Every finding on record at Kutz Rehabilitation and Nursing

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every twelve months for five (E17, E18, E19, E20 and E21) out of five sampled employees. Findings include: 3/3/26 1:38 PM - Review of the following staff performance evaluations revealed a lack of evidence of a performance evaluation for the past year and was confirmed by E24 (former DON):1. E17 (CNA) had a hire date of 10/29/24. 2. E18 (CNA) had a hire date of 3/3/20.3. E19 (CNA) had a hire date of 3/26/15. 4. E20 (CNA) had a hire date of 6/29/23.5. E21 (CNA) had a hire date of 1/20/12. 3/3/26 3:10 PM - Findings were discussed with E2 (DON).3/4/26 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview, record review, and review of other facility documents, it was determined for one (R10) out of three residents reviewed for abuse, the facility failed to ensure that the allegation of verbal abuse from a staff member was reported to the State Survey Agency within the required time. Findings included: 9/10/25 5:54 PM - A facility reported incident submitted to the State Survey Agency documented, Resident [R10] reported to [E6] SSD (Social Services Director) that on 8/22/25 during the 11 PM to 7 AM shift he went outside off campus to smoke and when he returned to the facility and started walking toward the [unit number] unit's nursing station and he had an encounter with [E7] (RN.) Per R10, E7 stated, [R10] when I am here on the night shift, you are not allowed to [expletive] go outside. E10 reported that he replied, I don't know who the [expletive] you are talking to, but you can't talk to me like a piece of [expletive.] R7 replied, If you go out that door, I am telling the staff not to buzz you back in.2/26/26 11:00 AM - During an interview, the Surveyor asked E1 about why the incident report was submitted to the State Survey Agency on 9/10/26 when the resident reported the incident on 8/23/25. E1 stated, We thought it was more like a grievance and was investigating it that way. When we realized that it was actually a reportable incident and we reported it right away.The facility failed to report the allegation of verbal abuse with the 2-hour reporting requirement.2/26/26 2:20 PM - Findings were confirmed with E1 (NHA) and E2 (DON.)3/4/26 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview, record review, and review of other facility documents, it was determined for one (R10) out of three residents reviewed for abuse, the facility failed to ensure that R10 was free from verbal abuse from a staff member. Findings included: 12/2017 - A facility document entitled, Resident Abuse Prevention, Protection, Identification, Suspected Crime, Incident Reporting and Investigation Policies and Procedures, revised 12/2022, 12/2023, 3/2024, 3/2025, and 5/2025 included, The facility will prohibit, prevent and not tolerate residents to be subjected to abuse.by anyone, including staff members.R10's clinical record revealed:1/10/25 - R10 was admitted to the facility with diagnoses, including but not limited to, cancer of the rectum. 7/15/25 - R10's quarterly MDS assessment documented a BIMS score of 15, indicating a fully intact cognitive status. R10's MDS also documented that he was independent for ambulation with a rolling walker.9/10/25 5:54 PM - A facility reported incident submitted to the State Survey Agency documented, Resident [R10] reported to [E6] (SSD) that on 8/22/25 during the 11 PM to 7 AM shift he went outside off campus to smoke and when he returned to the facility and started walking toward the [unit number] nursing station and he had an encounter with [E7] (RN.) Per R10, E7 stated, [R10] when I am here on the night shift, you are not allowed to [expletive] go outside. E10 reported that he replied, I don't know who the [expletive] you are talking to, but you can't talk to me like a piece of [expletive.] R7 replied, If you go out that door, I am telling the staff not to buzz you back in.9/16/25 - The facility's 5-day follow up report submitted to the State Survey Agency documented that based on the facility's investigation and review of video camera recording the allegation of verbal was substantiated and E7 was terminated.2/26/26 9:00 AM - During a telephone interview, E9 (CNA) stated, The nurse [E7] was upset that night because she was called to come into work. I saw and heard her talking to the resident [R10] loudly about his smoking. She also used curse words at him when he answered her back. The Surveyor asked E9 why this incident was not reported to the facility's administration right away. E9 stated, It was during the night shift and she [E7] was the supervisor.2/26/26 9:30 AM - During a telephone interview, E8 (RN) stated, I saw the nurse talking to the resident, but I was too far away to hear what they were saying.2/26/26 10:00 AM - During a telephone interview, E7 stated, I was the on-call nurse, and I was called to come into work. I spoke to the resident about going out to smoke, but I don't recall cursing at him.2/26/26 11:00 AM - During an interview, the Surveyor asked E1 (NHA) about why the incident report was submitted to the State Agency on 9/10/26 when the resident reported the incident on 8/23/25. E1 stated, We thought it was more like a grievance and were investigating it that way. When we realized that it was actually a reportable incident, we reported it right away.2/26/26 1:30 PM - The facility provided the Surveyor with abuse prevention and resident protection education that was provided to the staff. During a combined interview, E14 (CNA), E15 (LPN), E17 (CNA), E20 (CNA) and E21 (CNA) confirmed that they received education and training on abuse prevention. Based on review of the facility corrective actions, interview with staff members and no further episodes of abuse, this deficient practice is considered past non-compliance with a correction date of 9/12/25.2/26/26 2:00 PM - Findings were confirmed with E1 and E2 (DON.) 3/4/26 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined for one (R81) out of three residents reviewed for accidents, the facility failed to ensure that R81 received adequate supervision and assistance to prevent accidents to the extent possible. Findings include: 3/17 - A facility document entitled, Falls, revised 2/25 and 3/25, included, To institute individualized practices to minimize the resident's risk of falling and to maximize safety from falls .High Risk - a Fall Risk Evaluation score of 6 or greater.R81's clinical record revealed: 1/17/18 - R81 was admitted to the facility with diagnoses including, but not limited, to left side weakness after a stroke. 2/6/18 - R81's care plan for bed mobility included, Extensive - total dependence, support of two persons. 5/26/25 - R81's fall risk evaluation documented a score of 10, indicating a high fall risk. 5/28/25 - R81's quarterly MDS assessment documented a BIMS score which indicated an inability to participate in a cognitive assessment. The MDS also documented that R81 was completely dependent on the staff for all activities of daily living. 8/22/25 8:30 PM - A facility reported incident report submitted to the Division included, At 1730 [5:30 PM] during peri care from his aid, the resident was turned on to his side and fell from the bed to the floor. The resident suffered head trauma and is on blood thinners .the resident was sent to the ER [Emergency Room] for evaluation .8/23/26 4:00 AM - R81 returned to the facility from the ER. The ER report included, .A small laceration on the top of your scalp, this has been fixed by tying a knot with your hair to bring the edges of the laceration together and securing it with some glue.2/26/26 10:00 AM - The Surveyor attempted to call the staff member who took care of the resident when the fall occurred. The phone call was not answered. During an interview, E1 (NHA) stated that education on safe patient handling was provided to the aide. The Surveyor asked education was provided to other staff member. E1 stated, No.2/26/26 11:10 AM - A review of the facility's corrective action after the fall revealed that the staff member who provided care for R81 during the fall received education on fall prevention. The facility lacked evidence that timely education for other staff members who provide care was provided.2/26/26 2:20 PM - Findings were confirmed with E1 (NHA) and E2 (DON.) 3/4/26 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record reviews, it was determined that for two (R16 and R79) out of six residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure each dependent resident received the necessary services to maintain grooming and personal hygiene. For R16, the facility failed to provide incontinence care during the evening shift when her clothes and linens were found saturated with urine. For R79, the facility failed to ensure that R79's morning care was done when he was found wearing his pajamas in the afternoon. Findings include: 1. Review of R16's clinical record revealed:6/19/24 - R16 was admitted to the facility with diagnoses including dementia.7/24/24 - R16 was care planned for impaired thought processes related to dementia.10/30/24 - R16 was care planned for ADL self-care performance deficit related to osteoarthritis and dementia with interventions including partial to substantial assistance of one person for personal and oral care and scheduled toileting every 2 hours. R16 required one staff person for toileting and required partial assistance of one person staff to move between surfaces and as necessary.8/6/25 - A quarterly MDS (Minimum Data Set) assessment revealed that R16's cognition was moderately impaired with a BIMS score of 9. R16 dependent with toileting and required substantial/maximal assist with personal hygiene and upper and lower body dressing. R16 who required partial, moderate assistance with toilet transfer was frequently incontinent of bowel and bladder.8/19/25 - R16's August 2025 CNA (Certified Nurse Assistant) Documentation Survey Report revealed that on 8/19/25 during the 3-11 shift, E14 (CNA), the assigned CNA for R16 documented N/A or Not Applicable for R16's toileting schedule for 3-11 shift at 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM. 8/19/25 - A facility incident report submitted to the state agency revealed that E14 failed to provide incontinence care to R16 on the 3-11 shift. 8/22/25 - A Facility 5-day follow up summary report documented, [R16's] clothing and linen was observed by oncoming 11-7 am shift saturated with urine. E28 [LPN] from 3-11 pm shift confirmed findings when notified. CNA [E14] responsible for the for 3-11 pm care of [R16] states [R16] was resistant to care assist during shift, however E28 [LPN] nor E27 [RN] were notified to possibly provide assistance or documentation. Resident care was provided by oncoming shift CNA [E9]. Unable to prove resident care was given during shift to combat allegation . 3/3/25 1:48 PM - In a telephone interview, E9 confirmed and stated, I went to do my rounds and saw [R16's] clothing and linen saturated and soaked with urine. Her bed mattress was also wet. I cleaned and changed [R16] and I also cleaned and wiped her bed. I notified the nurse of the incident.3/3/26 3:00 PM - Finding was discussed with E2 (DON).2. Review of R79's clinical record revealed: 6/18/25 - R79 was admitted to the facility with diagnoses including dementia, stroke and weakness.6/27/25 - An admission MDS (Minimum Data Sheet) assessment revealed that R79's cognition was moderately impaired with a BIMS score of 11. R79 required setup or clean - up assistance with eating, partial/moderate assistance with oral hygiene and upper body dressing. R79 required substantial/maximal assistance with toileting, shower/bathing, lower body dressing and personal hygiene. 6/27/25 (revised 7/23/25) - R79's was care planned for ADL self - care deficit and interventions included but not limited to partial assistance by one staff person for dressing, partial to substantial assistance with personal hygiene and oral care and substantial assistance for toileting.8/4/25 3:11 PM - A facility incident report submitted to the state agency documented that R79's daughter in law [FM1] approached E22 (LSW) because [FM1] did not believe [R79] had received morning care. [R79] was still in his pajamas in bed when [FM1] arrived and [R79] had yet to receive his lunch tray.8/4/25 - A written statement by E16 (CNA) documented that between 8:30 AM and 9:30 AM R79 was eating breakfast. At 10:00 AM, E16 found R79 asleep in bed. At 12:55 PM, E26 (RN Sup) paged E16 and questioned if E16 had missed or had performed care on R79.8/4/25 2:59 PM - R79's August 2025 CNA (Certified Nurse Assistant) Documentation Survey Report revealed that on 8/4/25 on the 7-3 shift, R79's dressing task was marked completed by E16. 8/11/25 - A facility follow up summary documented that R79 was assigned to E16 during the 7-3 shift on 8/4/25. E16 confirmed that care was not provided to R79 prior to E26 questioning her.3/3/26 9:48 AM - In an interview, E22 stated that FM1 came to see her around 3:00 PM on 8/4/25 to report that R79's morning care was not done as he was still wearing his pajamas. She also confirmed that . Only after the family reported to me, and I notified the nurse, then the CNA changed [R79].3/3/26 1:55 PM - During a telephone interview, E16 confirmed that she was only able to change and provide care to R79 in the afternoon after she was called by E26. 3/3/26 3:35 PM - Finding was discussed with E2 (DON).3/4/26 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and review of clinical records and other documentation as indicated, it was determined that for four (R63 and R23) out of eight residents reviewed for falls, the facility failed to ensure that each residents' plan of care was followed to prevent accidents. For R63, the facility improperly transferred the resident using one staff person stand and pivot when R63 required two staff persons and hoyer lift. As a result, R63 was harmed when the resident sustained a lower leg laceration requiring sutures in the emergency room. For R23, a dependent resident for bed mobility, rolled off the bed on to the floor during incontinence care. R23 was sent to the emergency room after the fall. Findings include: A facility policy titled Falls revised 3/2025 documented . 1. To institute individualized practices to minimize the resident's risk of falling and to maximize safety from fall; and to assess each resident of their fall risk on admission, and on a regular basis . 2. The fall risk assessment will categorize the risk for falling according to the following criterion: 1. Low - Risk - a fall risk evaluation score of less than 6. 2. High - Risk - a fall risk evaluation score of 6 or greater. 1. Review of R63's record revealed: 9/19/24 - R63 admitted to the facility with diagnoses including, but were not limited to, dementia, aphasia and history of falls. 10/21/24 - A physician's order documented, Hoyer lift transfer assist of two person. 12/5/24 - R63's Fall Risk Evaluation documented that the resident was a high fall risk. 1/3/25 at 11:05 AM - The facility's incident report documented that E20 (CNA) was assisting resident with transfer from bed to wheelchair where he obtained a laceration to right lower extremity. Resident unable to give description . R63's POA and E11 (contracted Physician) were notified. 1/3/25 at 11:49 AM - E20's written statement as part of the facility's investigation documented, . was transferring patient from bed to chair and leg was up against the leg rest connector . blood running down patient leg, along with a (sic) open area . Were you being assisted by anyone . no assistant (sic) from anyone . 1/3/25 at 1:19 PM - The hospital record documented, . suffered a laceration of . right leg while transferring from his bed into . wheelchair . Wound was thoroughly irrigated . and then repaired with . sutures and then Steri-Strips were placed over top of the area . The facility failed to report R63's 1/3/25 incident to the State Agency as required. In response to this incident, the facility did the following: - on 1/6/25, E3 (SD) provided E20 (CNA) one-on-one education and return demonstration for safe resident transfers. The skill competency was documented and signed by both E3 and E20. 3/24/25 10:34 AM - During an interview, E20 confirmed that she stood R63 up to transfer, his feet got twisted, leg was bleeding and he was sent to the emergency room. E20 stated that it was her first day shift and she asked another staff person how R63 transferred and was told stand and pivot transfer. When asked about her training, E20 confirmed that she had training on resident transfers during her orientation in April 2024 and had one-to-one education after R63's incident. 3/21/25 12:21 PM - Finding was reviewed with E1 (CEO) and E2 (DON). 3/25/25 at 1:08 PM - During an interview with E1 and E2 regarding the QAPI efforts in the facility, E1 stated that the facility currently has an ongoing initiative with a high fall risk committee reviewing falls every Monday. 2. R23's clinical record revealed: 8/24/23 - R23 was admitted to the facility with the following diagnoses including, but were not limited to, large habitus (body structure), compressed lower back nerves, muscle weakness, nerve pain, anxiety and osteoporosis. 9/23/23 - R23's care plan for ADL (activities of daily living) self-care performance deficit related to (sic) unspecified abnormalities of gait and mobility with interventions to include: 1. Bed mobility the resident requires (sic) x1 staff to turn and reposition in bed and as necessary. 12/3/24 - R23's quarterly MDS documented, R23 required substantial maximum assistance to roll from lying on back to left and right side and return to lying on back on the bed. 12/3/24 - R23's fall risk evaluation revealed a score of 7 and was a high risk for falls. 12/4/24 - R23's quarterly MDS assessment revealed the resident was cognitively intact. 12/22/24 - R23's fall risk evaluation revealed a score of 7 and was a high risk for falls. 12/22/24 3:55 AM - A facility incident report documented, CNA did not assure resident positioning safety prior to attempting to provide care therefore contributing to the resident's fall onto floor. [E40] CNA assigned to educational courses for resident safety. Resident taken to ER (sic) for evaluation for complaints of pain and returned to facility within 24 hours with no acute findings. Bed enablers applied for additional positioning assistance. 12/22/24 - A facility statement for E40 (CNA) documented, I was giving [R23] care this morning at 4 AM she went to turn to her left side and continued forward out of the bed she had little to no room to actually move well from side to side when asked about a bigger bed for her I was told she was unable to get a bigger bed. 3/5/25 - R23's quarterly MDS assessment revealed the resident was cognitively intact. 3/18/25 - R23's care plan created on 9/23/25 was updated with a new intervention to turn and reposition: two-person assist with all turns and repositioning for safety. The intervention was added to R23's care plan at least three (3) months after the residents fall from the bed on 12/22/24. 3/20/25 2:05 PM - During an interview, R23 was observed lying in a standard sized bed on her back with a fall mat on the right and left side of the bed. R23 stated, I slipped out of the bed I was turning over and I fell out of the bed, the bed is not wide enough for me if I turn over, I am right here on the edge. R23 also stated. I'm afraid when I am being turned in the bed, I'm always on the edge of the bed no matter what, when I fell off the bed, I was right on the edge the aide could not grab me and then after that they put down mats, but I am still afraid of falling. 3/21/25 11:00 AM - During an interview E2 (DON) stated, [R23] is not bariatric weight we moved her room to give her more space in her room. E2 also confirmed all residents in the building have enablers that are attached on their bed. When E2 was asked about approaches to assist with preventing another fall for R23, E2 stated, I think the CNA was educated on proper turning and repositioning and to be careful when providing care for R23 when in the bed. 3/21/25 1:10 PM - During an interview with E16 (DOR), it was revealed that the current therapy department arrived in October 2024 and that all the beds in the facility had enablers on them. E16 stated and confirmed, [R23] had enablers on the bed in October 2024. Additionally, E16 stated, she is in a standard bed and because she is a large lady it is a tight fit she is afraid when turning in the bed, and nursing said that she does not meet the classification for a larger bed. The facility failed to ensure R23's safety when E40 asked R23 to turn in the bed during incontinence care and R23 rolled off the bed on to the floor. The resident was sent to the hospital emergency room after the fall. R23's ADL care plan intervention was not updated for 2 person staff assist for turn and reposition with all turns and repositioning for safety until 3/18/25. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

