kicking at staff and struck R109 on the arm. During an interview on 02/28/24 at 10:58 AM, LPN1 stated she reported the incidents that occurred on 09/27/23 and 10/19/23 to her supervisor, but she could not remember who that was. 3. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Registered Nurse (RN) 7, dated 10/31/23 at 5:53 AM, indicated R95 was physically aggressive throwing punches, kicking at staff and attempting to hit a fell ow resident, but staff intervened before R95 struck the other resident. During an interview on 02/29/24 at 9:24 AM, RN7 stated all incidents on 10/31/23 were reported to the oncoming staff through the shift-to-shift report but that she did not report the incident to a supervisor as abuse since R95 attempted but wasn't able to hit the other resident. 4. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN5, dated 11/04/23 at 2:37 PM, indicated R95 continued to be agitated and running into other residents with his wheelchair and kicking the door of nurse's station. During an interview on 02/29/24 at 10:36 AM, the Director of Nursing (DON) stated any abusive behaviors should have been reported to a supervisor who would notify the DON and Administrator. The DON confirmed, as the abuse coordinator, that the incidents of abuse on 09/27/23, 10/19/23, 10/31/23, and 11/04/23 were not reported to the state survey agency within two hours or at all. During an interview on 03/01/24 at 10:08 AM, the Administrator stated she expected all incidents of aggression or abuse to be reported to the state survey agency within two hours. Review of facility's policy titled, Abuse, Neglect and Exploitation, revised 07/25/22, revealed . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, stage agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. the allegation involves abuse or results in serious bodily injury, note all alleged abuse will be reported to licensing not later than two hours. b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 25232

Based on record review, interview, document review, and policy review, the facility failed to conduct a thorough investigation for multiple incidents of abusive behavior of one resident (Resident (R) 95) out of a total sample of 41 residents. Findings include: Review of R95's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, irritability and anger, delusional disorders, and anxiety disorder. Review of R95's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/31/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Further review revealed R95 had physical behavior symptoms directed at others. Cross Reference: F600-Free from Abuse and Neglect. 1. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Registered Nurse (RN) 2, dated 08/24/23 at 1:46 AM, indicated R95 became verbally aggressive toward both of his roommates waking them both up. This incident of verbal abuse was not investigated. 2. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Assistant Director of Nursing (ADON), dated 08/24/23 at 3:15 AM, indicated R95 was found in R24's room swinging his arms at R24 while R95 was in his wheelchair and told staff he hit R24 in the face. Review of the facility's Incident Report for Web Intake, provided by the facility, revealed investigation of the incident on 08/24/23 at 3:15 AM consisted of one staff's statement. There were no statements by any residents or additional staff. 3. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Licensed Practical Nurse (LPN) 1, dated 09/27/23 at 1:26 AM, indicated R95 was exhibiting aggressive behaviors and went into a female residents' room, was touching their feet, and both residents yelled at R95 to get out of the room. R95 got up off his wheelchair and sat down on one of the female resident's wheelchairs. R95 could not be redirected and started kicking and punching at female staff members. A male nurse from another unit came and picked R95 up and placed him in his own wheelchair and he eventually self-propelled to another unit. Review of the facility's Incident Report for Web Intake, provided by the facility, revealed the incident that occurred on 09/27/23 at 1:26 AM was not investigated by the facility. 4. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated 10/19/23 at 7:53 PM, indicated R95 became physically aggressive throwing punches, kicking at staff, and struck R109 on the arm. Review of the facility's Incident Report for Web Intake, provided by the facility, revealed the incident that occurred on 10/19/23 at 4:58 AM consisted on one staff's statement. There were no statements by any residents or additional staff. 5. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN7, dated 10/31/23 at 5:53 AM, indicated R95 was physically aggressive, throwing punches, kicking at staff and attempting to hit a fell ow resident. Review of the facility's Incident Report for Web Intake, provided by the facility, revealed the incident that occurred on 10/31/23 at 5:53 AM was not investigated by the facility. 6. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN5, dated 11/04/23 at 2:37 PM, indicated R95 was agitated and running into other residents with his wheelchair and kicking the door of nurse's station. Review of the facility's Incident Report for Web Intake, provided by the facility, revealed the incident that occurred on 11/04/23 at 2:37 PM was not investigated by the facility. During an interview on 02/29/24 at 10:36 AM, the Director of Nursing (DON) stated the incidents on 08/24/23 and 10/19/23 were investigated but agreed there should have been more staff and residents interviewed. The DON stated the incidents that occurred on 09/27/23, 10/31/23, and 11/04/23 were not investigated because staff did not report the incidents to her as the Abuse Coordinator. During an interview on 03/01/24 at 10:08 AM, the Administrator stated staff should have ensured staff and residents involved in an incident were all interviewed who may have had exposure or knowledge. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 07/25/22, revealed an immediate investigation was warranted when suspicion of abuse neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation; . investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect exploitation and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 106) was on a toileting program to enhance his continence out of 41 sampled residents Findings include: Review of R106's Face Sheet located in the hard chart revealed he was admitted to the facility on [DATE], from the hospital, with diagnoses of toxic encephalopathy, sepsis, atrial fibrillation, disorder of prostate, acute respiratory failure, depression, and anxiety. Review of R106's admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 01/02/24, revealed R106 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. Review of the Bowel and Bladder section of the MDS revealed R106 was on a toileting program for bowel and bladder incontinence due to being incontinent of bowel and bladder. Further review revealed a toileting program could include scheduled toileting, prompted voiding, and bowel and bladder retraining. R106 was dependent on staff for care with the assistance of two staff. Review of the admission comprehensive care plan, located in the EMR under the Care Plan tab, with an initiated date of 12/27/23, targeted date of 03/22/24, and revised on 01/04/24, revealed a care plan for incontinence of bowel and bladder. Interventions included cleaning the peri area after incontinence and monitoring for any causes of incontinence. Toileting program was not one of the interventions. Review of the Task for Certified Nursing Assistants (CNAs) in the EMR under the Task tab, revealed R106 was on a toileting program that consisted of toileting after meals, at bedtime, and as needed. During an observation and interview on 02/26/24 11:00 AM, R106 was lying in bed in his room. R106 revealed he was incontinent, but he could tell when he needed to go to the bathroom. R106 revealed he wore a brief, and the staff changed him. During an interview on 02/26/24 at 9:40 AM, CNA8, who provided care to R106 that day, revealed R106 was not on a toileting program, but was a check and change every two to three hours. CNA8 revealed R106 could not tell ahead of time when he had to go but would be able to tell after he had urinated or had a bowel movement. During an interview on 02/28/24 at 9:43 AM Licensed Practical Nurse (LPN) 4 revealed, after reviewing the task page for the CNA, which told them how to care for a resident, that R106 was on a toileting program before meals, bedtime, and as needed. LPN4 further revealed the task probably should have been a check and change because he was using a [mechanical] lift to get up. LPN4 stated therapy was working with him and now he was a two-person physical assist. LPN4 further revealed R106 could still be on a toileting program and use a urinal and bedpan even if a [mechanical] lift was used. Interview with LPN4 further revealed the CNA task for nights did not show where the task of toileting had been done. LPN4 revealed R106 was alert and oriented and could make his needs known. LPN4 revealed being able to utilize a toileting program would give R106 more control, independence, and increase quality of life for him. During an interview on 02/29/24 at 3:00 PM, the Director of Nursing (DON) revealed a resident was assessed for incontinence on admission, quarterly, annually, and as needed. The DON stated that they would determine the level of the resident's continence status. She further revealed either a toileting program or a check and change program would be initiated and it would be assigned as a task for the CNA on the computer. The DON further revealed if a resident was on a toileting program, proper staff should have offered toileting, a urinal, use a bedside commode, or taken them to the bathroom, if the resident was able. The DON further revealed if the resident needed a lift, they may have needed a bedside commode. The DON revealed that just because the resident used a [mechanical] lift did not mean they could not be toileted. She stated a toileting program was supposed to promote continence, as much as possible, quality of life and try to preserve as much function for the resident as they could. The DON revealed staff were trained on toileting programs and how to care for continence. She stated the unit manager was the person responsible for documenting the care plan over to the Task, so the CNAs knew what care to provide for the resident. During an interview on 02/29/24 at 4:32 PM, R106 revealed he had asked staff to take him to the bathroom, but they told him to just go in his brief. During an interview on 02/29/24 at 5:56 PM, LPN4 revealed she did the task for the CNAs under bowel and bladder. LPN4 revealed if R106 could tell when he had to have a bowel movement then staff should have put him on bedpan or used a urinal. LPN4 revealed she thought the CNAs were just changing him. During an interview on 03/01/24 at 8:25 AM, the Administrator revealed staff followed the policy on toileting. The Administrator further revealed all CNAs were trained on the toileting program and provided appropriate care to the resident. The Administrator revealed if a resident told a staff member that they had to go to the bathroom then staff should have, at least, attempted to assist them. During an interview on 03/01/24 at 11:02 AM the Director of Rehabilitation (DOR) revealed R106 had been receiving occupational therapy for about a month that included positioning and a splint to the left elbow. She revealed R106's right hand was okay. The DOR further revealed R106 would be able to use a urinal with the help of someone positioning him first and handing him the urinal. She stated he then would be able to do his business and hand the urinal back to the staff when he was finished. The DOR revealed R106 could also be put on a bedpan with assistance with rolling over to put it under him and removing it. The DOR further revealed R106 was able to tell you when he had to have a bowel movement or urinate. Record review of the facility's policy titled, Bowel and Bladder Management version one, effective 04/01/20, revealed the purpose of the policy was to address residents' individual needs with respect to bowel and bladder. The policy revealed each resident would be assessed for bowel and bladder functioning on admission, each quarterly MDS, and any change in condition. The policy revealed a plan of care would be developed and may include a bladder retraining program.

Based on observation, record review, interviews, review of facility provided incident (FRI), and review of facility policy, the facility failed to ensure that one of five residents (Resident (R) 32) reviewed for unnecessary medications out of 41 sampled residents, were free from unnecessary medications. R32 was administered another resident's (R9) medications resulting in a potential for R32 to have an adverse effect. In addition, two of five residents (R30 and 44) observed during medication administration, were not identified using two of four identifiers. Findings include: 1. Review of R32's Face Sheet, provided by the facility, revealed that R32 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety, major depressive disorder (MDD), and mood disorder. Review of Incident Report [Number], (initial reporting) provided by the facility and dated 08/25/23, revealed On 08/24/23, an agency nurse on dementia unit administered medications to the wrong resident. Resident [R32] immediately assessed and physician notified. The physician orders to monitor blood pressure every four hours for 24 hours and to hold trazodone (anti-depressant medication) dose for today. [R32's] vital signs have remained stable. Investigation in progress. Review of Event Investigation Interview Record, provided by the facility and dated 08/25/23, for Licensed Practical Nurse (LPN) 8, revealed When giving medication, [R9] was in the dining room with other residents. Prior to giving medication, I asked another nurse who [R9] was because the resident's do not appear as the photos on EMAR [electronic medication administration record] and [R9] was not in the room to identify which bed [R9] was in. The nurse described [R9] with the blanket. So, I approached [R32] with the blanket and gave medication. Review of LPN3's Event Investigation Interview Record, provided by the facility and dated 08/25/23, revealed Med nurse approached me and told me that she gave the medication to the wrong resident [R32]. I questioned her as to what happened. She stated the other nurse said the resident with the blanket. I checked [R9's] picture on EMAR, the photo looked the same as the resident. Informed the nurse that there is a photo (clear) on the EMAR. Review of the Assistant Director of Nursing (ADON) Event Investigation Interview Record, provided by the facility and dated 08/25/23, revealed Followed up [R9's] identifier on the EMAR. [R9's] photo appeared the same as the resident in person. Review of LPN9's Event Investigation Interview Record, provided by the facility and dated 08/31/23, revealed [LPN8] asked me who is [R9], and I said [R9] has the blanket over her head. [R32] has blanket on her lap. Review of facility provided Incident Report [Number], (5-day summary) dated 08/31/23, revealed Root Cause Analysis: [R32] is an [AGE] year-old long term care female resident in the dementia unit. Has a diagnosis Alzheimer Disease, type 2 diabetes mellitus (DM), anxiety disorder, mood disorder, insomnia, dementia with behavior disturbance, bipolar disorder, osteoarthritis to hip, pain right ankle/joints, chronic kidney disease (CKD), gastroesophageal reflux disease (GERD), hypotension, myoclonus, atherosclerotic heart disease and vitamin deficiency. Medications include aspirin (ASA), sertraline, nitroglycerin, Lantus, trazodone, Humalog insulin, isosorbide mononitrate. Has a Brief Interview for Mental Status (BIMS) score of three (severely cognitive impairment). R32 has multiple behavior care plans in place such as unsafe transfers, attempting to put self on the floor to pray, asking repetitive questions, hoarding, physical aggression, and verbal aggression. Uses a wheelchair for locomotion and independently wanders around in her wheelchair. Requires one person assist with transfers. She passively participates in activity, 1:1 and requires invitation to activity of choice. Her favorite activities: visit from Deacon, church service, music, folding items and socializing with others. Result of Investigation: On 08/24/23 at 09:28 AM, a resident [R32] was inadvertently given another resident [R9] medication of Amlodipine (blood pressure medication) 10 milligrams (mg) and Risperdal (anti-psychotic medication) .5 mg. Nurse A [LPN 8] who was involved with the medication variance stated that R9 was in the dining room with other residents on the dementia unit. Prior to administering the medications, Nurse A [LPN8] asked Nurse B [LPN9] to verify the residents [R9] identify. Nurse B [LPN9] described the resident [R9] as the one with the blanket. Nurse A [LPN8] then approached a resident [R32] with a blanket and gave the medication. After administering the medications Nurse A [LPN8] realized that there were two residents in the dining room who had blankets. In fact, [R32] was administered [R9's] medications. Once the variance was identified [R32] was immediately assessed. Vital signs were within normal limits and [R32] was in no apparent distress. The physician was immediately notified, an order was obtained to monitor blood pressure (BP) every four hours for 24 hours. [R32's] BP and pulse remained stable, with no signs or symptoms of distress/discomfort, along with good fluid intake within the monitoring period. Additionally, an order was provided to hold [R32's] trazodone for 24 hours. The family was informed of the variance and physicians orders. A drill down of the event indicated that Nurse A [LPN8] to identify did use two identifiers prior to administering the medications (picture in electronic health record (EHR) and confirming the resident's identity with [LPN9]). However, the descriptor provided by Nurse B [LPN9] the one with the blanket was not specific enough for Nurse A [LPN8] to identify the correct resident. Nurse A [LPN8] should have asked Nurse B [LPN9] to verify the resident's identity by physically approaching the resident vs [versus] a generalized description the one with the blanket. Nurse A [LPN8] was immediately educated on the seven rights of medication administration. Emphasis was placed on the right individual and two sources required to ensure that the medication is administered to the right resident. What is considered a two-patient identifier? 1. Resident's photo on EMAR. 2. If the resident is alert and oriented ask the resident to identify him/herself and cross reference to picture on EMAR. 3. If the resident is not alert and oriented ask another staff member to verify. This is accomplished by walking up to the resident then confirming identity with another staff member and not using general descriptors such as resident with gray hair, the resident wearing a blanket to identify a resident. 4. Use resident's arm name band if they use one. A medication administration competency was completed for Nurse A [LPN8] before her next scheduled shift. A facility wide education for licensed nurses was initiated on the day of the medication variance. Education was provided emphasizing the correct of two identifiers during medication administration. Additionally, the education was placed on the dashboard in the electronic health record (EHR) for all nurses to view when in the EHR. A further drill down indicated that on the [name of unit] unit (the dementia unit) identifier (ID) bands were not being utilized due to resident's being nonadherent. The facility implemented a system change on the [name of unit] unit. Residents on the [name of unit] unit will now wear name ID bands. An order to check placement of ID band every shift has been implemented. Residents that are identified as nonadherent will be care planned and the second identifier will be another staff member physically identifying the resident vs a generalized statement the resident with the blanket. Were changes made to the care plan? Yes. If yes, please explain: vital signs monitored as ordered. Medication reviewed with on hold medication order. Were system changes put into place? Yes. If yes, please explain: The facility will have the Staff Developer/designee complete one random medication administration competency for agency nurses weekly x four, then monthly x three, then quarterly x three until 100% compliance is achieved. Results of audit will be reported and discussed in quality assurance (QA). During an interview on 02/26/24 at 4:05 PM, the Staffing Development Coordinator (SD) stated that after the incident, the nurse [LPN8] that gave the wrong medication to the wrong resident was immediately in-serviced and a medication observation was observed on her. The staffing coordinator Indicated that prior to the medication error, all nurses, including agency nurses, were in-serviced on appropriate identifiers to be used. Review of Medication Administration Inservice, provided by the facility and dated 08/07/23, revealed LPN8 attended the in-service. The in-service included a medication error scenario and talked about the seven rights of medication administration. Review of undated Seven Rights of Medication Administration for Nurses, provided by the facility, revealed Let's look at the rights of Medical Administration: 1. Right Individual: You need to check at least two sources to make sure you are giving the medication to the right person. Even if you know the patient well, it is possible to make a mistake and to give the medication to the wrong person. This can happen particularly when you are doling out medications to more than one patient at the same time. You can avoid errors by collecting medication for only one individual at a time. Do not hold onto the medication but instead give the medication to the patient immediately. Do not talk to anyone from the time you take the medication out of the locker and the time you give it to the patient. When you are giving out medications, focus on that task alone and do not do anything from the time you first have contact with the medication and the time the patient is given the medication. If there is any doubt that you are giving a medication to the wrong person, do not give the medication until you are sure you are giving it to the correct individual. 