3. A review of R11's clinical record revealed: 3/24/21 - R11 was admitted to the facility. 11/16/24 - R11 was admitted to hospice care. 3/12/25 - A review of the medications on the 2/26/25 hospice plan of care document in the electronic medical record (EMR) compared to the medications that the facility had profiled for R11 in the facility EMR revealed the following discrepancies: -Ativan 0.5 mg by mouth every four hours as needed for agitation that was ordered by hospice on 11/16/24 was on the hospice medication list but not on the current facility medication list. -Miralax 17 grams, 1 scoop daily by mouth for constipation, was ordered by the facility on 11/1/24 was on the facility medication profile, but not on the hospice list of medications. -Omeprazole 40 mg, 1 capsule daily for reflux, was ordered by hospice on 11/16/24 was on the hospice medication list, but not on the current facility medication list. 3/11/25 1:50 pm - During an interview, E17 (RN/UM) confirmed that the hospice medications on R11's 2/26/25 hospice plan of care did not match the current medications that the facility was administering to R11. 4. A review of R18's clinical record revealed: 2/1/23 - R18 was admitted to the facility. 1/4/24 - R18 was admitted to hospice care. 3/12/25 - A review of the medications on the 2/26/25 hospice plan of care document in the R18's chart compared to the medications that the facility had profiled in R18's EMR revealed the following discrepancies: -Sertaline 50 mg, give by mouth daily, was ordered by the facility on 2/2/23, but it was not on the 2/26/25 hospice plan of care medication list. Sertaline is a medication to help mood disorders. -Trazodone 50 mg, give 100 mg by mouth daily at bedtime, was ordered by the facility on 12/12/24, but the dosage was different, it was listed on the 2/26/25 medication list as Trazodone 150mg by mouth daily at bedtime. Trazodone treats sleeping problems and depression. 3/14/25 9:20 AM - During an interview, E2 (DON) confirmed that the hospice medications on the R18's 2/26/25 hospice plan of care did not match the current medications that the facility was administering to R18. 5. A review of R54's clinical record revealed: 12/16/24 - R54 was admitted to the facility, already under the care of hospice. 3/12/25 - A review of the medications on the hospice plan of care document in the R54's chart compared to the medications that the facility had profiled in R54's EMR revealed the following discrepancies: - Trazodone 50 mg ½ tab by mouth daily, ordered by the facility on 12/17/24, was not on the hospice medication list. 3/14/25 9:25 AM - During an interview, E2 (DON) confirmed that the hospice medications on R54's hospice plan of care in the chart did not match the current medications that the facility was administering to R54. The facility failed to ensure that the most recent hospice plan of care included the services furnished by the facility. The most recent hospice care plan medication list for R11, R18 and R54 did not match the medications that R11, R18 and R54 were receiving from the facility.The medication discrepancies between the facility and hospice medications as described above could lead to a delay in symptom treatment for R11, R18 and R54. The facility and the hospice medications should match so that the end-of-life care is seamless and without potential care delays. Based on record review and interview, it was determined that for seven (R7, R11, R18, R24, R54, R63, R80) out of fifteen residents reviewed for quality of care, the facility failed to provide the residents' care in accordance with the professional standards of practice. For R7, the facility failed to monitor R7's vital signs after noting a change in physical status on 10/16/24; failed to ensure the Provider ordered lab work to check R7's phenytoin levels and serum sodium orders were completed. The facility failed to identify and notify the Provider about the low heart rate, which resulted in a delay in care of R7 obtaining the appropriate level of care. The failure to monitor R7's phenytoin level resulted in in a harm as R7 was admitted to the hospital on [DATE] for lethargy and change in mental status with a critically high phenytoin level of 38.5 mg/L. For R63, the facility failed to monitor timely and accurately document the resident's vitals signs after an unwitnessed fall. For R11 and R54, the facility failed to ensure that each residents' most recent hospice plan of care included the services furnished by the facility. For R24, the facility failed to ensure the resident's skin discoloration was identified and assessed. Findings include: 1. Review of R7's clinical record revealed: Cross refer F580, F726, F755 and F760 Desmopressin: The major adverse effect of desmopressin for which to monitor is hyponatremia . Hyponatremia is an absolute contraindication to the administration of desmopressin . The National Library of Medicine, 2025. www.ncbi.nlm.nih.gov Phenytoin, a seizure disorder drug, has a narrow therapeutic range. Therapeutic range is defined as between 10-20 mg/L. Routine monitoring of serum phenytoin levels is not recommended. However, in clinical suspicion of drug toxicity, serum phenytoin levels should be measured. Clinical signs of phenytoin toxicity include: nystagmus, slurred speech, lethargy and confusion among other symptoms . National Library of Medicine, Phenytoin Toxicity 2022 [DATE]:15 (11): e253250. Temperature - may vary with the time of day and method used (axillary slightly lower) 98.6 F (37 C) is considered normal oral temperature, but range is 96.4 F (35.8C) to 99.1 F (37.3C). Pulse - Normal adult pulse (heart rate) is 60 to 80 beats/minute; regular in rhythm. Lippincott Manual of Nursing Practice 11th edition, 2019. 1/10/20 - R7 was admitted to the facility with diagnoses including but were not limited to, seizure disorder, diabetes insipidus and hypopituitarism. 11/16/23 - E4 (contracted MD) ordered in R7's EMR, Dilantin oral capsule 100 mg (phenytoin sodium extended)- give 100 mg by mouth three times a day for seizure disorder. 2023 - R7 had phenytoin levels drawn on 1/24/23, 4/11/23 and 8/3/23. 2/5/24 - E4 ordered in R7's EMR, CBC with diff, phenytoin free blood level, Vitamin D25-OH, total blood level. Fax results to Neurology . The facility failed to provide evidence that these labs were obtained. 8/24/24 - E4 ordered in R7's EMR, Phenytoin (anti-seizure medication) oral capsule 100 mg- give 1 capsule by mouth three times a day for seizures. 8/25/24 - E4 ordered in R7's EMR, Desmopressin Acetate oral tablet 0.1 mg- give 0.5 mg tablet by mouth in the morning for diabetes insipidus. 8/26/24 - The quarterly Minimum Data Set (MDS) documented R7's BIMS (basic Inventory of Mental Status) score as 15, which reflected normal cognition. 9/11/24 - E4 ordered in R7's EMR, BMP, TSH, free T4 one time for hyponatremia, hypothyroid. 9/19/24 12:52 PM - The facility laboratory reported R7's serum sodium level as 132 mmol/L. The normal serum sodium level is 135 to 145 mmol/L. 10/16/24 12:22 AM - E24 (RN/Shift supervisor) documented in R7's EMR progress note, Fall details: Date/Time of fall: 10/15/24 11:50 PM fall was not witnessed .Provider: [E4] Time notified 10/16/24 Notified of: fall . Resident found sitting on the floor legs facing the head board of the bed .Resident stated she was self transferring from wheelchair to the bed, when she fell. VS (vital signs) 154/66, p (pulse) 43, 97.6 T (temperature), 18 rr (respirations), bs (blood sugar) 89 . 10/16/24 1:13 AM - R7's heart rate was documented in the EMR as 43 bpm (beats per minute) (irregular- new onset) and temperature of 97.6 F (Fahrenheit). 10/16/24 3:36 AM - R7's heart rate was documented in the EMR as 43 bpm and temperature 97.7 F. The facility failed to identify that R7's heart rate was low and notify the provider of this change. 10/16/24 6:45 AM - E10 (LPN) documented in R7's EMR progress note, Resident rang at 2350h (11:50 PM hour), employee went into the room and found the resident sitting on her buttocks on the floor . VS were obtained BP (blood pressure) 154/66, HR 43 SPO2 97%, . 10/16/24 10:45 PM - R7's heart rate was documented in the EMR as 41 bpm and temperature 97.2 F. There were no documented vital signs after 10/16/24 10:45 PM until 10/17/24 1:20 PM, which was thirty-six hours later, despite R7's heart rate being documented as bradycardic at 41 bpm. It should also be noted that the vital signs documented in the hospital transfer note did not include a temperature, respirations, and pulse oximetry. Additionally, the facility failed to monitor R7 with a full set of vital signs including temperature, pulse ox and blood pressure after R7 was documented as having a low heart rate. 10/17/24 1:20 PM - E17 (RN/UM) documented in R7's EMR progress note, resident had a sudden change in mental status. 148/43 BP, 44 HR and extremely lethargic. MD was called, new order to send to ED (emergency department) for evaluation . Resident left the facility at 1320 (1:20 PM) on a stretcher with 2 EMTS (emergency medical technicians) . R7 was transferred to the hospital thirty-six hours after being documented as bradycardic with a heart rate in the 40's. 10/17/24 to 10/28/24 - For eleven days, R7 was hospitalized for mental status change and visual changes. R7's hospital admission diagnoses included: hyponatremia (low serum sodium level) and phenytoin toxicity. R7 presented to the hospital on [DATE] with a phenytoin level of 38.5 mg/L (milligram/Liter) (normal phenytoin range is 10-20 mg/L) and a serum sodium level of 130 ( normal sodium range is 135-145). 10/17/24 2:09 PM - C4 (hospital emergency room MD) documented in R7's ED Physician Record, .History of Present Illness: [AGE] year old female .Patient 's sister notes that the patient has been lethargic over the past 2 weeks . 10/17/24 2:18 PM - The hospital laboratory reported R7's serum sodium level as 130 mmol/L, with the normal range being 135 to 145 mmol/L. The facility's failure to monitor R7's vital signs and appropriately respond to her bradycardic heart rate resulted in a delay of obtaining the next level of care for R7. 10/18/24 2:46 AM - The hospital laboratory reported R7's phenytoin level as 38.5 mg/L, which is nearly double the therapeutic range. Review of R7's physician orders for 2024 to date revealed no other order for a phenytoin level until 10/31/24, which was after R7's eleven-day hospitalization from 10/17/24 to 10/28/24 during which R7 was discovered to have phenytoin toxicity. The facility's failure to monitor R7's phenytoin level resulted in R7 experiencing phenytoin toxicity. 10/18/24 3:39 AM - C1 (hospital emergency room MD) documented in R7's hospital admission history and physical, Upon arrival to the ED (emergency department), vital were remarkable for hypothermia to 33.8 (degrees Celsius) and bradycardia to 42 . she did ultimately require 4 L nasal cannula, however does not require oxygen at home . The documented temperature of 33.8 C was the equivalent of 92.8 F. R7's most recent documented temperature prior to this hypothermic temperature obtained 10/18/24 3:39 AM in the hospital ED was on 10/16/24 at 10:45 PM. The facility failed to obtain a temperature as part of her vital signs when R7 was noted to have a mental status change on 10/17/24 at 1:20 PM. 10/24/24 12:23 PM - C1 (Hospital emergency room MD) documented in R7's discharge summary, .Hypothermia - Patient initially hypothermic with temp (temperature) 33.1 (91.6 F), thought to be secondary to phenytoin toxicity versus adrenal crisis. She (R7) was treated with Bair Hugger (a convective temperature management medical device used in hospitals to maintain a patient's core body temperature) and had symptomatic improvement. 3/24/25 3:54 PM - During a telephone interview, E4 (contracted MD) stated that she was not notified that R7's heart rate was in the 40's in October 2024. She stated that her practice's on-call coverage starts at 5 PM to 8 AM and that she does not typically receive a sign-out of any issues overnight so unless the staff told he or wrote in the doctor's book that R7 was bradycardic in the 40's, there would be no way for her to know. E4 did confirm that R7 was evaluated by a provider on 10/17/24 (the same day that R7 was transferred to the hospital) for nasal congestion but no vital signs were documented in that progress note. The constellation of failing to monitor vital signs, failing to identify and notify a provider about a low heart rate led to a significant time delay in obtaining the appropriate level of care that R7 required during this health crisis. The failure to monitor R7's serum phenytoin levels led to a critically phenytoin level that was diagnosed during R7's 10/17/24 hospitalization. 6. A review of R24's clinical record revealed: 6/27/18 - R24 was admitted to the facility with diagnoses including, but were not limited to paralysis of one side of the body due to a stroke, and blood clots. R24's current physician's orders included Aspirin 81mg, daily, and showers and skin checks on Tuesdays and Fridays on the 3-11 shifts. R24's current ADLs (activities of daily living) records revealed that her baths/showers on were scheduled on Mondays and Thursdays on the 7-3 shift. R24's current care plan documented, . At risk for bleeding related to use of aspirin . The interventions included, Monitor for any signs or symptoms of bleeding, as well as to notify the doctor with any concerns or changes. 3/3/25 - R24's clinical records lacked evidence that a skin check was completed. 3/6/25 11:05 AM - R24 was observed with purple and black discoloration on her left forearm, around the elbow area. 3/6/25 3:46 PM - R24's clinical records documented that a skin assessment was completed but failed to include the purple and black discoloration on the left forearm. 3/11/25 6:52 PM - R24's skin assessment was documented but failed to include the purple and black discoloration on the left forearm. 3/12/25 10:00 AM - During an interview, E2 (DON) stated that R24 had discoloration on the left elbow area, and it should be documented during bi-weekly skin assessments. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2, E3 (SD/ICP) and nine department managers/representatives. 2. The facility's policy entitled Fall Prevention Program, last reviewed/revised 2/2025, stated, . 9. In the event of a resident fall, the RN is to assess the resident and document the incident per the following instructions: a. An incident Report is to be completed . b. The 72 hour Fall Risk Assessment is to be completed in [name of electronic medical record system] . i. Document all assessments and actions . It should be noted that although the facility's policy stated that a 72 hour Fall Risk Assessment was to be completed in [electronic medical record system], the actual document nursing staff are currently using to monitor a resident after a fall on every shift for 72 hours was the Post Fall Evaluation (PFE). Review of R63's clinical record revealed: 9/19/24 - R63 was admitted to the facility with diagnoses that included, but were not limited to, dementia, aphasia and history of falls. 10/1/24 at 4:42 PM - A nurse's note documented, Late Entry: Resident found on the floor sitting on his bottom on top of his floor mat between his chair and his bed at 1600 [4 PM]. Resident was assessed no signs of bruises or trauma. There was no evidence of R63's initial vital signs and assessment was obtained and documented in the RN's initial assessment immediately after R63's unwitnessed fall during the evening shift of 10/1/24. 10/2/24 at 1:33 AM - A Post Fall Evaluation by E10 (LPN) documented the following vital signs (VS): - Temperature: [blank] . - Blood Pressure: 125/72 Date: 10/3/2024 01:34 [1:34 AM] . - Pulse: 79 Date: 10/3/2024 01:34 . - Respiration: 20 Date: 10/3/2024 01:34 . - O2 sats: 98% Date: 10/3/2024 01:34 . - Pain Level: 0 Date: 9/29/2024 07:36 . 10/2/24 8:35 AM - A Post Fall Evaluation by E10 (LPN) documented the following VS: - Temperature: [blank] . - Blood Pressure: 125/72 Date: 10/3/2024 01:36 [1:36 AM] . - Pulse: 79 Date: 10/3/2024 01:36 . - Respiration: 20 Date: 10/3/2024 01:36 . - O2 sats: 98% Date: 10/3/2024 01:36 . - Pain Level: 0 Date: 9/29/2024 07:36 . It should be noted that E10 documented the same vitals signs on both 10/2/24 PFEs timed 1:33 AM and 8:35 AM. 10/2/24 8:37 PM - A Post Fall Evaluation by E10 (LPN) documented the following VS: - Temperature: 98 Date: 10/3/2024 01:38 [1:38 AM] . - Blood Pressure: 119/68 Date: 10/3/2024 01:38 . - Pulse: 73 Date: 10/3/2024 01:38 . - Respiration: 20 Date: 10/3/2024 01:38 . - O2 sats: 98% Date: 10/3/2024 01:38 . - Pain Level: 0 Date: 9/28/2024 07:36 [7:38 AM] . 10/3/24 1:40 AM - A Post Fall Evaluation by E10 (LPN) documented the following VS: - Temperature: 98 Date: 10/3/2024 01:41 [1:41 AM] . - Blood Pressure: 119/68 Date: 10/3/2024 01:38 [1:38 AM] . - Pulse: 73 Date: 10/3/2024 01:38 . - Respiration: 20 Date: 10/3/2024 01:38 . - O2 sats: 98% Date: 10/3/2024 01:38 . - Pain Level: 0 Date: 9/28/2024 07:36 [7:38 AM] . It should be noted that E10 documented the same vitals signs on both 10/2/24 and 10/3/24 PFEs respectively timed 8:37 PM and 1:40 AM. The facility failed to ensure that vital signs were being accurately captured, monitored and documented every shift for 72 hours by nursing for R63, a dependent, non-verbal resident who had an unwitnessed fall on 10/1/24. 3/20/25 8:10 AM - During an interview, E9 (RN) explained the facility's procedure after a resident falls. When an incident report is started, a Fall Risk Assessment and Post-Fall Evaluation (PFE) forms are automatically triggered and are to be completed by a nurse. E9 stated that Charge Nurses are to complete PFEs every shift for nine (9) shifts [72 hours]. E9 explained that the PFE included entering vital signs, pain level, bruising, confusion, change of condition. E9 explained and showed the Surveyor that the PFE captured the date that it was opened, then the nurse has the ability to select box Finish Later or Complete. Complete button can only be selected if all the information was entered otherwise it remains shaded out and unable to be selected. When the PFE was completed and the nurse clicks the Complete button, then the nurse will check the box to sign, date and exit the form. The PFE form then locks. 3/21/25 at 12:21 PM - Finding was reviewed with E1 (CEO/LNHA) and E2 (DON). Surveyor reviewed the vital signs that were entered on R63's PFEs by E10 (LPN) that were timed on four back-to-back shifts: 10/1/24 - 10/2/24 night shift; 10/2/24 day shift; 10/2/24 evening shift; and 10/2/24 - 10/3/24 night shift. When asked if E10 (LPN) worked four 8-hour shifts back-to-back, E2 (DON) nodded her head no.

4.Review of R41's clinical record revealed: Cross refer F755, example 1 10/21/23 - R41 was admitted to the facility with multiple diagnoses, including human immunodeficiency virus (HIV) disease and chronic obstructive pulmonary disease (COPD). R41's medication orders included the following: -Dovato Oral Tablet 50-300 mg, give one tablet daily for antiviral. -Formoterol Fumarate Inhalation Nebulization Solution 20mcg/2ml, inhale 2 ml orally two times a day for COPD. 3/25/25 - A review of the Medication Administration Record (MAR) revealed that Dovato and Formoterol medications were not administered on the following dates: Dovato 1/13/25, 1/14/25, 2/15/25, 2/16/25, 2/18/25, 2/19/25, 3/24/25, and 3/25/25. Formoterol 2/6/25 AM, 2/23/25 AM, 2/26/25 AM, 3/17/25 PM thru 3/22/25 AM. 3/25/25 10:15 AM - During an interview, E9 (RN) confirmed the missing doses of medication of Dovato and Formoterol. 3/26/25 11:45 AM - Finding was reviewed during the exit conference with E1 (CEO/LNHA), E2, E3 (SD/ICP) and nine department managers/representatives. Based on record review and interview, it was determined that for four (R7, R17, R41 and R68) out of fourteen residents reviewed for medications, the facility failed to ensure the residents were free from significant medication errors. For R68, the facility failed to prevent R68 from receiving three doses of Zosyn in six hours on 2/11/25. For R7, the facility failed to obtain R7's cortef (a critical med) from 10/28/24 to 11/2/24. For R17, the facility failed to have available R17's sevelamer medication causing R17 to miss twenty-seven out of seventy-two opportunities for this medication administration from 3/10/25 to 3/25/25. For R41, the facility failed to have the resident's Dovato and Formoterol medications available. Findings include: Facility's Medication Administration Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physicians and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 10. Ensure that the six rights of medication administration are followed: a. right resident, b. right drug, c. right dosage, d. right route, e. right time, f. right documentation. 11. Review MAR (Medication Administration Record) to identify medication to be administered . Date reviewed/revised 12/2024. 1. Review of R68's clinical record revealed: Zosyn is an antibiotic combination of piperacillin and tazobactam, which are penicillin class antibiotics that are used to fight infections caused by bacteria. www.drugs.com/zosyn.html January 2025 12/5/24 - R68 was admitted to the facility with diagnoses including, but were not limited to, Parkinson's disease, diabetes and osteomyelitis of the vertebrae and sacral region. 1/14/25 - E4 (contracted MD) ordered in R68's EMR, Piperacillin Sod- Tazobactam (Zosyn) solution 4.5 gm - Give 4.5 gm intravenously every 6 hours for wound infection. As a result of this order, February 2025 Medication Administration Record (MAR) scheduled R68 to receive this antibiotic at 12 midnight, 6:00 AM, 12:00 PM and 6:00 PM. 2/11/25 approximately 3 PM - During change of shift report, E14 (LPN) reported to E29 (LPN) that she [E14] gave IVSS (intravenous soluset solution) Zosyn at both 8:30 AM and 1:19 PM. E29 alerted [E30] RN supervisor of the incorrect timed medication error. Review of R68's February 2025 MAR revealed E14 signed out the 1:19 PM Zosyn dose at the 1200 time slot but did not document the 8:30 AM dose on the MAR. Further review revealed E29 documented appropriately holding the 6 PM Zosyn dose as was instructed by E4 when she was alerted to this medication error. On 2/11/25, R68 received three doses of IVSS Zosyn between 6 AM and 1:19 PM, when R68 should have only received two doses during this time period. The third dose was given on the night shift at aprroximately 5:30 AM, prior to E14 (LPN) assuming care fo R68. 3/17/25 1:34 PM - During an interview, E14 (LPN), who was a new nurse and was hired on 7/23/24, stated, I was pulled to the 400 unit. It was the first time that I worked there. I had never given an IVSS antibiotic before. I asked a nurse to help me at 9 AM and we hung the med [Zosyn] and ran it. Then I did it alone at the 12 noon dose We did not check the MAR for the 9 AM dose . 2. Review of R7's clinical record revealed: Cross refer F580, F684, F711, F726 and F755 1/10/20 - R7 was admitted to the facility with diagnoses including, but were not limited to, seizure disorder, diabetes insipidus and hypopituitarism. 10/28/24 - E4 (contracted MD) ordered in R7's EMR, Cortef oral tablet 10 mg (hydrocortisone)- give 1 tablet by mouth one time a day for hypopituitarism and Cortef oral tablet 5 mg (hydrocortisone)- give 1 tablet by mouth one time a day for hypopituitarism. Review of R7's October 2024 MAR revealed E7 (LPN) documented on 10/29/24 and 10/31/24 at both the 9 AM 10 mg Cortef and the 12 PM 5 mg Cortef doses 9, which per the MAR legend means other/See progress notes. E26 (LPN) documented on 10/20/24 at both the 9 AM 10 mg Cortef and the 12 PM 5 mg Cortef doses 9, which per the MAR legend means other/See progress notes. 10/29/24 9:56 AM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . Medication n/a (not available). 10/29/24 1:21 PM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . Medication n/a (not available). 10/30/24 9:10 AM - E26 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . awaiting arrival. 10/30/24 2:20 PM - E26 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . awaiting arrival. 10/31/24 10:48 AM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . awaiting pharmacy delivery. 10/31/24 2:04 PM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . awaiting pharmacy delivery. Review of R7's November 2024 MAR revealed E27 (RN) documented on 11/1/24 at both the 9 AM 10 mg Cortef and the 12 PM 5 mg Cortef doses 9, which per the MAR legend means other/See progress notes. 11/1/24 8:17 AM - E27 (RN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . not available in passport machine. 11/1/24 2:45 PM - E27 (RN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . N/A (not available) waiting for pharmacy delivery. R7 missed nine doses of her ordered Cortef (hydrocortisone). 3/24/25 10:45 AM - During an interview, E26 stated, The pharmacy was not sending the med [Cortef]. 3/24/25 11:46 AM - During a telephone interview, C2 (contracted pharmacist) stated, The electronic transfer of R7's Cortef was on 10/28/24. It is a pretty common drug and the pharmacy should have it on hand. C2 stated that R7's Cortef was ordered and only profiled on 10/28/24 as the medication required a prior authorization. 3/24/25 1:38 PM - During a telephone interview, F1(R7's family member) stated, The doctor [E4] called in a prescription to [local pharmacy]. [F2, R7's family member] went to [local pharmacy] and paid out of pocket for the medication . No, we were not reimbursed . 3/24/25 2:30 PM - During a telephone interview, C3 (local [pharmacy] pharmacist) stated, According to our records, they [F2] paid cash so they would not need a prior authorization. The script (prescription) was filled on 11/29/24. 3. Review of R17's clinical record revealed: 1/23/20 - R17 was admitted to the facility with diagnoses including, but was not limited to, end stage renal disease with dependence on renal dialysis. 12/27/23 - R17 was ordered in his EMR, Sevelamer Carbonate oral packet 2.4 gm- give 1 packet via PEG (percutaneous endoscopic gastrostomy) tube with meals for ESRD (end stage renal disease). 3/10/25 12:58 PM - E8 (LPN) documented in R17's EMR progress notes, Spoke with pharmacy, medication [sevelamer] will be sent out on next run. Made MD aware. NNO (no new orders). 3/10/25 1:01 PM - E31 (LPN) documented in R17's EMR progress notes, Sevelamer carbonate oral packet . not available. 3/11/25 7:12 PM - E32 (LPN) documented in R17's EMR progress notes, Sevelamer carbonate oral packet 2.5 gm, not available, on order from pharmacy. 3/14/25 11:44 AM - E9 (RN) documented in R17's EMR progress notes, Message left for the nurse at the Nephrology office in reference to the pharmacy needing prior [NAME] (sic) in order for him [R17] to continue to receive his sevelamer Carbonate oral packet 2.4 gm. Awaiting return call. 3/14/25 6:21 PM - E32 documented in R17's EMR progress notes, Sevelamer ., not available from pharmacy . 3/15/25 6:03 PM - E31 documented in R17's EMR progress notes, Sevelamer . not available. 3/16/25 6:48 PM - E31 documented in R17's EMR progress notes, Sevelamer . not available. 3/17/25 4:37 PM - E32 documented in R17's EMR progress notes, Sevelamer . on order from pharmacy . 3/18/25 5:42 PM - E32 documented in R17's EMR progress notes, Sevelamer . not available from pharmacy . 3/19/25 11PM - E33 (LPN) documented in R17's EMR progress notes, Sevelamer . call out to pharmacy regarding med availability, med is being reordered this evening and will be out on next available run per [pharmacy staff] from pharmacy. 3/20/25 8:57 AM and 11:29 AM - E8 documented in R17's EMR progress notes, Sevelamer . Medication on back order per pharmacy. MD made aware. NNO (no new orders) for a (sic) interchangeable medication. 3/20/25 6:15 PM - E32 documented in R17's EMR progress notes, Sevelamer . not available from pharmacy. Pharmacy called . 3/21/25 6:06 PM - E32 documented in R17's EMR progress notes, Sevelamer . on back order from pharmacy . 3/24/25 9:24 AM - E9 (RN) documented in R17's EMR progress notes, Call nephrology in references to Sevelamer not covered through his [R17} insurance. Therefore, the medication is not delivered to us. Message left for the second time with Nephrology and awaiting return call. 3/24/25 3:24 PM - E9 documented in R17's EMR progress notes, Spoke with nurse from Dialysis in reference to Sevelamer not been (sic) covered by his [R17's} insurance and prior auth needs to be send (sic) to pharmacy in order for prescription to be filled. [E11 (contracted MD)] made aware. The facility failed to notify the dialysis center that R17 was not receiving his ordered Sevelamer prior to 3/24/25. 3/24/25 6:43 PM - E31 documented in R17's EMR progress notes, Sevelamer . not available. 3/25/25 9:16 AM - E8 documented in R17's EMR progress notes, Sevelamer . Spoke with pharmacy, medication is on order and will be sent out as soon as they receive medication. 3/25/25 11:15 AM - Review of R17's March 2025 MAR revealed that R17 missed thirty-two of the seventy-three scheduled dosages of Sevelamer for the month of March 2025.