2. During medication administration observation on 02/27/24 at 8:34 AM while gathering R44's medication, LPN6 looked at R44's picture, but while administering medications, LPN6 did not use another source of identifier to appropriately identify R44. During medication administration observation on 02/27/24 at 9:46 AM while gathering R30's medication, LPN5 looked at R30's picture, but while administering medications, LPN5 did not use another source of identifier to appropriately identify R30. During an interview on 02/27/24 at 1:50 PM, LPN8 indicated that she had to write a statement for an incident that occurred while she was passing medication on the dementia unit. She stated that she had not worked in that unit before the day of the incident. She stated that most of the residents did not wear armbands, nor did their pictures in the EMAR look like them. She stated that the pictures on the EMAR were so old, she told the Director of Nursing (DON) that residents should have armbands on, and pictures should be updated. She stated that day she had to ask another staff member as to which resident was which. She stated that she did ask another nurse [LPN9] who the resident was; however, did not get a particular description of the resident [R9]. LPN8 stated the other nurse said that this resident was the one with a blanket and gray hair, as she was pointing in the direction of two residents [R9 and R32] but not being specific which resident was who. She claimed that she did not ask for further clarification. She claimed that the other nurse did not go over to either resident or say who was who. She stated that she was re-educated and worked at the facility after this incident. During an interview on 02/27/24 at 4:15 PM, the Staffing Development Coordinator stated that she gave all nurses an in-service on medication administration on 08/07/23. She stated that she went over the four resident identifiers, which were photos in the EMR, asked the resident their name, looked at their arm bands, and/or asked another staff to verify the resident, that nurses needed to follow during medication administration. She confirmed that these were the resident identifiers that were currently being used by nurses administering medication. She confirmed that LPN8 attended this in-service on 08/07/23. During an interview on 02/28/24 at 5:15 PM, LPN9 stated that the issue was identifying the residents at the time to give medication. She indicated that she described R9 and R32 to LPN8. She stated these two residents were African American, gray hair, females, sitting in the dementia unit's dining room. LPN9 stated she did not recall if R32 and R9 were sitting close together. She stated that LPN8 did not work on the dementia unit, so she was not familiar with the residents. She indicated that sometimes in the EMR, the pictures are old and did not reflect the resident's appearance at that time. She stated in addition, not every resident wore wrist bands. During an interview on 02/28/24 at 6:00 PM, the Director of Nursing (DON) stated that she expected staff who were administering mediation to use at least two identifiers to ensure that the medication was being given to the correct resident. She stated that nurses could use another staff member to identify the resident, asked residents their name if there was no cognitive impairment, using pictures in the EHR, and the nurse could use the resident's name band. During an interview on 02/29/24 at 12:38 PM, the ADON stated that the unit manager reported to her that LPN8 had made a medication error. She confirmed that R32 received R9's medications. She stated that she followed up with LPN8, asking her what happened, and LPN8 stated that the other staff said that R9 was the one with a blanket. During further interview, she stated that LPN8 recognized the medication error right away because there were two residents with blankets. The ADON stated that R32 liked her blanket on her lap and R9 liked the blanket over her head. She stated that LPN8 completed training afterwards. She stated in addition, pictures were discussed about being updated. During an interview on 02/29/24 at 3:20 PM, LPN6 confirmed that back in August 2023, she was trained over the phone about the necessary identifiers when administering medication. LPN6 stated these were wrist band, photo, asking resident their name, and/or getting another staff member. During an interview on 02/29/24 at 3:45 PM, LPN5 confirmed that she should have used at least two identifiers when administering R30's medication. She stated that R30 had an arm band on his wheelchair; however, she did not look at it. She stated that she received training upon hire regarding this. Review of facility's policy titled,. Resident Identification, revised 12/26/22, revealed The law requires nursing home to promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination. To meet federal guidelines the facility will identify the residents to provide care. Procedure: 1. All residents' information will be entered in the EMAR once admitted to the facility and will be updated as needed. 2. Information from the referral sources will be used in conjunction with the family/resident interview. 3. Identification of residents prior to all tasks rendered to the residents. 4. The facility will update the resident's picture as needed. Resident Identifier: A. When asking the resident for their name, cross reference resident name with EMAR. B. May use residents' photo from the EMAR. C. May use residents name band/bracelet. D. May resource other staff. Review of facility's policy titled, Medication Administration, dated 04/01/20, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 3. Identify resident by photo in the medication administration record (MAR).

Based on observation and interview, it was determined that the facility failed to maintain safe water temperatures for the sinks in resident bathrooms and a shower room on one out of three resident units. Additionally, one out of four of the facility's boilers was set to 141 degree's. Findings include: 3/3/23 - Following initial pool observations of hot to touch water temperatures, the following water temperatures were obtained by E26 (Maintenance Director): 10:13 AM - room [ROOM NUMBER] bathroom sink water temperature was 122 F. 10:15 AM - Unit 300 shower room sink water temperature 131.5 F. 10:29 AM - room [ROOM NUMBER] bathroom sink water temperature 137.8 F. 10:31 AM - room [ROOM NUMBER] bathroom sink water temperature 125.0 F. During an interview on 3/3/23 at 10:35 AM, E26 reported that expected water temperatures for resident safety should be, Between 110 -115 degrees. E26 then went into the facility basement to do visual inspections of facility pipes. 3/3/23 11:14 AM - The Surveyor accompanied E26 to the facility boiler room. The temperature gauges of one of the facility's four boilers was set at 141 degrees. E26 reported he would adjust the boiler to a reduced temperature for resident safety. 3/3/23 2:11 PM - 2:20 PM - The Surveyor accompanied E26 to measure the water temperatures for the bathroom sinks for rooms, 303, 311, 317 and the 300 unit shower room. All of the sinks had returned to safe water temperatures of less than 115 degrees. 3/7/23 - E1 (NHA) provided the Surveyor a copy of an email from an outside contractor's report that indicated, Rooms closer to your water heater were getting hot .recommend replacement of the mixing valve needs for more uniform dispersal of hot water to all rooms. Findings were reviewed during the exit conference on 3/10/23 at 12:30 PM with E1 (NHA) and E2 (DON).

Based on observation and interview, it was determined that for one (R107) out of six residents reviewed for ADL's, the facility failed to ensure dignity when a soiled blanket was observed on the resident. Findings include: 3/6/23 12:30 PM - R107 was observed in bed covered by a blanket with four moderately sized areas of a brown crusted and smeared substance visible on the blanket. During an interview on 3/6/23 at 12:45 PM, E20 (CNA) confirmed the areas and stated she will remove the blanket and place it in the laundry. Findings were reviewed during the exit conference on 3/10/23 at 12:30 PM with E1 (NHA) and E2 (DON).