3. Cross refer to F760, example 4 On 10/28/24 at 2:10 PM, the facility reported the following medication error incident to the State Agency: On Monday, October 7, 2024 nursing supervisor informed DON that medications had been found on a medication cart and left un-administered. Supervisor investigated and found that all medications had been documented as 'Administered'. Schedule review showed that LPN [name of E46] had been assigned to the residents whose medications were left un-administered . The incident occurred on 10/3/24 day shift and involved the following four residents: R4, R47, R52 and R84. 11/4/24 - The facility's 5-day follow-up investigation submitted to the State Agency reported: . the facility is able to SUBSTANTIATE . The facility discharged E46 (LPN) on 10/9/24 from working in the facility for progressive disciplines r/t [related to] medication administration resulting in termination. Review of E46's discipline record revealed previous medication administration occurrences: - 5/30/24 Medication Administration Error: E46 did not administer an anticonvulsant medication prescribed for an unidentified resident's seizure disorder as it was found in the medication cart still in the packaging. Medication was administered two hours after it was due. E46 received verbal coaching documented in E46's file on 6/4/24. - 9/18/24 Falsification of Medical Records: E46 documented administration of medication and assessments on an unidentified resident that was not in the building. E46 received a FINAL written coaching with a day off without pay and was documented in E46's file on 9/19/24. - 10/9/24 Falsification of Medical Records: On 10/3/24, E46 documented administration of medication for four residents which were later found in the medication cart during the next shift. E46 was terminated and documented in her file on 10/10/24. 3/21/24 10:26 AM - Surveyor requested evidence of E46's competency for medication administration since her hire date of 3/4/24. 3/26/25 2:00 PM - During an interview, E3 (SD/RN) confirmed that the facility did not have a medication administration competency for E46. The facility failed to ensure that E46 had a medication administration competency since her hire date of 3/4/24. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2, E3 (SD/ICP) and nine department managers/representatives. Based on observation, record review and interview, it was determined that for five (R4, R47, R52, R68 and R84) out of fourteen residents reviewed for medications, one (R7) out of eight residents reviewed for falls, the facility failed to have competent nursing staff to meet the needs of the residents. For R7, the facility failed to ensure the licensed nurses had the specific competencies to recognize when R7 became bradycardic from 10/16/24 to 10/18/24. For R68, the facility failed to ensure the licensed nurse had the specific competencies to administer IVSS medication. For R4, R47, R52 and R84, the facility failed to ensure a nurse had a medication administration competency when each resident was not administered prescribed medications. Findings include: Facility's Orientation policy: It is the policy of this facility to develop, implement, and maintain an effective orientation process for all new staff ., consistent with their expected roles . 5. Checklists will be used to document training and competency evaluations during the orientation process . 11. All documentation to support completion of the orientation process shall be maintained in the employee's educational file. Date reviewed/revised 2/2025. 1. Cross refer F580, F684, F755 and F760 Review of R7's clinical record revealed: 1/10/20 - R7 was admitted to the facility with diagnoses including, but were not limited to, seizure disorder and hypopituitarism. 10/16/24 12:22 AM - E24 (RN/shift supervisor) documented in R7's EMR progress note, Fall details: Date/Time of fall: 10/15/24 11:50 PM fall was not witnesses . Provider: [E4] Time notified 10/16/24 Notified of: fall . Resident found sitting on the floor legs facing the head board of the bed . Resident stated she was self transferring from wheelchair to the bed, when she fell. VS (vital signs) 154/66, p (pulse) 43, 97.6 T (temperature), 18 rr (respiratory rate), bs (blood sugar) 89 . 10/16/24 1:13 AM - R7's heart rate was documented in the EMR as 43 bpm (beats per minute) (irregular- new onset). 10/16/24 3:36 AM - R7's heart rate was documented in the EMR as 43 bpm. 10/16/24 6:45 AM - E10 (LPN) documented in R7's EMR progress note, Resident rang at 2350h (11:50 PM), employee went into the room and found the resident sitting on her buttocks on the floor . VS were obtained BP (blood pressure) 154/66, HR 43 . 10/16/24 10:45 PM - R7's heart rate is documented in the EMR as 41 bpm. 10/17/24 1:58 PM - C4 (hospital emergency room MD) documented in R7's heart rate as 42. R7 was documented in her EMR as having a low heart rate in the 40's from 10/15/24 at 11:50 PM until 10/16/24 at 10:45 PM, which was almost 24 hours in duration. R7 was found to be bradycardic with a heart rate of 42 upon arrival to the hospital emergency room on [DATE] at 1:58 PM. Review of R7's EMR progress notes revealed no mention of R7's low heart rate other than documentation of the number by any of staff that cared for R7 from 10/15/24 night shift until 10/17/24 dayshift when R7 was sent to the hospital for a change in mental status. 3/21/25 10:10 AM - Review of E10 (LPN)'s skills checkoff for vital signs revealed that E10, who was hired on 1/22/24 and cared for R7 on 10/16/24 night shift, was signed off by her preceptor [E28 (ADON)] on each skill. However, the form was not signed or dated as completed by the assessor, nor was a final score documented. Additionally, E10 did not fill in the five test questions at the bottom of the checkoff sheet. Question four was pertinent to this situation as it asked 4. The appropriate pulse range for an adult is: _______ to ________ beats per minute. For E24, who worked as the RN supervisor on night shift on 10/16/24, the facility was not able to produce any skills checkoff list for this employee. 3/21/25 3:45 PM - During an interview, E3 (SD/ICP) stated that E24 was hired prior to her and therefore, she does not have copies of her skills checkoff lists. The facility was unable to provide evidence that these two nurses had the specific competency to recognize that R7's heart rate was too low and needed to be intervened upon. 2. Cross refer F760, example 1 and F940 Review of R68's clinical record revealed: 12/5/24 - R68 was admitted to the facility with diagnoses including, but were not limited to, Parkinson's disease, diabetes and osteomyelitis of the vertebrae and sacral region. 1/14/25 - E4 (contracted MD) ordered in R68's EMR, Piperacillin Sod- Tazobactam (Zosyn) solution 4.5 gm - Give 4.5 gm intravenously every 6 hours for wound infection. As a result of this order, February 2025 Medication Administration Record (MAR) scheduled R68 to receive this antibiotic at 12 midnight, 6:00 AM, 12:00 PM and 6:00 PM. 2/11/25 approximately 3 PM - During change of shift report, E14 (LPN) reported to E29 (LPN) that she [E14] gave IVSS (intravenous soluset solution) Zosyn at both 8:30 AM and 1:19 PM. E29 alerted [E30] RN supervisor of the incorrect timed medication error. Review of R68's February 2025 MAR revealed E14 signed out the 1:19 PM Zosyn dose at the 1200 time slot but did not document the 8:30 AM dose on the MAR. Further review revealed E29 documented appropriately holding the 6 PM Zosyn dose as was instructed by E4 when she was alerted to this medication error. 3/17/25 1:34 PM - During an interview, E14 (LPN), who was a new nurse and was hired on 7/23/24, stated, I was pulled to the 400 unit. It was the first time that I worked there. I had never given an IVSS antibiotic before . I was not trained about IV (intravenous) antibiotics during orientation because we did not have anyone in the building with IV antibiotics . The facility was not able to provide evidence of E14's skills checkoff with regard to medication administration: intravenous. 3/21/25 3:45 PM - During an interview, E3 (SD/ICP) confirmed that that the facility did not have a skills checkoff for Medication Administration: Intravenous for E14. The facility failed to ensure E14 had the specific competencies to administer medications to R68.

Based on record review and interview, it was determined that the facility failed to implement and maintain an effective training program for new LPN staff regarding intravenous medication administration prior to being assigned to independently provide this service to R68 on 2/11/25. Findings include: Cross refer F726, example 2 and F760, example 1 Review of R68's clinical record revealed: 3/17/25 1:34 PM - During an interview, E14 (LPN), who was a new nurse and was hired on 7/23/24, stated, [On 2/11/25] I was pulled to the 400 unit. It was the first time that I worked there. I had never given an IVSS antibiotic before . I was not trained about IV (intravenous) antibiotics during orientation because we did not have anyone in the building with IV antibiotics . 3/20/25 1:45 PM - Review of the Facility Assessment (dated [DATE]) revealed that administration of IV medication (page 12 of the Facility Assessment) occurs in only 0.5% of their admissions/stays, which is very low relative to the benchmark. The Facility Assessment (page 26) also documented that the Staff training/Competencies/Skills in the area of IV medication was insufficient and an Action Plan was in place. It should be noted that this IVSS medication error occurred seven months after the Facility Assessment had concluded that the staff skills with regard to IV medication was lacking and an Action Plan had been put into place. 3/21/25 10:10 AM - The facility provided copies of the new orientee skills checkoff packet, which contained a skills checkoff for Medication Administration: Intravenous. 3/21/25 3:45 PM - During an interview, E3 (SD/ICP) confirmed that that the facility did not have a skills checkoff for Medication Administration: Intravenous for E14. The facility was unable to provide evidence of a training process for new staff to learn the skills necessary to care for a resident that requires IVSS medication administration when there are no residents in house with this need. The facility did not provide any information regarding the Action Plan for IV Medication that was referenced in the Facility Assessment. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 and nine department managers/representatives.

Based on record review and interview, it was determined that for one (R45) out of ten residents reviewed for antibiotic use, the facility failed to ensure that an antibiotic stewardship program was implemented that consistently monitored prescription antibiotic usage. Findings include: Facility's Definitions Policy per McGreer's - It is the policy of this facility to adhere to the definition of infection listed below when conducting monthly surveillance of infections . Colonization - term used to describe the presence of bacteria, viruses, or other microscopic organisms that are not causing adverse clinical s/s [signs or symptoms], Fever - single oral T [temperature] 100 degrees F [Fahrenheit] or repeated oral T > [greater] 99 degrees F, or a single T > 2 degrees F over baseline from any site, . Leukocytosis - neutrophilia [> 14,000 leukocytes (white blood cells)/ mm3] or left shift [6 % bands or >/= 1,500 bands/mm3] . Facility's Antibiotic Stewardship Program - The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events . Policy explanation and compliance guidelines: . 4. The physician will refer to the appropriate algorithm for prescribing antibiotics and will document his/her findings in the resident's medical record . Date reviewed/revised 12/2024 Review of R45's clinical record: 6/19/24 - R45 was admitted to the facility with diagnoses including, but were not limited to, dementia and irritable bowel syndrome with diarrhea. 6/19/24 - R45's medication allergies were listed in the EMR as oxycodone, remeron, penicillin, and erythromycin. 1. UTI (urinary tract infection) September 2024 9/24/24 5:26 AM - E51 (LPN) documented in R45's EMR progress notes, Resident has asked to use the bathroom and has urinated 5+ times this shift. This was documentation of increased frequency of urination. 9/24/24 12:18 PM - E7 (LPN) documented in R45's EMR progress notes, . resident was c/o (complaint of) painful urination . This was documentation of painful urination. 9/26/24 3:06 PM - R45's voided urine sample culture was reported to the facility with final report: colony count 50,000 gram negative rods, Organism identification: E.coli. This culture report failed to meet McGreer's criteria for UTI without an indwelling catheter as the microbiologic colony count was less than 100,000 cfu/ml. 9/27/24 - E11 (contracted MD) ordered in R45's EMR, Bactrim DS tablet 800- 160 mg (sulfamethoxazole- trimethoprim)- give 1 tablet by mouth two times a day for cystitis (inflammation of the bladder) for 7 days. Review of R45's EMR vital signs revealed no fevers during the entire month of September 2024. R45's record review demonstrated that there was insufficient data to meet McGreer's criteria for infection surveillance that would necessitate an antibiotic. 2. UTI October 2024 10/10/24 - E4 (contracted MD) ordered in R45's EMR, Keflex oral capsule 500 mg (Cephalexin)- give 1 tab by mouth two times a day for UTI for 3 days. Review of R45's EMR lab results revealed that on 10/10/24 R45 had a urinalysis done, but a urine culture was not performed. The urinalysis revealed the specimen was negative for ketones and nitrites and bacteria was absent. There was a large number or urine leukesterase. Review of R45's EMR progress notes prior to and on 10/10/24 revealed no documentation of any pain on urination, fever, increased frequency, incontinence or urgency or gross hematuria. Review of R45's vital signs revealed no fevers for the entire month of October 2024. R45's record lacked sufficient data to meet McGreer's criteria for infection surveillance that would necessitate the use of an antibiotic. 3. UTI January 1, 2025 12/20/24 1:17 AM - E51 (LPN) documented in R45's EMR progress notes, Resident stated that her body hurts all over. 1/1/25 -E11 (contracted MD) ordered in R45's EMR, Bactrim DS oral tablet 800-160 mg (sulfamethoxazole-trimethoprim)- give 1 tablet by mouth two times a day for frequency, burning X 3 days. Start after urine collected. 1/2/25 12:00 AM - E30 (RN supervisor) documented in R45's EMR progress notes, Primary nurse reported resident is having urine frequency and burning on urination. Afebrile . Bactrim DS one tab BID X 3 days to start after urine is collected. 1/3/25 8:12 PM - E11 discontinued Bactrim DS due to rash to face and neck. 1/4/25 12:56 PM - R45's voided urine sample culture was reported to the facility with final report: colony count 50,000 gram negative rods, Organism identification: E.coli. 1/7/25 - Ciprofloxacin was added to R45's medication allergy profile. This culture report failed to meet McGreer's criteria for UTI without an indwelling catheter as the microbiologic colony count is less than 100,000 cfu/ml. R45's EMR vital signs lacked evidence of any fevers during the entire month of January 2025. 4. UTI January 15, 2025 1/15/25 - E11 ordered in R45's EMR, Cefuroxime Axetil oral tablet 250 mg- give 1 tablet by mouth two times a day for UTI for 5 days. This antibiotic was started as the result of R45's hospital ER visit on 1/15/25 after a fall. 1/15/25 1:44 AM - C5 (hospital emergency room MD) documented in R45's ED Physician Record, ED (emergency department) progress . UA notable for 3+ [NAME] (leukesterase), 11-20 WBCs (white blood cells), rare bacteria, consistent with UTI . Patient's recently completed course of Keflex for UTI 2 days ago, also was briefly on Bactrim, however reportedly this caused her to have a rash and so was stopped. Given persistent evidence for UTI on repeat UA here in the department, will give prescription for a 5day course of cefuroxime . CBC without leukocytosis . Stable for discharge . 1/16/25 8:08 AM - Hospital lab final urine culture report documented 10,000 - 100,000 cfu/ml mixed gram positive and gram-negative growth. Mixed flora may represent colonization or contamination. Repeat collection if clinically indicated. The facility failed to follow up with the hospital lab to get the final culture report. R45's EMR vital signs revealed lacked evidence of fevers during the entire month of January 2025. 5. CAP (community acquired pneumonia) January 2025 1/22/25 - E51 (LPN) documented in R45's EMR progress notes, Resident noted with a non-productive cough at this time . 1/23/25 12:52 PM - R45's CXR report revealed, Lungs: bibasilar airspace opacities. 1/24/25 - E11 ordered in R45's EMR, Doxycycline Hyclate oral capsule 100 mg- give 1 capsule by mouth two times a day for CAP for 5 days. R45's EMR vital signs lacked evidence of fevers, and respiratory rate ranged from 16 to 19 breaths per minute during the entire month of January 2025. R45's EMR lab results lacked evidence that a CBC lab work was drawn during the month of January 2025 so there was no documentation of leukocytosis. R45's record review demonstrated that there was insufficient data to meet McGreer's criteria for infection surveillance that would necessitate an antibiotic. The facility failed to ensure the facility's antibiotic stewardship program prevented the inappropriate use of antibiotics. On five separate occasions from September 2024 to January 2025, R45 was inappropriately prescribed antibiotics when her presenting symptoms did not meet McGreer's criteria. R45 has documented drug allergies to three classes of antibiotics: macrolide antibiotics (erythromycin), penicillin antibiotics and fluroquinolones antibiotics (cipro). The facility's failure to appropriately utilize antibiotics with R45, who already has a limited catalog of antibiotics available for her usage, has the potential to create resistance to the antibiotics available to her. It should be noted that only two of R45's five infections were listed on the monthly antibiotic surveillance line listings that were reviewed for the months of September 2024 to February 2025. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives

Based on interview, record review and identified deficiencies during the survey, it was determined that the facility's QAPI program failed to effectively address ongoing issues that impact quality of care with respect to staff to resident abuse, repeated medication errors by nursing staff and the continued lack of availability of medications from the pharmacy for multiple residents. Findings include: 3/25/25 1:08 PM - During a combined interview with E1 (CEO/LNHA) and E2 (DON), E1 stated that the QAPI Committee discusses all medication errors in their meetings. E1 mentioned that the 10/3/24 medication error incident involving four residents was reviewed and staff nurses were educated in November 2024. The Surveyor reviewed that there were additional medication errors on 1/3/25 and 2/11/25. E2 stated that the facility provided education in November 2024, December 2024 and again in February 2025. Also Supervisors started doing medication pass audits after the 2/11/25 incident. The Surveyor was informed that the facility has not had a consistent Staff Development nurse and they have not been able to conduct a skills fair for staff. While the medication errors by nursing are routinely discussed during the QAPI meetings and staff education was provided, the facility's QAPI Committee documentation lacked evidence of measurable goals, what systemic changes were implemented and monitoring the performance to ensure the changes were successful and sustained. Medication audits provided and reviewed by the Surveyor were done on 2/5/25 and 2/11/25. No additional information was provided. An additional concern identified during the survey was about the lack of availability of medications for some residents, E1 stated that this was discussed in the last QAPI meeting in March 2025 (during the survey) where the pharmacy representative was present. Surveyor asked about how do you get information about residents' medications not being available? E2 stated that they [Management] are notified by nursing staff when they bring it to their attention. E1 and E2 confirmed that there have been issues with the current pharmacy since October 2024. Surveyor was told that since October 2024, it would improve at times, but for the past month there have been issues with obtaining residents' medications. With respect to the two incidents of staff to resident abuse on 12/22/24 and 1/15/25 and both identified in the current survey as deficiencies, E1 confirmed that there was no current PIP (performance improvement plan) for abuse. E1 stated that the QAPI Committee discusses abuse at each meeting. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1, E2, E3 (SD/ICP) and nine department managers/representatives.