Based on interview and review of facility documentation, it was determined that for one (R98) out of three Medicare Part A discharges reviewed, the facility failed to provide notice to R98's financial Power of Attorney (POA) regarding the discontinuation of his Medicare Part A coverage for skilled services. Additionally, the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms were left unsigned with a handwritten note that stated the resident refused to sign. Findings include: Review of R98's clinical record revealed: 11/23/22 - R98 was admitted to the facility with a past medical history of bleeding inside the skull. R98's face sheet or personal profile revealed that he was assigned a financial POA. R98 started Medicare Part A skilled services on this date. 11/29/22 - R98's Admission Minimum Data Set (MDS) assessment documented that R98 had a Brief Interview of Mental Status (BIMS) of 12 meaning moderate cognitive impairment with poor decision making and requiring cues and supervision. 1/4/23 - R98 was discharged from Medicare Part A skilled care services and remained living in the facility as a long-term care resident. 3/3/23 - A review of R98's SNF Beneficiary Notification documented by E5 (Social Service Director - SSD) and E25 (Social Service Worker), dated 1/2/23, revealed, Resident presented (with) NOMNC & ABN. Refused to sign both. 3/7/23 2:02 PM - During an interview, R98 stated that he did not recall being presented with any Medicare forms or refusing to sign such forms. R98 further stated, I don't remember refusing to sign anything. 3/7/23 3:01 PM - In an interview, E5 (SSD) stated, The resident is his own responsible party, but has a financial POA. When asked if R98's POA was notified of the Medicare Part A discharge forms, E5 stated, He [R98] is a BIMS of 12, he is his own responsible party. I did not notify his POA because it was about his own personal care and his therapy ending, but I get it, best practice .the POA should have been notified. Findings were reviewed with E1 (NHA), E2 (DON), and E7 (ADON) during the Exit Conference on 3/10/23, beginning at 12:30 PM.

Based on observation and interview it was determined that for two (100 and 200) out of three units toured, the facility failed to ensure areas were in good repair. Findings include: 1. 3/3/23 8:13 AM - During an observation on the 100's unit, room [ROOM NUMBER] was observed with the wall nearest to the window having peeled paint and separation of the base board from the wall. 2. 3/3/23 11:05 AM - During an observation on the 200's unit, room [ROOM NUMBER]'s bathroom sink was observed with a missing faucet handle on the left side, the faucet was still operational. During an interview on 3/8/23 at 11:20 AM, E26 (Maintenance Director) confirmed the findings. Findings were reviewed during the exit conference on 3/10/23 at 12:30 PM with E1 (NHA) and E2 (DON).

Based on interview, record review and review of other facility documentation, it was determined that for one (R7) out of one sampled resident reviewed for grievances, the facility failed to ensure that concerns received by the facility included prompt efforts to resolve the problems. Findings include: A facility policy and procedure titled, Grievance Concern Process (updated 4/1/20) documented: Procedure: 5. Upon identification of a resident or resident representative concern, complete the grievance-concern form identifying the issue and forward the form to the Grievance Officer. Review of R7's clinical records revealed: 12/20/22 - R7 was admitted to the facility. 12/26/22 - R7's Admission MDS Assessment documented that R7 had a BIMS score of 13. 3/2/23 10:05 AM - During an interview, R7 stated, Another resident (R22) is asking me to marry her. I don't like that. In addition, R7 was observed to have a distressed facial expression and was tearful. 3/3/23 2:38 PM - In a follow up interview, R7 revealed he had spoken to his family about R22 making unwanted comments. R7 was distressed and tearful during the interview. 3/6/23 9:50 AM - In an interview R7 reported (R22) was throwing kisses at me on the weekend. I was crying. I was trying to stay away from her. It was after dinner. I told the nurse at the desk, she talked to (R22). 3/6/23 12:21 PM - During an interview, R7's RP1 (Responsible Party) stated, I have already told them (the facility) it really upsets him and my brother told them about it too. I talked to E4 (LPN) about this. 3/6/23 12:45 PM - During an interview, E4 stated, If a family member called and I am the Nurse who took the concern, I fill out a grievance form, notify the Social Worker and the Administrator. Additionally, E4 stated, If it's a nursing concern, I will make sure that I listen to the concern and let the DON (Director of Nursing) know. 3/6/23 1:00 PM - During a follow up interview, E4 stated I was told that it was not an enjoyable visit and that (R22) was very disruptive during the visit. E4 further confirmed and stated, I know that I dropped the ball with this and I know that I should have followed up with the grievance process. 3/7/23 - A review of the facility's grievance-concern log lacked evidence that a grievance concern was submitted for R7 and RP1's concern. The facility failed to promptly act on a concern, additionally no actions were taken to work towards resolution for the grievance involving R7. 3/10/23 Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the Exit Conference, beginning at 12:30 PM.

Based on record review and interview, it was determined that for one (R47) out of 33 sampled residents, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R47's oral cavity assessment when her use of the upper partial denture was not accurately coded. Findings include: Review of R47's clinical record revealed: 5/8/20 - R47 was admitted to the facility. 2/14/23 - R47's Quarterly Oral Cavity Assessment revealed that R47 had a partial upper denture. 2/21/23 - R47's Quarterly MDS Assessment revealed that R47 had no broken or loosely fitting full or partial denture. 3/2/23 1:52 PM - An interview with R47 revealed that she used to have an upper denture, but stopped wearing it when it went missing. 3/10/23 9:36 AM - During an interview, E6 (RNAC) confirmed that she did not know that R47 didn't know that R47 had a partial upper denture. E6 stated, I see these are not correct, I will make whoever did this aware. 3/10/23 - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the Exit Conference, beginning at 12:30 PM.

Based on record review and interview, it was determined that for one (R53) out of 33 sampled residents for care plan investigations, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings. Findings include: Review of the facility's policy entitled Comprehensive Care Plan, with an effective date of 4/1/20, stated, .The comprehensive care plan must be prepared with input from the IDT (includes but not limited to): - attending physician; - a registered nurse with the responsibility for the patient, - a nurse aide with responsibility for the patient, - a member of food and nutrition services staff . - other appropriate staff or professionals in disciplines as determined by the residents . The following was reviewed in R53's clinical record: 5/24/21 - R53 was admitted to the facility. 5/25/22 - An Annual MDS Assessment was completed. 6/2/22 - Review of the Multidisciplinary Care Conference (Care Plan Meeting) documentation lacked evidence of participation by the CNA and RN assigned to R53. For the Physician Summary section, E23 (LPN, UM) electronically signed for R53's Attending Physician (AP), E3. 8/24/22 - A Quarterly MDS Assessment was completed. 9/1/22 - Review of the Care Plan Meeting documentation lacked evidence of participation by the CNA and RN assigned to R53. For the Physician Summary section, E23 (LPN, UM) electronically signed for E3 (AP). 1/18/23 - A Quarterly MDS Assessment was completed. 3/1/23 - Review of the Care Plan Meeting documentation lacked evidence of participation by the CNA and RN assigned to R53. For the Physician Summary section, E23 (LPN, UM) electronically signed for E3 (AP). 3/7/23 10:32 AM - An interview with E5 (Social Services Director) revealed that for the above care plan meetings, E5 confirmed that the facility was unable to provide evidence that the RN and the CNA responsible for R53 participated in the meetings. E5 confirmed that R53's Attending Physician, E3 did not attend the meetings. 3/7/23 10:36 AM - An interview with E24 (CNA), who intermittently was assigned to provide care to R53, revealed that she was not invited to participate in the care plan meetings and does not recall being asked to provide information regarding care for R53. 3/8/23 11:54 AM - An interview with E23 (LPN) revealed that she was made aware of upcoming Care Plan Meetings for R53 following completion of the MDS assessments and she completed the Nursing and Physician Summary Sections of the Care Plan Meeting documentation. E23 verbalized that in completing the Nursing section, she would interview non-CNA staff and confirmed that the CNA responsible for R53 did not participate in completing this section nor the RN responsible for R53. For the Physician section, she completed the section by reviewing and documenting the most recent recertification progress note and electronically signs the Physician Summary Section with her name and title. 3/10/23 beginning at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observation, interview and record review, it was determined that for one (R88) out of six residents reviewed for ADL (Activities of Daily Living), the facility failed to provide nail care. Findings include: A facility policy and procedure titled, Activities of Daily Living (ADLS) - Maintain Abilities, updated 4/1/2020, documented: The facility will provide care and services for the following activities of daily living: a. Hygiene-bathing, dressing, grooming and oral care. Review of R88's clinical record revealed: 5/27/21 - R88 was admitted to the facility with a diagnosis of a stroke and left sided weakness. 5/27/22 - R88's Annual MDS Assessment documented R88 as totally dependent with physical assistance of one staff for personal hygiene and bathing. 11/25/22 - R88's Quarterly MDS Assessment documented R88 as totally dependent with physical assistance of one staff for personal hygiene and bathing. Review of R88's ADL care plan initiated on 3/29/22 (revised 2/28/23), revealed a lack of interventions to include the need for assistance with personal hygiene, bathing, dressing, grooming, and nail care for a totally dependent resident. 3/6/23 9:04 AM - A random observation of R88's hands revealed dried dark debris encrusted underneath each fingernail on the right hand. Additionally, R88's fingernails needed to be trimmed on both hands. 3/6/23 9:34 AM - During an interview, E20 (CNA) stated, We do nail care when it's needed and on their bath days. If the resident refuses, we tell the Nurse. 3/7/23 10:04 AM - R88 was observed and continued to have dry dark debris underneath each fingernail on the right hand, R88's fingernails on the right and left hands had not been trimmed. 3/7/23 10:06 AM - During an interview, E9 (RN) stated, Residents are given nail care when it is needed and on their shower days. 3/7/23 12:37 PM - During an interview, E21 (CNA) stated that R88 was totally dependent and that she gave (R88) a complete bed bath. When asked if E21 provided R88 nail care, E21 confirmed, No, I have not done her nail care yet. 3/7/23 12:48 PM - During an interview, E4 (LPN) stated, I will make sure they get cleaned and trimmed. 3/10/23 Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the Exit Conference, beginning at 12:30 PM.