2. Review of R7's clinical record revealed: Cross refer F580, F684, F726 and F760 1/10/20 - R7 was admitted to the facility with diagnoses including, but were not limited to, seizure disorder, diabetes insipidus, central blindness and hypopituitarism. 10/28/24 Monday - R7 readmitted to the facility after a hospitalization. 10/28/24 - E4 (contracted MD) ordered in R7's EMR, Cortef (hydrocortisone) oral tablet 10 mg - give 1 tablet by mouth one time a day for hypopituitarism. 10/29/24 9:56 AM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . Medication n/a (not available). 10/29/24 1:21 PM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . Medication n/a (not available). 10/30/24 9:10 AM - E26 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . awaiting arrival. 10/30/24 2:20 PM - E26 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . awaiting arrival. 10/31/24 10:48 AM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . awaiting pharmacy delivery. 10/31/24 2:04 PM - E7 (LPN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . awaiting pharmacy delivery. 10/31/24 11:03 AM - R7's facility lab results reported serum sodium level as 153 mmol/L (normal range 135-145 mmol/L). 11/1/24 8:17 AM - E27 (RN) documented in R7's EMR, Cortef oral tablet 10 mg . for hypopituitarism . not available in passport machine. 11/1/24 2:45 PM - E27 (RN) documented in R7's EMR, Cortef oral tablet 5 mg . for hypopituitarism . N/A (not available) waiting for pharmacy delivery. R7 missed nine doses of her ordered Cortef (hydrocortisone). 11/1/24 Friday 2:53 PM - E27 (RN/ADON) documented in R7's EMR as a communication with physician, Situation: Medication (hydrocortisone) unavailable per pharmacy, uncovered by insurance. Background: Sodium level high as result. Per Endocrinology, should be sent to emergency department for assessment and treatment. Assessment (RN)/ Appearance (LPN): Lethargy presented as longer response on questions. Recommendations: Physician [E4] to send e-script for hydrocortisone to commercial pharmacy [name of pharmacy] for family to self-pay/private pay and bring in to (sic) facility. Per physician, consulted and confirmed with endocrinology, this will avoid emergency room visit. Endo (endocrinology) also requesting to increase fluid intake by 500 ml and obtain urine for a specific gravity to potentially adjust medication. 11/1/24 2:57 PM - E27 documented in R7's EMR communication with family, Family notified of need for medication (Hydrocortisone) and that resident has not received this medication due to pharmacy not making the medication delivery. Per pharmacy, the medication is not covered by insurance any longer. Family requested to have prescription sent to commercial pharmacy for self-pay/private pay by family who will supply to the facility. 11/1/24 4:49 PM - E27 documented in R7's EMR, Resident father delivered bottle of 45 hydrocortisone tabs at 10 mg with direction to take 1.5 tabs twice daily. Counted and verified by [E27]. Bottle has two refills. Orders placed in PCC (point click care). 3/21/25 11:41 AM - During a telephone interview, E19 (contracted consultant pharmacist) stated, I don't have anything to do with supplying the medications. 3/24/25 10:15 AM - During an interview, E26 (LPN) stated, the pharmacy was not sending the medication. 3/24/25 11:46 AM - During a telephone interview, C2 (contracted pharmacy pharmacist director) stated, Cortef is a pretty common drug and the pharmacy should have it on hand. C2 stated that R7's Cortef order was ordered and only profiled on 10/28/24 as the medication required a prior authorization. 3/24/25 3:54 PM - During a telephone interview, E4 (contracted MD) stated that due to the hydrocortisone not being available, she reached out and spoke with R7's endocrinologist (C3) who informed her that if R7 did not receive the medication by 11/1 afternoon, she should be sent to the hospital emergency room for care. 3/25/25 10:54 AM - During a telephone interview, E19 (contracted consultant pharmacist) stated that he was unaware that R7's Cortef was not available from 10/28/24 to 11/2/24. He stated that the facility does not tell him if there are issues with obtaining medications due to prior authorizations being required. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives. Based on record review and interview, it was determined that for two (R41 and R7) out of fourteen residents reviewed for pharmacy services, the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: The facility's policy and procedure for Unavailable Medications: . 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine the reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. B. Notify the physician of the inability to obtain the mediation upon notification or awareness that the medication is unavailable . c. Notify the Nurse Supervisor/Unit manager of delay, so they can escalate the issue. Date revised: 3/2025 1. Review of R41's clinical record revealed: 10/21/23 - R41 was admitted to the facility with multiple diagnoses including human immunodeficiency virus (HIV) disease and chronic obstructive pulmonary disease (COPD). The following medications were ordered on 10/21/23: -Dovato Oral Tablet 50-300 mg, give one tablet daily for antiviral. -Formoterol Fumarate Inhalation Nebulization Solution 20mcg/2ml, inhale 2 ml orally two times a day for COPD. 3/25/25 -The following chart documents were reviewed for the medications Dovato and Formoterol: Dovato: Review of Medication Administration Record (MAR) for January 2025, February 2025 and March 2025 revealed that the antiviral medication Dovato was not administered to R41 on the following dates: 1/13/25, 1/14/25, 2/15/25, 2/16/25, 2/18/25, 2/19/25, 3/24/25 and 3/25/25. The MAR for the Dovato administration for dates above had the charting code 9 listed in each date. Review of the chart coding section of the MAR revealed that 9 meant: Other/See Progress Notes. Review of progress notes for several of the missed doses of Dovato medication revealed the following: 1/14/25 9:56 AM - Orders Administration Note: .Medication not available, awaiting pharmacy delivery. 2/16/25 10:49 AM - Called pharmacy regarding Dovota (sic). Per pharmacy, Dovota (sic) needs to be ordered from their supplier and should be available tomorrow. Md and primary nurse made aware. 2/17/25 3:42 PM - Dovato is out of stock at pharmacy. This writer spoke with the pharmacy today. They will try and get medication through there (sic) backup pharmacy. 2/19/24 2:44 PM - Call out to pharmacy, med is on back order not sure when it will be ordered. MD made aware. 3/25/25 9:18 AM - Spoke with pharmacy, medicatipon (sic) is on order and will be sent out as soon as they receive medication. Formoterol: Medication Administration Record (MAR) for February 2025 and March 2025 revealed that Formoterol was not administered to R41 on the following dates and times: 2/6/25 AM, 2/23/25 AM, 2/26/25 AM, 3/17/25 PM thru 3/22/25 AM. -Progress notes for several of the missed doses of Formoterol medication revealed the following: 2/23/25 6:08 AM - Medication has not arrived. Pharmacy called multiple times and no answer. Message left for on call but no answer 3/17/25 3:17 - Formotorol not available from pharmacy or back up 3/25/25 10:15 AM - During an interview, E9 (RN) confirmed the dates and times of the missed doses of Dovato and Formpterol. The facility failed to ensure resident medications were available.

3. Review of R27's clinical record revealed: 4/12/21 - R27 was admitted to the facility. 3/7/25 9:00 AM - An observation revealed side rails (enablers) present on both sides of R27's bed. 3/10/25 9:30 AM - An observation revealed side rails (enablers) present on both sides of R27's bed. 3/12/25 - A review of R27's clinical records revealed the lack of the following documentation: -Bed rail use assessments, including appropriate alternatives to the bed rails/enablers, risk of entrapment in the bed rail/enabler, and the risks versus benefits of the use of bed rails/enablers. -Informed consent. 3/13/25 10:31 AM - During an interview, E16 (contracted DOR) stated that an effort to obtain assessments for the facility bed rails/enablers was in progress, but that there were no bed rail/enabler assessments that her department had completed for any resident at that point. 2. Review of R47's clinical record revealed: 2/3/21 - R47 was admitted to the facility with diagnoses that included, but were not limited to, hemiplegia and hemiparesis following a stroke affecting the right dominant side and a cognitive communication deficient. 1/9/25 - The annual MDS assessment documented that R47 had a functional limitation in range of motion on one side of upper extremity and both sides on lower extremities. 3/18/25 9:08 AM - Observation of R47 in bed with bilateral 1/4 enablers positioned up. 3/18/25 9:16 AM - During an interview, E16 (contracted DOR) confirmed that no bed rail assessment has been completed for R47 at this time. E16 also stated that her therapy company, which started providing services in November 2024, does not have access to the previous therapy provider records. 3/18/25 10:35 AM - During an interview, E34 (CNA) stated that R47 uses the bed enablers with only his good arm (left). E34 stated that R47 cannot use his right arm or right leg. E34 stated that when she rolls him over toward the window (on the right side), R47 was able to use the right enabler to hold onto with his left hand; however, when he rolls over on his left side, R47 cannot use his right hand to grab the left sided enabler although he tries to grab it with his left hand. 3/18/25 10:43 AM - During an interview, E35 (LPN) was asked if she could provide the surveyor with R47's signed consent for the use of bed enablers. E35 reviewed R47's electronic clinical record and was unable to locate the signed consent. E35 stated that she would have to talk to therapy. The surveyor mentioned that the current therapy provider does not have access to the prior therapy company's documentation. E35 then said that she would have to elevate this request to someone higher that has access to the resident's therapy records. 3/21/25 11:30 AM - During a combined interview, finding was reviewed with E1 (CEO/LNHA) and E2 (DON). No further documentation was provided to the surveyor. The facility failed to ensure R47 was assessed for bilateral bed enablers and a signed consent was obtained before placing bilateral enablers on the resident's bed. Based on record review, observation and interview, it was determined that for four (R5, R23, R27, R47) out of four residents reviewed for bedrails, the facility failed to assess the residents prior to installing the bedrails/enablers and failed to obtain consent from the resident/POA/resident representative. Findings include: 1. Review of R5's clinical record revealed: 1/3/23 - R5 was admitted to the facility with diagnoses including, but was not limited to, stroke with left-sided weakness. 3/12/25 9:29 AM - The surveyor observed R5 lying in his bed, which had bilateral enablers at the head of the bed. 3/13/25 12:01 PM - The surveyor observed R5 lying in his bed, which had bilateral enablers. 3/20/25 4:10 PM- The surveyor requested evidence of therapy's assessment of R5 for the bedrail/enabler and a copy of the POA's consent for enablers. The facility was not able to produce evidence of R5's assessment by therapy for bedrails/enablers nor a copy of the consent from R5's POA for installing bedrails/enablers on his bed. 3/24/2511:24 AM - During an interview, E16 (contracted DOR) stated, We don't have a consent or assessment. 4. Review of R23's clinical record revealed: 8/24/23 - R23 was admitted to the facility with the following diagnoses including, but were not limited to, large body habitus, anxiety, compressed lower back nerves, muscle weakness, nerve pain and osteoporosis. 3/6/25 10:34 AM - An observation revealed bilateral enablers on R23's bed. 3/21/25 11:00 AM - During an interview E2 (DON) stated, We didn't know that a side rail assessment or consent was needed for a resident to have enablers on their bed. We are starting the process for the assessment for side rails and consent, therapy is now starting the evaluations for the enablers. 3/21/25 1:10 PM - During an interview E16 (contracted DOR) stated, We are starting to do the enabler evaluations for the residents that are curently on therapy case load. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2, E3 (SD/ICP) and nine department managers/representatives.

Based on record review and interview, it was determined that for four (R5, R13, R19 and R65) out of fourteen residents reviewed for abuse, the facility failed to report the allegations of neglect/abuse and injury of unknown source to the State Agency within the required timeframe. Findings include: The facility's Resident Abuse Policies and Procedures . Identification- under Delaware State Law, any employee who has reasonable cause to believe that a resident has been abused, mistreated, neglected, or has been subject to misappropriation of funds MUST file a report immediately . If there is reasonable suspicion of a crime, and the events that cause the reasonable suspicion result in serious injury, the report must be made immediately after forming the suspicion as follows: Serious bodily injury- within 2 hours, All others- within 24 hours . Revised 12/2023 1. Review of R5's clinical record revealed: 1/17/18 - R5 was admitted to the facility with diagnosis including, but was not limited to, stroke with left-sided weakness. 11/27/24 - R5's MDS documented that R5 was not able to complete the BIMS cognitive assessment. 1/16/25 Approximately 9:30 AM - E18 (CNA) noted a mark on R5's face and reported it to E15 (LPN). 1/16/25 6:14 PM - E9 (RN) documented in R5's EMR progress notes, During AM care, CNA [E18] noticed a skin tear to mid forehead and notify (sic) nurse. Neuro check completed and within normal limits, MD made aware and treatment order in place, POA also made aware. 1/17/25 10:15 PM - E28 (RN/ADON) reported the incident of alleged injury of unknown source during care to the State Agency. The report of the alleged injury of unknown source was submitted thirty-five hours after this injury of during care was first noted. 3/13/25 2:20 PM - During an interview, R1 (R5's roommate) reported that on 1/16/25 in the early morning when the CNA [E42 (agency CNA)] was turning R5 to perform incontinence care with R5, R5's head struck the enabler bar on the bed. R5 then said, Well, do I have to wear a helmet to get changed? R1 stated that he did not see any other staff in the room until E18 (CNA) came in on day shift and noted the facial skin tear. 2. Review of R13's clinical record revealed: 9/15/22 - R13 was admitted to the facility with diagnoses including, but was not limited to, heart failure and dementia. 3/12/25 11:35 AM - Review of a facility grievance revealed that during a resident led meeting on 4/17/24, R13 reported that on 4/14/24 her CNA [E43 (agency CNA)] stated, You are not coming out of the bathroom until you brush your teeth. R13 explained that she preferred to eat her breakfast and then brush her teeth. Per R13, E43 blocked her from exiting the bathroom and would not listen. 5/2/24 5:55 PM - E21 (LSW) reported the incident to the State Agency documenting that the incident of alleged mistreatment occurred on 4/14/24 at 9 AM. The report of the alleged mistreatment was submitted eighteen days after the alleged incident and fifteen days after the facility became aware of the allegation. 3. Review of R65's clinical record revealed: 10/6/23 - R65 was admitted to the facility, with diagnoses including, but were not limited to, heart failure and breast cancer. 3/12/25 11:40 AM - Review of a facility grievance revealed that during a resident led meeting on 4/17/24, R65 reported that on 4/12/24 another resident (R16) was throwing up so she (R65) went to the nurses' station to report it. R65 reported that there were four employees at the nurses' station and one stated that R16's assigned CNA was on dinner break and that the assigned CNA would check on R16 when she returned from her dinner break. 5/2/24 5:03 PM - E21 (LSW) reported the incident of alleged neglect to the State Agency. The report of the alleged neglect was submitted twenty days after the incident and fifteen days after the facility was aware of the allegation. 4. Review of R19's clinical record revealed: 1/15/25 - R19 reported to facility administration including E21 (LSW) that he alleged that E22 (CNA) verbally abused him during an interaction related to his request for assistance to use the toilet. 1/21/25 - The facility reported the incident of verbal abuse to the State Agency. The facility failed to report R19's allegation of verbal and emotional abuse to the State Agency in the required time of 2 hours. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