Based on observation, interviews, and record review, it was determined that for one (R1) out of two residents sampled for ROM (Range of Motion), the facility failed to ensure that bilateral palm protectors were used to prevent a further decrease in ROM. Findings include: Review of R1's clinical revealed the following: 8/12/13 - R1 was admitted to facility. 1/1/22 - A Physicians order documented bilateral palm protectors with foam inserts provided for daily use. Check placement every shift. Apply bilateral palm protectors with inserts to both hands, on at all times except for hygiene, therapy, and skin inspections. 1/1/22 - A Physicians order documented to ensure palm protectors are received back from laundry, every day shift Friday. 4/14/22 - A care plan for R1's contractures of the fingers related to decreased mobility included interventions of bilateral palm protectors to be on at all times, off with hygiene care, as tolerated. Also, wear palm protectors to hands every shift, check skin underneath the palm protector every shift, and report to Nurse any signs of skin breakdown, as tolerated. 4/14/22 - A care plan for potential skin impairment related to palm protectors to bilateral hands included an intervention to clean the palm protectors every Friday. 3/2/23 11:37 AM - R1 was observed sitting in a wheelchair with no palm protectors in place. 3/2/23 1:02 PM - R1 was observed sitting in the dayroom with no palm protectors in place. 3/3/23 9:25 AM - R1 was observed in bed with no palm protectors in place. 3/7/23 10:06 AM - An interview with E16 (LPN, UM) confirmed if palm protectors are unavailable, nursing staff may apply alternatives such as a rolled washcloth or carrot. 3/7/23 12:48 PM - An interview with E17 (Therapy Director) revealed that if orthoses (R1's palm protectors) are in laundry, it was acceptable to use alternatives. E17 was unaware that R1 did not have orthoses on 3/2/23 or 3/3/23. E17 stated that therapy offers palm protectors or carrots to replace the orthoses and keeps extra palm protectors in place if needed. 3/7/23 1:04 PM - An interview with E18 (CNA) confirmed that R1's palm protectors were in laundry on 3/2/23 and E18 was unable to recall if alternatives were used. 3/7/23 1:06 PM - An interview with E16 (LPN, UM) confirmed that R1's palm protectors were in laundry on 3/2/23. Findings were reviewed with E1 (NHA) and E2 (DON) during an exit conference on 3/10/23 at 12:30 PM.

Based on observation, interview, and record review, it was determined that the facility failed to provide routine dental services for two (R47 and R51) out of two sampled residents reviewed for dental services. Additionally, the facility failed to identify in the policy and procedure circumstances for when the loss or damage of dentures is the facility's responsibility. Findings include: A facility policy and procedure titled, Dental Services, updated 4/1/20, documented, 1. The facility will assist residents in obtaining routine and 24-hour emergency dental care .4. If any resident is unable to pay for dental services, the facility will attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs and maintain his or her highest practicable level of well-being. This can include finding other providers of dental services, such as a dental school or the provision of dental hygiene services at a site. The facility failed to have a policy that identified when it was the facility's responsibility to pay for and not charge the resident when loss or damage of dentures and/or partials were determined to be the facility's responsibility. 1. Review of R47's clinical record revealed: 5/8/20 - R47 was admitted to the facility. 8/24/21 - A Grievance/Concern form submitted by the facility for R47 documented that the resident reported a missing upper partial. Resolution of the concern, dated 8/27/21, revealed that R47 agreed to wait to be seen by the facility Dentist. 11/9/21 - A dental appointment notification form documented R47 was scheduled to see the Dentist on 11/11/21. 2/15/22 - A dental consultation note lacked evidence of R47's missing upper partial. 3/30/22 - A care plan for potential for alteration in oral status due to oral hygiene and periodontal disease with a revision date of 2/13/23, documented, . dental consults as ordered and indicated. 3/6/23 9:35 AM - An interview with E4 (LPN-UM) revealed that she was not aware that R47's upper partial was lost. 3/2/23 1:58 PM - During an interview, R47 revealed that the upper partial was lost when R47 was in another room in the facility. 3/6/23 10:20 AM - During an interview, E5 (Social Services Director) revealed that R47 was her mother. E5 stated, I can tell you that she had a partial, she wanted to be seen by the Dentist. In addition, E5 revealed that R47 had a tooth that needed to be pulled before R47 could be fitted for a new upper partial. E5 stated, My mother did not want to get the tooth pulled, she didn't want all those needles and things done. E5 revealed that her mother stated, No, I'm eating without them, I don't want those needles. 3/9/23 1:10 PM - In a follow up interview, E5 revealed that the facility was behind in getting their residents scheduled to be seen by the Dentist. E5 stated, My mother was not seen by the Dentist on 11/11/21 because there were so many residents to be seen, but she saw him on 2/15/21. 3/10/23 9:04 AM - During an interview with E1 (NHA) she stated, There is no documentation from the E28 (Dentist) that R47 refused to have the partial replaced. E1 revealed that R47 was going back and forth with whether or not she wanted the work done so no, the Dentist did not document her refusal. The facility failed to ensure that R47 obtained needed dental services after R47's upper partial was lost until six months later on 2/15/22. 20835 2. Review of R51's record revealed the following: 10/10/19 - R51 was admitted to the facility. 4/1/20 - The Annual MDS Assessment documented that R51 did not have any broken or chipped teeth. 3/26/21 - A dental service invoice documented that routine dental services were performed on R51 on 3/26/21. There was lack of evidence of any routine dental consultation since 3/26/21. 3/2/23 2:11 PM - During an interview, R51 revealed that she has a chipped tooth and has not had a routine dental evaluation for over a year. 3/6/23 12:27 PM - An interview with E5 (Social Service Director) confirmed that R51's dental consultation was in 2021 and added that arrangements for routine dental services were behind due to changes in the dental provider. E5 confirmed that routine dental consult are to be offered minimally on an annual basis and E5 confirmed that R51 was not offered a routine dental consult in 2022 nor was R51 scheduled for an upcoming consultation. 3/10/23 beginning at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on review of clinical records and other documentation and interviews, it was determined that for 2 (R39 and R97) out of 42 Stage 2 sampled residents, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being in accordance with each individual's plan of care. For R39, the facility failed to have a system to evaluate R39 with 0% meal consumption after receiving a fast acting insulin which led to a significant hypoglycemic episode requiring emergency medical services and the administration of two medications: [REDACTED]. For R97, the facility failed to follow current physician orders [REDACTED]. Findings include: 1. The manufacturer's prescribing information for Humalog insulin, last revised 11/16/15, stated, Humalog is a rapid acting insulin . administer Humalog by subcutaneous injection within 15 minutes before a meal or immediately after a meal . the dosage of Humalog must be individualized based on the . individual's metabolic needs, blood glucose monitoring results . under Warnings and Precautions: . [DIAGNOSES REDACTED]: may be life-threatening. Monitor blood glucose and increase monitoring frequency with changes to . meal pattern . dosage adjustments may be needed with changes . in meal patterns ( . timing of food intake) . other factors which may increase the risk of [DIAGNOSES REDACTED] include changes in meal pattern (e.g. timing of meals) . [DIAGNOSES REDACTED] . may be treated with intramuscular/subcutaneous [MEDICATION NAME] or concentrated intravenous glucose. R39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R39 was care planned for potential for complications related to diabetes mellitus, last revised on 4/1/16. R39's goal was that he would not have significant complications related to . [DIAGNOSES REDACTED] episodes x 90 days. Interventions included: diet as ordered, patient education on dietary management, patient education s/s (signs and symptoms) of possible complications and praise for good dietary compliance. In addition, R39 was care planned for actual infection: UTI, last revised on 4/1/16, with an intervention to monitor food/fluid intakes. R39 had the following active physician orders [REDACTED].