2. A review of R19's clinical record revealed: 3/3/22 - R19 was admitted to the facility with diagnoses including a stroke which affected his right dominant side, cerebral palsy, and muscle weakness. 1/5/25 - R19's most recent quarterly MDS documented a BIMS' score of 10, which indicated a mild cognitive impairment, and R19 required substantial assistance with toileting. 1/15/25 - A facility's reported incident submitted to the Division documented, that R19 reported to E21 (LSW) at approximately 2:30 PM he asked E22 (CNA) to use the toilet. E22 entered his room and asked, What do you want? R19 stated that he needed to use the bathroom, and E22 replied, Its's too late, you should have asked to go to the bathroom at 2:00 PM. R19 described E22 as yelling at him and being Really mad. R19 also reported that after E23 assisted him onto the toilet, E22 returned and scolded him for attempting to wipe himself. 1/15/25 - During an interview, E23 (CNA) stated, I was coming to duty and I heard E22 talking to the resident [R19] very rudely. I saw that he (sic) very upset, I talked to him to calm him down. 3/13/25 - During an interview, R19 stated, I felt like I was being punished and yelled at by E22 when I asked If I could use the bathroom. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives. Based on interview, observation and record review, it was determined that for two (R19 and R82) out of fourteen residents reviewed for abuse/neglect, the facility failed to ensure that each resident remained free from abuse or neglect from staff. For R82, the facility failed to ensure the resident was free from neglect. For R19, the facility failed to ensure the resident was free from verbal and emotional abuse from a staff member. Findings include: A facility policy titled Resident Abuse Policies and Procedures, revised 12/2023, stated, The facility will prohibit, prevent and not tolerate residents to be subject to abuse, violence, neglect, mistreatment, or misappropriation of property by anyone, including: staff members, other residents, family members, resident representatives, friends, volunteers, consultants, visitors, or any other individuals . 1. Cross Refer F677, example 2 A review of R82's clinical record revealed: 12/9/24 - R82 was admitted to the facility with the following diagnoses left knee fracture, muscle weakness and osteoporosis. 12/9/24 11:00 PM - A physician's order for R82 documented, immobilizer to left leg at all times do not bend left knee every shift. 12/16/24 - A review of R82's MDS five day admission assessment documented R82 was cognitively intact and required partial moderate assist for transfers. 12/23/24 2:40 PM - A facility reported incident documented, [R82] reported to E21 (LSW) that on 12/22/24 on 3-11 shift [R82] asked her assigned CNA to assist with transferring out of the bed. Further review of the incident report revealed the CNA told [R82] she could transfer herself and that R82 did not need the CNA's help. Additionally, on 12/31/24 the facility's follow up report documented [R82] reported to E21 (LSW) E38 (CNA) replied to R82's request for help stating, You don't need me, you can do it yourself, you don't need my help and that E38 was nasty when speaking to R82 which caused the resident distress. 3/20/25 12:30 PM - A review of a facility's discipline report titled Performance Conduct Title for E38 dated 10/27/23 documented . 1. Misconduct based on failure to assist a resident for the remainder of the shift and confirmed with video surveillance. In addition, on 12/27/24 E38's facility discipline documented . 2. Termination for misconduct allegation of abuse. 3/21/25 11:00 AM - During an interview E2 (DON) confirmed, review of the video footage of the shift in question revealed E38 did not provide the care that was documented in R82's record. Timeline of video camera footage E38 entered R82's room [ROOM NUMBER]:42:44 PM, E38 exiting at 3:42:59 15 seconds after entering R82's room, E38 entered R82's room [ROOM NUMBER]:15:12 PM E38 exited at 3:52:15 PM 2 minutes and 3 seconds after entering R82's room, E38 entered R82's room [ROOM NUMBER]:02:23 PM and exited at 5:02:46 PM 23 seconds after entering the room. E38 spent a total of 2 minutes and 41 seconds providing care to this resident in a 8 hour shift. [E38] documented in R82's chart for toileting times 3:40 PM, 5:41 PM, 7:30 PM, 8:00 PM, and 9:30 PM. [E38] documented repositioning [R82] at 2:56 PM, 4:41 PM, 6:22 PM, 8:22 PM and 10:00 PM. These times are not shown to have occurred on the video footage. R82 had a left knee fracture and required partial moderate assistance for toileting, bed mobility and transfers. Despite the documentation that E38 was in the room [ROOM NUMBER] minutes would not have been enough time to provide care for R82. 3/21/25 1:28 PM - An interview with E21 revealed [R82] was in a brace that immobilized her leg to extend out and she needed help with transfers. E21 stated, [E38] told [R82] she needed to transfer herself. E21 also stated, [R82] was very upset.

Based on review of the facility's Resident Abuse Policies and Procedures, last revised 12/2023, it was determined that the facility failed to develop a written policy and procedure that clearly addressed sections under Identification and Reporting. Findings include: Review of the facility's Resident Abuse Policies and Procedures included, but was not limited to, the following: POLICY . Any allegation of abuse, neglect, mistreatment, injury of unknown origin, suspected commission of a crime, misappropriation of resident property or financial exploitation will be thoroughly investigated and reported . While the facility policy under the separate section for Definitions listed the different types of abuse, neglect, exploitation of residents, the section for Identification lacked evidence that the facility addressed in the written procedures how staff can identify different types of abuse by resident outcomes, such as an unwitnessed injury that was suspicious or multiple injuries over time or unexplained changes in resident behaviors or activities. Under the section for Reporting, the facility failed to clearly delineate the reporting times for abuse, neglect, mistreatment under the Federal and State regulations, whichever is more stringent with the reporting timeframe. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

Based on interview and review of clinical record and other documentation as indicated, it was determined that for one (R7) out of thirty-five sampled residents, the facility failed to consult the provider of the significant change in R7's physical status with her heart rate (HR) running in the 40's. Findings include: Cross refer F684, F726, F755 and F760 R7's clinical record revealed: 1/10/20 - R7 was admitted to the facility with diagnoses including, but were not limited to, seizure disorder and hypopituitarism. 10/16/24 12:22 AM - E24 (RN/shift supervisor) documented in R7's EMR progress note, Fall details: Date/Time of fall: 10/15/24 11:50 PM fall was not witnessed . Provider: [E4, contracted Physician] Time notified 10/16/24 Notified of: fall . Resident found sitting on the floor legs facing the head board of the bed . Resident stated she was self transferring from wheelchair to the bed, when she fell. VS (vital signs) 154/66 (blood pressure), p (pulse) 43, 97.6 T (temperature), 18 rr (respiratory rate), bs (blood sugar) 89 . 10/16/24 1:13 AM - R7's heart rate was documented in the EMR as 43 bpm (beats per minute) (irregular- new onset). 10/16/24 3:36 AM - R7's heart rate was documented in the EMR as 43 bpm. 10/16/24 6:45 AM - E10 (LPN) documented in R7's EMR progress note, Resident rang at 2350h [11:50 PM hour], employee went into the room and found the resident sitting on her buttocks on the floor . VS were obtained BP (blood pressure) 154/66, HR 43 . 10/16/24 10:45 PM - R7's heart rate was documented in the EMR as 41 bpm. Review of R7's documented heart rate from 8/26/24 to 10/16/24 revealed R7's baseline heart rate range was 50 to 96 bpm, with no documented heart rates in the 40's. 10/18/24 3:39 AM - C1 (hospital emergency room MD) documented in R7's hospital admission history and physical, Upon arrival to the ED (emergency department), vital were remarkable for hypothermia to 33.8 (degrees Celsius) and bradycardia to 42 . 3/24/25 3:54 PM - During a telephone interview, E4 (contracted MD) stated that she was not notified that R7's heart was in the 40's on 10/15/24 and 10/16/24. E4 also stated that due to the fall occurring on night shift, the covering service would have been notified about the fall as they provide call coverage from 5 PM to 8 AM daily. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

Based on observation, interview and record review, it was determined that for one (R23) out of thirty-five residents sampled, the facility failed to provide a special need for a larger bed. R23 rolled out of the bed on to the floor during incontinence care and was transported to the emergency room for evaluation and treatment. Findings include: Cross Refer F689, example 2 A review of R23's clinical record revealed: 8/24/23 - R23 was admitted to the facility with the following diagnoses including, but were not limited to, large body habitus, anxiety, compressed lower back nerves, muscle weakness, nerve pain and osteoporosis. 12/22/24 3:55 AM - A facility incident report documented R23 had a fall that a (CNA) did not assure positioning safety prior to attempting to provide care therefore contributing to the resident's fall onto floor. Resident taken to the ER (sic) for evaluation for complaints of pain returned in 24 hours with no acute findings. 12/22/24 - A facility statement for E40 documented, I was giving [R23] care this morning at 4AM she went to turn to her left side and continued forward out of the bed she had little to no room to actually move well from side to side when asked about a bigger bed for her I was told she was unable to get a bigger bed. 3/19/25 - Review of R23's quarterly MDS assessment for 12/4/24 and 3/5/25 revealed the resident was cognitively intact. 3/20/25 11:53 AM - Review of R23's ADL (activities of daily living) care plan interventions created on 9/23/23 documented . 1. Bed mobility the resident requires by (sic) x1 staff to turn and reposition in bed and as necessary. Further review of R23's care plan revealed an intervention created on 3/18/25 to turn and reposition: 2 person assist with all turns and repositioning for safety. The intervention was added to R23's care plan 3 months after the residents fall on 12/22/24. 3/20/25 2:05 PM - During an interview, R23 was observed lying in a standard sized bed on her back with a fall mat on the right and left side of the bed. [R23] stated, I slipped out of the bed I was turning over and I fell out of the bed, the bed is not wide enough for me if I turn over, I am right here on the edge. R23 also stated, I'm afraid when I am being turned in the bed, I'm always on the edge of the bed no matter what, when I fell off the bed, I was right on the edge the aide could not grab me and then after that they put down mats, but I am still afraid of falling. 3/21/25 11:00 AM - During an interview, E2 (DON) stated, [R23] is not bariatric weight we moved her room to give her more space in her room. E2 also confirmed all residents in the building have enablers that are attached on their bed. When E2 was asked about approaches to assist with preventing another fall for R23, E2 stated, I think the CNA was educated on proper turning and repositioning and to be careful when providing care for R23 when in the bed. 3/21/25 1:10 PM - During an interview with E16 (DOR), it was revealed that the current therapy department arrived in October 2024 and that all the beds in the facility had enablers on them. E16, stated and confirmed, [R23] had enablers on the bed in October 2024. Additionally, E16 stated, she is in a standard bed and because she is a large lady it is a tight fit she is afraid when turning in the bed, and nursing said that she does not meet the classification for a larger bed. The facility failed to accommodate R23 a resident that would be more comfortable in a larger bed. 3/24/25 10:30 AM - Findings were reviewed and confirmed with E1 (CEO/LNHA) and E3 (SD). 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1, E2 (DON), E3 and nine department managers/representatives.

Based on observation, record review and interview, it was determined that for one (R26) out of thirty-five sampled residents, the facility failed to treat R26 with dignity. Findings include: R26's clinical record revealed: 9/3/20 - R26 was admitted to the facility. 2/28/25 - R26's quarterly MDS documented that R26 was totally dependent for the functional ability to shower or bathe self. 3/13/25 10:32 AM - The surveyor observed R26, who was wearing only a hospital gown, being wheeled through the hallway on a shower transport stretcher by E17 (RN/UM) and E18 (CNA) to the shower room (about 500 yards) with R26's legs and feet exposed. 3/13/25 10:35 AM - During an interview, E18 confirmed that R26 did not have a blanket covering her legs and feet during transport. 3/26/25 11:45 AM - Findings were reviewed during the exit conference with E1 (CEO/LNHA), E2 (DON), E3 (SD/ICP) and nine department managers/representatives.