>- Accu-check before meals and at bedtime for [DIAGNOSES REDACTED]. - Humalog insulin 100 unit/ml - administer 8 units before meals. - Humalog insulin 100 unit/ml - administer per sliding scale before meals: If blood sugar is less than 80, call MD; If blood sugar is 80 to 250, give 0 units; If blood sugar is 251 to 300, give 2 units; If blood sugar is 301 to 350, give 4 units; If blood sugar is 351 to 400, give 6 units; If blood sugar is greater than 400, call MD. - [MEDICATION NAME]100 unit/ml - administer 18 units at bedtime. 4/18/16 at 7:30 AM - R39's accu-check was 182 and he was administered 8 units of the routine dose of Humalog insulin. R39 ate 100% of breakfast and drank 360's ml's of fluid. 4/18/16 at 11:30 AM - R39's accu-check was 311 and he was administered 8 units of the routine dose of Humalog insulin plus 4 units of Humalog insulin per the sliding scale. R39 ate 75% of lunch and drank 120 ml's of fluid. 4/18/16 at 12:14 PM - A physician's progress note stated that she was asked to see R39 for increased confusion and delusions. The progress note stated that R39 was alert and oriented, slow to respond and able to converse appropriately. The progress note stated that R39's increased confusion was due to progressive dementia and multiple diagnostic tests were ordered, including an urinalysis. 4/18/16 - According to the MAR, R39's accu-check was 102 and he was administered 8 units of the routine dose of Humalog insulin, which were both documented at 4:50 PM by E4 (RN). The facility's Meal and Intake Sheet stated that R39 did not eat dinner or drink. 4/18/16 at 8:22 PM - A nurse's note stated, At 19:45 PM (7:45 PM) CNA called this Nurse (E3) to check on resident. According to CNA she was about to check the resident for incontinence when she noticed that resident tongue was sticking out and was drooling and mouth foamy. CNA tried to wake him but unresponsive. On assessment resident diaphoresis accu-check was done with 120 . result and also noted decerebrate posturing while taking vital signs. Called resident name but does not respond chest rub done still did not respond. VS T-94.5, P-66, R-16, BP-237/101, O2 sat-90% . order to send to hospital for further evaluation. 911 was called and resident left . at 2012H (8:12 PM) . The ALS report on 4/18/16 stated the following: Primary impression: [DIAGNOSES REDACTED] . Upon arrival, R39 was found in a semi-fowlers position in bed, slumped over to the left, drooling and unconscious. Facility staff stated that R39 was last seen at 5:30 PM and he is hypertensive, diabetic and had a blood glucose of 120 . During transport, ALS reassesses the Pt and finds him to have a bgl of 41 . give 1 mg of [MEDICATION NAME]. After administration of [MEDICATION NAME], IV is established . Pt's bgl is rechecked just prior to arrival at (hospital) ER . is now 39 . It was unclear how the blood sugar was 120 at 7:45 PM in the facility and now 41 at 8:25 PM during transport. The ALS timeline on 4/18/16 was as follows: - 8:05 PM, dispatch notified. - 8:07 PM, ALS unit enroute to facility. - 8:12 PM, ALS unit arrived at patient's bedside. - 8:14 PM, ALS vital signs were blood pressure 230/120, pulse 70, respiration 22, SpO2 95% on low O2 concentration (1-6 L). - 8:15 PM, ALS - ECG interpretation: sinus rhythm. - 8:23 PM, ALS unit left facility. - 8:25 PM, ALS checked blood sugar, which was 41. - 8:27 PM, ALS administered 1 mg of [MEDICATION NAME] by intramuscular injection. Response: unchanged. - 8:29 PM, ALS obtained IV access and obtained blood draw. Blood pressure 202/105, pulse 66, SpO2 99%. - 8:30 PM, ALS rechecked blood sugar, which was 39. - 8:32 PM, ALS arrived at hospital ER. R39's ER hospital records stated the following: - 8:38 PM, blood pressure was 183/102, pulse 77, respirations 18, SpO2 93% on 4 L of oxygen. - 8:38 PM, D50 [MEDICATION NAME] medication administered. - 8:48 PM, blood pressure was 163/95, pulse 73, respirations 18, 98% SpO2 on 4 L of oxygen. - 8:41 PM, blood glucose was 54. - 8:46 PM, R39 was moaning. - 8:50 PM, R39 was administered IV [MEDICATION NAME]. - 9:14 PM, blood pressure was 183/74, pulse 57, respirations 13, Temp 35.1 degrees C, SpO2 100% on 4L of oxygen. - 9:51 PM, blood pressure was 184/71, pulse 61, respirations 14, Temp 36.0 degrees C, SpO2 100% on 2L of oxygen. - 11:07 PM, blood pressure was 162/64, pulse 59, respirations 13, Temp 36.6 degrees C, SpO2 100% on room air. The hospital ER's assessment and plan stated, Patient initially found to be hypoglycemic and I suspect this is origin of patient's altered mental status . We'll administer D50 and repeat Accu-Chek (sic) . After receiving an amp of D50 patient's mental status immediately started improving. He woke up became combative. He moved all his extremities equally with good strength. His verbalizations are mostly moaning and screaming. He was given [MEDICATION NAME] IV . is improving after [DIAGNOSES REDACTED] . Final Impression . [DIAGNOSES REDACTED], UTI, altered mental status . Blood sugar 231 and 243 on repeat after D50. Further review of the hospital records revealed that blood pressure medication was not administered until 4/19/16 at 3:38 AM after R39 was admitted to a hospital medical floor. In an interview on 4/28/16 at 3:26 PM, E6 (CNA) stated that she was R39's routine assigned CNA. When asked about the events on 4/18/16, E6 stated that R39 wanted to go to bed before dinner and she persuaded him to stay up in his chair. Dinner was at 5 PM. R39's meal tray was delivered to the hallway on the second cart (approximately 10 minutes later) and she set it up in his room. E6 explained what was on the meal tray and offered him a drink as R39 was legally blind. R39 stated that he did not want to eat. E6 removed the meal tray and placed it back on the cart in the hallway then went to feed another resident. Between 5:45 PM and 6:00 PM, E6 returned to R39's room and offered him something to drink. R39 drank approximately 1 ounce of apple juice while E6 held the cup for him. E6 then put R39 to bed ensuring placement of his oxygen nasal cannula and exited the room. E6 stated that she returned to the room at approximately 7:45 PM to assist R39's roommate and found R39 laying in bed on the left side with saliva coming out of his mouth. E6 stated that R39 did not respond when she called him by name and that she could tell something was wrong. E6 immediately called E4 (RN) to the room. E6 stated that E4 tried talking to R39 and vital signs were taken. E4 asked E6 to call E3 (RN, UM), who was in another unit, to assist. E6 stated that E3 asked E4 what was R39's blood sugar level. During the interview, E6 stated that she did not tell E4 that R39 did not eat dinner nor did E4 ask her if he ate dinner before R39 was found unresponsive in his room. In an interview on 4/28/16 at 3:57 PM, E4 stated that she was the routine evening shift nurse for R39. On 4/18/16, E4 stated she performed her accuchecks but was not sure about the time. E4 stated that she saw a stack of trays in the hallway and at that point gave her insulin's between 5:00 PM and 5:15 PM then continued with her medication pass. E4 stated that CNA's were cleaning up meal trays and she was still giving out medications. E4 stated at approximately 7:45 PM, E6 stuck her head out of R39's room and yelled there was something wrong with R39. E4 stated that R39 was drooling, decerabrate hands, unresponsive and his oxygen nasal cannula was pulled off. E4 stated that E3 came from another unit, vital signs were taken and R39's blood sugar was 120. E4 stated that E3 called 911 and it took about 10-15 minutes for EMS to arrive. E4 stated that R39 was still unresponsive. E4 stated that E3 asked E6 if R39 ate and E6 said that he did not eat but drank some apple juice. E4 stated that the hospital ER called and spoke with E3 later and stated that R39's blood sugar was 40. E4 stated that she had no reason to believe that R39 would not eat or wasn't feeling well. E4 also stated that CNA's would tell her if residents refuse their meals. The facility failed to provide the care and services necessary to maintain the highest practicable physical well being in accordance with R39's plan of care when the facility failed to have a system to evaluate R39 with 0% meal consumption after receiving a fast acting insulin which led to a significant hypoglycemic episode requiring emergency medical services and the administration of two medications: [REDACTED]. Findings were reviewed with E2 (DON) on 4/28/16 at 4:30 PM. 2. R97 had a physician's orders [REDACTED].< 100 and call MD if > 400. R97 had a care plan for potential for complications related to diabetes, dated 4/19/16. Interventions included to administer medications as ordered. A. Review of the April 2016 MAR indicated [REDACTED]. A site was listed for the Insulin injection indicating it was given and there were no comments listed. There were also no nurse's notes written as to why the Toujeo [MEDICATION NAME] Insulin was given when the BS was < 100 and it should have been held according to the current physician's orders [REDACTED].>B. Review of the April 2016 MAR indicated [REDACTED]. A site was listed for the Insulin injection and there were no comments listed. There were also no nurse's notes written as to why the Toujeo [MEDICATION NAME] Insulin was given when the BS was < 100 and it should have been held according to the current physician's orders [REDACTED].>C. Review of the April 2016 MAR indicated [REDACTED]< 100 and call MD if > 400. Review of the April 2016 MAR indicated [REDACTED]. A site was listed for the Insulin injection and a comment was written held to after breakfast. There were no nurse's notes written as to why the Toujeo [MEDICATION NAME] Insulin was given when the BS was < 100 and it should have been held according to the current physician's orders [REDACTED].>D. A nurse's note, dated 4/29/16 and timed 8:04 AM, stated that R97's BS was 50 at 7:00 AM and he was given insta-glucose (to raise his BS). R97's BS was 65 when rechecked at 7:30 AM and at that point, he was given 8 ounces of orange juice. Upon recheck at 7:45 AM, R97's BS was 98 and MD made aware and nurse was directed to hold all morning insulins. R97 also had sliding scale coverage with another type of Insulin based on his BS results, dated 4/21/16, however, it was only for 11:30 AM and 4:30 PM BS's and coverage started with BS's of 151 and above. Review of the April 2016 MAR indicated [REDACTED]. Two conflicting comments were written by nursing at 8:11 AM, stating, Not Administered . MD request to hold and . insulin held until after resident eat (sic). It is unclear by the comments written whether Toujeo [MEDICATION NAME] Insulin was administered or not, and if so, what time it was administered. R97 also had a physician's orders [REDACTED]. MAR indicated [REDACTED]. Two conflicting comments were written by nursing at 8:11 AM, stating, Not Administered . MD request to hold and . insulin held until resident eats. It was unclear by the comments written whether [MEDICATION NAME] was administered or not, and if so, what time it was administered. A nurse's note, dated 4/29/16 and timed 10:13 AM, stated, . (name of physician) assessed . Med review completed . new order to change accu checks . with sliding scale. Decrease Toujeo to 40 units in the AM . hold [MEDICATION NAME] if blood sugar less than 200 . A physician progress notes [REDACTED]. [DIAGNOSES REDACTED]: appetite poor this AM, will hold Toujeo and [MEDICATION NAME] . Concerns were discussed with E2 (DON) during a telephone interview on 5/3/16 at 4:15 PM. E2 stated she would discuss concerns with E14 (LPN) the next morning. E2 was interviewed again via telephone on 5/4/16 at 8:40 AM. E2 stated it was E14's day off, however, she talked to him via telephone and E14 reported that for all of the above examples when R97's BS was < 100, a physician was present and aware of R97's status. E2 also stated that E14 further told her that the physician gave verbal orders to give the Insulins after breakfast, however, he forgot to write the physician orders. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for R97 in accordance with his comprehensive assessment and plan of care. The facility failed to follow current physician orders [REDACTED].< 100, Toujeo was given despite a parameter to hold for BS < 100) and although listed as held on the MAR indicated [REDACTED]. Additionally, the facility failed to obtain new physician orders [REDACTED]. Concerns were discussed with E2 during an exit conference on 5/4/16 at 11:45 AM.

Based on clinical record review, staff interview and review of hospital records, it was determined that for one (R3) of seven (7) residents sampled, who had a pressure sore (ulcer), the facility failed to provide the necessary treatment and services to promote healing and to prevent infection. The facility failed to monitor and assess R3's pressure ulcer when treatments were provided in order to identify worsening of the ulcer and signs of infection. Record review revealed that weekly changes in the wound were only documented by the consultant wound care nurse. While facility staff provided the wound treatments there was no evidence in the clinical record that staff assessed the wound. Upon admission to the hospital, R3's pressure sore was found to be infected. Findings include: R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Admission Assessment, dated 5/29/12, stated that R3 was admitted with a Stage 2 pressure ulcer (partial thickness loss of dermis (inner layer of the two main layers of cells that make up the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (layer or mass of dead tissue separated from surrounding living tissue); may also present as an intact or open/ruptured blister) on the sacrum (triangular shaped bone at bottom of spine). A Braden Score (tool used to determine risk for development of pressure ulcers) of 11 (severe risk score of 9 or less; high risk score of 10 to 12; moderate risk score of 13 to 14; mild risk score of 15 to 18), completed on 5/29/12, indicated R3 was at high risk for development of pressure ulcers. The facility developed a care plan, dated 5/31/12 for the problem of potential for pressure ulcers. Care plan interventions included air overlay mattress on bed, turn and reposition every 2 hours and as needed, monitor for nutrition/hydration, weekly skin checks on shower days by nurse, and preventative skin measures as ordered. The 6/4/12 admission Minimum Data Set (MDS) assessment stated R3's cognitive skills for daily decision making were moderately impaired and that the resident was totally dependent on facility staff for all activities of daily living (ADLs). The 6/4/12 MDS assessment also stated that R3 was incontinent of bowel and bladder and was at risk for development of pressure ulcers. R3's admission weight on 5/29/12 was 189.6 lbs (pounds). Review of physician's orders [REDACTED]. On 6/20/12, R3's weight was 178.6 lbs. A 6/21/12 nutrition note stated that the resident was accepting SF shakes well, but that meal intakes were suboptimal and that she had experienced a significant weight loss in approximately 2 weeks. On 6/21/13 a physician's orders [REDACTED]. Review of the June 2012 meal consumption records revealed that R3's intakes were poor, ranging 25-50% with refusals. The June 2012 meal intake sheets also documented that the SF shakes were consumed at 100% and that bedtime snacks were offered. The clinical record review revealed that treatment was provided as ordered and that the Stage 2 pressure ulcer was healed on 7/3/12. A physician's orders [REDACTED]. Review of meal consumption records revealed that R3's intakes continued to decline and that R3's weight was 175.5 lbs on 7/25/12. The clinical record documented that the resident's intake was poor, despite staff and family attempting to feed. A nurse's note, dated 7/25/12 and timed 1:15 PM stated that per the family, they want to keep the current plan of care and want to avoid the placement of a PEG tube (percutaneous endoscopic gastrostomy - used to feed nutrients directly into the stomach). Review of R3's meal intakes through August 2012 revealed that intakes continued to decline. The clinical record revealed that R3 had an upper gastrointestinal endoscopy (looking inside the body with a device with a light attached) performed. This exam revealed that R3 had a large, ulcerated mass in the upper region of the stomach which was felt to be causing discomfort, decreased appetite and the refusal to eat. Surgery to remove the mass and place a PEG tube was scheduled for 9/4/12. Review of the clinical record from 7/3/12 through 8/16/12 revealed documentation that R3 was turned and repositioned every 2 hours, that every 2 hour skin checks and weekly skin checks were completed, that nutrition/hydration was monitored and that the prescribed EPC cream was applied. A nurse's note, dated 8/16/12 and timed 11:00 PM, stated that R3 had an open area measuring 1.5 centimeters (cm) on the sacrum with no drainage noted, that treatment was initiated and that the physician was notified. There were no additional notes or documents found in the clinical record regarding this wound. The clinical record lacked evidence that this new pressure ulcer on R3's sacrum was thoroughly assessed for staging of the wound, size, color and type of tissue in the wound bed, description of wound edges and surrounding tissue and presence of pain. A physician's orders [REDACTED]. This order failed to state the frequency with which the dressing was to be changed. Review of the treatment administration record (TAR) revealed that the Replicare order included a note that it be changed every three (3) days and as needed. The documentation revealed that the Replicare was changed on 8/17/12 and 8/20/12. On these two (2) days there was no evaluation of the wound noted in the clinical record (e.g., condition of wound, presence of any complications such as increasing signs of infection, redness around the wound, increased drainage, etc.). A care plan was initiated on 8/17/12 for actual pressure ulcer sacral (sacrum) area. Interventions included measure on weekly wound rounds, notify of worsening wounds and treatment per MD (Medical Doctor) order. On 8/20/12 an order was written to discontinue the previous treatment to the pressure ulcer and to start cleansing the open area on the sacrum with NSS, apply [MEDICATION NAME] (absorbent wound dressing), cover with foam dressing daily and as needed. There was no assessment noted in the clinical record of the current status of this wound when this order was written. The 8/20/12 change of orders indicated that the wound had deteriorated, but there was no documented assessment of this wound in the clinical record. The TAR documented that the treatment was completed on 8/20/12 and 8/21/12. There was no documentation regarding the condition of the wound on these 2 days. On 8/21/12 (5 days after the wound was first identified), the first Wound Evaluation Form was completed by C1 (Nurse Practitioner/Wound Care Consultant - NP/WCC). This form stated that the sacral wound was due to pressure, that it's initial Stage was II (2), that it's visual Stage was III (3) (full thickness tissue loss; Subcutaneous fat may be visible but bone, tendon or muscle is not exposed; Slough may be present but does not obscure the depth of tissue loss; May include undermining and tunneling), that there was light drainage, the wound bed color was 90% yellow, 10% red and that the periwound (area of skin surrounding a wound) was red. An order was written on 8/21/12 for the wound to be cleansed with NSS, apply Santyl (enzymatic debrider - topical enzyme aids in removal of dead tissue), add [MEDICATION NAME], cover with foam dressing change daily and as needed. C1 visited the facility once a week in order to evaluate wounds. Review of the TAR revealed the treatment was signed off as completed on 8/22/12, 8/23/12 and 8/25/12 through 8/31/12. There were no initials for 8/24/12 to signify that the treatment was completed that day. Additionally, there was no other documentation regarding assessment of the condition of the wound on these days. There was no evidence that facility staff increased assessment and monitoring of this wound after was found to have worsened on 8/21/12 by the NP/WCC. On 8/28/12 a weekly Wound Evaluation was completed by C1. The form stated that R3's wound was a visual Stage III, measured 2 x 2 x UTD (unable to determine), had light serous (transparent, pale yellow body fluid) drainage, the wound bed was 90% yellow and 10% black, slough and necrosis (death of body tissue) were present, there was no tunneling or undermining and that the periwound was red. This form also documented that the wound had worsened and the treatment remained to cleanse with NSS, apply Santyl, add [MEDICATION NAME], cover with foam change daily and as needed. Again there was no evidence that facility staff increased their monitoring or that assessments were completed after R3's pressure ulcer deteriorated further. Review of the September 2012 TAR revealed that during the monthly recheck and reorder of treatments, the facility failed to transcribe the correct treatment order onto the TAR. The TAR indicated to cleanse the sacral open area, apply [MEDICATION NAME] and cover with foam dressing daily and as needed. The TAR failed to include the order for Santyl. The TAR revealed that from 9/1/12 through 9/4/12, Santyl was not applied to the wound as ordered. There was no evidence of assessments of the wound being completed during this time. A nurse's note, dated 9/4/12 and timed 10:20 AM stated that the resident was waiting to be picked up at 10:30 AM for surgery and that her temperature was 96.8 degrees Fahrenheit (F). Review of the hospital Progress Record revealed a nurse's note, dated 9/4/12 (untimed) that stated "Pt's (Patient's) surgery cancelled temp (temperature) 39 degrees (Celsius = 102.2 F) pt c (with) quarter size sacral wound c + (positive) pus and purulent (containing pus - forms in infected tissue) drainage noted..." A second nurse's note, dated 9/4/12 and timed 6:40 PM stated "...large sacral wound documented, foul odor..." The hospital Patient Care Flowsheet - Medical/Surgical 5 Day sheet stated, "(6:30 PM): sacral decubitous (sic) ulcer noted, 3 cm x 3 cm x 3.5 cm (length by width by depth). The hospital physician's History & Physical, dictated on 9/5/12, stated "...Wound cultures grew gram-positive cocci (type of bacteria) in pairs and moderate gram-negative rods (type of bacteria)...Fever/sepsis probably secondary to sacral wound..." A hospital Infectious Disease consult note, dated 9/5/12, stated "...brought in for the procedure but noted to be febrile (elevated body temperature)...found to have a purulent infected sacral wound which was the likely source of her fever. The surgery for [REDACTED]. There is necrotic debris and then purulent liquid material just coming right out of the wound into the bed with some mild odor to the wound...White count 9.4 (cells that fight off infection and count increases; found within normal limits)...likely infected sacral wound is the cause of her fever..." Further review of hospital records revealed that on 9/6/12, R3's sacral wound was debrided (removal of dead tissue with a sharp instrument). During an interview with E2 (Director of Nursing) on 2/11/13 at 1:30 PM, E2 stated that they do not stage wounds when first identified, that the wound care nurse starts staging so that one person is consistently doing it. E2 stated that when the nurses are completing wound care daily they should be observing for any changes in the wound and reporting it to the physician if any are noted and then they would write a note. She stated that they did do this on 8/20/12 when there was a treatment change ordered. She acknowledged that a nurse's note should have been written documenting the change. In a second interview with E2 on 2/11/13 at 2:40 PM, she stated that she had spoken with staff that had changed R3's sacral dressings from 9/1/12 through 9/4/12 and they stated that maybe there was a slight increase in drainage but no odor or other signs or symptoms of infection. E2 stated that E4 (nurse that changed dressing on 9/4/12) noted on 9/4/12 that there was increased drainage but R3 was going out for surgery and was not seen by the wound care nurse for the weekly assessment. E2 provided the surveyor with a "New Wound - Alert" sheet, dated 8/16/12, identified as belonging to R3. The "New Wound - Alert" sheet was not a part of R3's medical record. It stated the wound area was pink with no odor or drainage and measured 1.5 cm by 0.05 cm. A written statement completed by C1, dated 2/12/13 was submitted to the surveyor on 2/14/13 for review. This statement indicated that the wound initially presented as a Stage II and progressed to a Stage III. C1 further writes that no harm occurred to R3 by the application of [MEDICATION NAME] instead of Santyl. C1 writes that upon her assessments there were no clinical signs of infection. However the record indicates that C1 last assessed the resident on 8/28/12, 7 (seven) days before her admission to the hospital on [DATE]. The facility failed to consistently assess and monitor R3's wound as it continued to worsen. The facility failed to ensure that R3 received the necessary treatment and services to promote healing and prevent infection.