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of two residents (Resident (R) 8) reviewed for bowel and bladder was assessed following a decline in continence. In addition, the facility failed to ensure R8 had services and care implemented to maintain as much continence as possible. R8 declined from being continent/mostly continent of urine to becoming incontinent of urine and wearing incontinent briefs following a decline in her ability to use the walker and go to the toilet. Findings include: Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, weakness, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/23, located in the EMR under the MDS tab, revealed R8 used a walker for ambulation, and walked in her room with extensive assistance of one person and required extensive assistance from one person for toilet use. R8 was coded as being always continent of urine. Review of the quarterly Bowel and Bladder Program Screener signed on 09/27/23 in the EMR under the Assessment tab revealed R8 was identified as voiding appropriately without incontinence Not always, but at least daily. R8 was able to get to the bathroom and transfer to the toilet or commode with the assistance of one person. R8 was usually aware of the need to use the toilet. The resident's score was 15 and R8 was noted to be a good candidate for retraining. Review of the quarterly MDS with an ARD of 12/20/23 in the EMR under the MDS tab revealed R8's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R8 required substantial/maximal assistance with toileting hygiene and she was always incontinent of bowel and bladder. No trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had been attempted since urinary incontinence was noted. R8 had not transferred to the toilet or walked during the assessment period. R8 used a wheelchair for locomotion. Review of the EMR revealed the quarterly Bowel and Bladder Program Screener to be completed with the quarterly MDS with an ARD of 12/20/23 was not completed. Review of the EMR revealed the Elimination Pattern Evaluation tool, triggered due to R8's decline in urinary continence between 9/21/23 and 12/20/23, had not been completed. The facility failed to complete the five-day voiding pattern and evaluate the potential for an individualized toileting/training program as directed by the Bladder Management Program policy. Review of the POC [Point of Care] Response History from 01/18/24 - 02/16/24 revealed that R8 was incontinent 86 times and was continent once. Review of the Care Plan dated 04/10/17 in the EMR under the Care Plan tab revealed R8 was at risk for incontinence of bladder and directed staff to take R8 to the toilet. The care plan was not updated. Cross reference F657. During an interview on 02/12/24 at 10:00 AM, R8 stated she had been not allowed to go to the bathroom during certain times of the day, such as during lunch because the staff were serving lunch and feeding residents. R8 stated the staff put her in an incontinence brief and she no longer used the toilet. R8 stated she used to sit in a recliner in the room and she had been able to walk short distances in the room such as to the toilet with staff assistance. R8 stated it had been decided she would now stay in bed versus sitting in the recliner since she lost her ability to use her walker due to a loss of function in her hand. R8 verified she no longer walked and was dependent on staff to change her brief. R8 stated when she got out of bed, a Hoyer mechanical lift was used. Observations during the survey revealed that R8 remained in her bed and she was not observed in a recliner. R8 was in bed on 02/12/24 at 11:45 AM; 02/13/24 at 10:13 AM, 10:19 AM, 10:22 AM, 10:26 AM, 10:31 AM, 2:50 PM; and on 02/15/24 at 8:40 AM. During an interview on 02/13/24 at 3:18 PM, Certified Nursing Assistant (CNA) 12 stated R8 was currently on a check and change program in which her incontinence brief was changed after it was wet. CNA12 verified R8 had previously been toileted when she sat in the recliner (a few months ago); however, she was no longer toileted and remained in the bed and was always incontinent. During an interview on 02/14/24 at 12:02 PM, Registered Nurse (RN) 1 stated R8 required more care than she had previously. RN1 stated, I think she knows when [she] needs changed. RN1 stated, prior to R8 remaining in the bed, she was continent of urine and used a walker to go to the bathroom. RN1 stated R8 previously needed assistance with wiping and pulling her pants up after using the toilet. RN1 stated R8 had been in the bed versus the recliner for about three to four months and since staying in bed, RN1 stated R8 could no longer ambulate using the walker due to the loss of function to her hand and that was why she was no longer taken to the toilet. RN1 stated R8 was no longer using the toilet and was incontinent. RN1 stated staff did not use the Hoyer to transfer R8 to the toilet or to a commode. During an interview on 02/15/24 at 10:07 AM, MDS Coordinator (MDSC) 2 stated R8 used to be continent and could walk to the toilet. MDSC2 stated R8 could not walk anymore and her incontinence brief was now changed while she was in bed. MDSC2 verified the MDS assessments from September 2023 to December 2023 showed a decline in R8's continence. MDSC2 stated the quarterly Bowel and Bladder Program Screener due in December 2023 had not been completed. MDSC2 stated R8 was identified as being a good candidate for a toileting program; however, a toileting program had not been attempted. During an interview on 02/16/24 at 10:14 AM, RN2 stated when R8 used the toilet previously she wore a pad in her underwear for dribbling. R8 voided on the toilet and knew when she needed to void. RN2 stated R8 lost her physical ability to hold the walker due to an issue with her hand. This had prevented R8 from being able to use the toilet. During an interview on 02/16/24 at 3:00 PM, the Former DON stated there should be a form in the software to record voiding patterns and completion of the form should be triggered from the change from being continent to incontinent. The Former DON stated interventions should be implemented following the change to becoming incontinent. During an interview on 02/16/24 at 4:36 PM, the Administrator stated the facility used to implement toileting plans. The Administrator reviewed R8's EMR and verified there was no voiding pattern form completed. The Administrator stated the forms had changed recently with a software change. The Administrator stated if documents were not opened correctly, additional assessments such as for incontinence, would not trigger when they should. Review of the Bladder Management Program dated December 2023 and provided by the facility revealed, It is the policy of this facility to assess residents for continence and to provide the care and treatment required to reach his/her highest level of continence possible. Procedure: 1. The Bowel and Bladder Program Screener tool will be utilized on admission, readmission, and quarterly and/or in response to a change in a resident's status . A score of 7-14 points= Resident is likely to benefit from a bladder toileting schedule (timed voiding) . A score of 15 - 21 pointes= Resident is likely to benefit from a bladder toileting schedule . The resident's voiding pattern will be evaluated for 5-10 days utilizing the Elimination Pattern Evaluation tool on residents Task . Once the voiding pattern form is completed, the Nurse Assessor will review findings and determine appropriate program .

Based on observations, interviews, record review, and facility policy review, the facility failed to prevent a fall for one of seven residents reviewed for falls (Resident (R) 30). This failure resulted in harm to R30 when the nursing assistant failed to ensure R30 was safe while dressing her in her room; R30 fell and suffered a concussion and an abrasion to her forehead and was hospitalized for eight days. Findings include: Review of R30's undated ''Admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed R30 was admitted to the facility on [DATE] with multiple diagnoses to include dementia with agitation, epilepsy, and heart failure. Review of R30's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 09/01/23, located in the EMR under the ''MDS'' tab, revealed a ''Brief Interview for Mental Status (BIMS)'' score of 99 which indicated the resident was not interviewable. The facility assessed R30 as severely impaired cognitively for decision making. The MDS indicated R30 required extensive assistance of one person for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS revealed R30 was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. Review of R30's ''Care Plan,'' dated 10/05/22 and located in the EMR under the ''Care Plan'' tab, revealed the problem ''[R30] likes to walk but is unsteady'' with care planned interventions as ''NURSING REHAB[Rehabilitation]/RESTORATIVE: Walking program will Ambulate up to 300 ft. [feet] 1 [one] time/day with hand held assist 1-2 [one to two] person 7 [seven] days/wk. [week].'' Continued review of the care plan, dated 02/24/23, revealed R30 was at high risk for falls. Continued review of the care plan, dated 09/05/20, revealed the problem ''ADL self-care performance deficit r/t [related to] Confusion, Dementia, decrease in mobility, OA [osteoarthritis], IBS [irritable bowel syndrome], muscle weakness'' with interventions of ''Dressing: extensive assistance, support of one person and ''Toilet Use: extensive assistance, support of one person.'' Review of R30's ''Fall Risk Evaluation,'' dated 12/01/23 and located in the EMR under the ''Evaluations'' tab, revealed the facility assessed R30 with a score of 13 which indicated she was at risk for a fall due to having a balance problem while walking. Review of R30's ''Nursing Progress Notes,'' located in the EMR under the ''Prog Note'' tab revealed the following: On 01/08/24, ''Nurse called stat [immediately] to room, upon enter [sic] the room resident was found on floor face down on floor. CNA [certified nursing assistant] stated that she was giving resident AM [morning] care when she pulled away and fell forward, hitting head and face. This nurse log rolled resident and found her unresponsive with snoring respiration, positive pulse, pupils was non-reactive then she begin [sic] to shot [sic] them tight and I was unable to open her [sic] reopen her eyes. 911 called and emergency transfer made, MD [medical director] made aware, resident family also made aware. Resident left facility 911 at 8:41[AM].'' On 01/10/24, ''Hospital Update today, 01/10/24: Resident continues with poor responsiveness although awake. CT [computed tomography] was negative for fracture and brain bleed. Continues to be monitored for neuro status. No further updates at this time.'' On 01/16/24, '. Admission Details: Arrived by: ambulance. Admission mode: stretcher . Skin: Skin Issue: #001: New. Issue type: Skin tear. Location: Right anterior elbow. Length (cm [centimeter]): 0.5 Width (cm): 0.5 Depth (cm): 0 Peri wound: Normal. Painful: No. Normal skin turgor. Skin note: right inner elbow skin tear .5cm and bruise left hip 2cm .'' Review of the facility-provided ''5-day Report/Findings,'' dated 01/13/24, revealed ''Result of investigation: Employee stated she was providing care. She put her shirt on while in the chair and her pants on resting below the knees. Employee stated, she stood the resident up to complete incontinence care, changed incontinence garment, and leaned down to grab resident's pants from around her ankles attempting to pull her pants up. The employee stated the resident quickly turned and attempted to move away from the caregiver and fell face down. The RN [Registered Nurse] that arrived found the resident face down with a piece of incontinence tab found torn and near the resident on the floor. The residents' pants were down around her ankles. Shoes and socks on. Head towards reclining chair, feet towards resident's bathroom. Resident was initially unresponsive, and initial assessment warranted an emergency transport to the ER [emergency room ]. MD immediately informed. Hospital findings/ verbal report CT Head - shows no brain bleed, + [positive] concussion. Large hematoma noted to right side of forehead, right eye is swollen. Slight bruise to right back of shoulder and on right side of neck- Resident is intermittently awake. Opens both eyes. Starting to take in small amounts of food by mouth. root cause analysis res [resident] impulsive with no safety awareness. transfer status of one and ambulates with one with hands on assistance and a safety belt to avoid falling. ho [history of] wanting to stand and walk in the middle of care. res ho attempting to move away during care when in the bathroom or when in upright position. Per multiple staff members, care easily provided when res lying in bed. Care planned revisions: increased safety awareness secondary to actual fall during care/ staff to request assistance toileting, and dressing due to impulsivity and risk for falls with care. Observation on 02/16/24 at 9:58 AM with Licensed Practical Nurse (LPN) 1 revealed when she stood R30 up out of the wheelchair, R30 leaned forward and was reaching her hands for assistance. Attempts to interview R30 were not possible because the resident was nonverbal. During an interview at this time, LPN1 stated R30 was steady on her feet when standing at times but she would start walking as soon as you stood her up prior to the fall and the restorative aides were aware of her unsteadiness on her feet as well. During an interview on 02/15/24 at 1:32 PM, RN5 revealed she investigated R30's fall that occurred on 01/08/24 and wrote and sent the 5-day investigation report to the State Agency (SA). RN5 stated her investigation revealed CNA4 began performing care to R30 in the bathroom in her room and CNA4 applied the gait belt to the resident and walked then seated R30 in the recliner where she put on her pants around her ankles, socks, shoes, and top. RN5 stated CNA4 stood R30 up from the recliner without the gait belt on and went behind R30 then pulled up her pants then moved forward then she tripped and fell . RN5 indicated R30 was unresponsive after the fall and was sent to the hospital immediately. RN5 confirmed that CNA4 did not ensure R30 was safe when she was providing care to her. During an interview on 02/16/24 at 10:05 AM, LPN4 acknowledged she was assigned to R30 and when R30 was assisted from a sitting to standing position, she was steady on her feet for a few seconds then she would start walking. LPN4 stated the aides should stand in front of her when dressing her to keep her from falling because she would start walking immediately and was a high fall risk due to her impaired cognition. During an interview on 02/16/24 at 10:10 AM, CNA4 verified she had walked R30 in the past and knew R30 was impulsive and would start walking when stood up. CNA4 confirmed that on 01/08/24, she moved R30 from the bathroom to the recliner in her room with a gait belt on her, removed the gait belt after seating her in the recliner, stood R30 up from the recliner to pull up her pants from behind her, then R30 walked away and fell . CNA4 stated R30 was steady on her feet without the gait belt on when she stood her up from the recliner and felt it was a safe decision at that point to leave it off and pull up her pants from behind R30. During an interview on 02/16/24 at 10:26 AM, Physical Therapist (PT)1 verified R30 was a high fall risk due to impaired cognition and did not follow commands. PT1 stated R30 for most part was steady on her feet but could not walk alone, would lean forward, and start to walk when stood up and moved fast. During an interview on 02/16/24 at 11:03 AM, CNA15 stated she had worked at the facility for one year and was always assigned to R30. CNA15 stated she performed R30's bed bath in the bed then dressed her because it was not safe to wash her in the bathroom. CNA15 confirmed R30 was steady on her feet sometimes but would start walking so she stood in front of her to keep her from falling. CNA15 indicated R30 was a high fall risk due to her impaired cognition and lack of safety awareness. During an interview on 02/16/24 at 11:35 AM, the Staff Development Coordinator (SDC) stated she began employment at the facility in October 2023 and started auditing falls to develop a working plan on how to move forward in training the nursing assistants but had not implemented trainings yet. The SDC stated if a resident was not able to bear weight they should be dressed in bed, then transferred to the chair for meals. The SDC confirmed R30 had a history of trying to walk away during care, and the fall could have been avoided by requesting staff assistance with care, not removing the gait belt, and standing in front of the resident while pulling up her pants. During an interview on 02/16/24 at 1:39 PM, the Medical Director verified she was notified on 01/08/24 that R30 fell in her room and was sent to the emergency room per her orders. The Medical Director stated R30 was found unresponsive after hitting her head on the floor. The Medical Director stated R30 had a concussion and an abrasion on her forehead. The Medical Director confirmed R30 was a high falls risk because she was unsteady on her feet and had dementia so severe that she thinks she can walk. Review of the facility-provided policy titled, ''Fall Program,'' dated March 2017, revealed ''Policy: It is the policy of this facility to institute individualized practices to minimize the resident's risk of falling. The facility will monitor safety and implement preventative interventions. Procedure: . 3. ln the event of a fall: a. The RN will assess the resident before he/she is moved and document the findings. b. The physician will be notified of assessment findings. The MD [medical director] will make the determination if hospitalization is indicated. c. Resident's representative will be notified and made aware of the physician recommendation. d. An incident report will be completed by the charge nurse/nursing supervisor. The report will be sent electronically to the Long Term Care Resident Protection Division as per state guidelines. e. A Post incident note will be completed by the charge nurse/nursing supervisor. f. Documentation will include witness statements and nursing assessment . Any abnormal findings will be reported to the physician as soon as possible. i. Nursing administration will complete a 5 day follow up of the incident and document findings accordingly as needed .''

Based on interviews, review of clinical records and other documentation as indicated, it was determined that for one (R1) out of five residents reviewed for death in the facility, the facility delayed in providing CPR to R1 upon finding the resident unresponsive at approximately 2:30 AM on [DATE]. Facility nursing staff failed to locate R1's accurate code status in the electronic health record (EHR) and called 911 three (3) times. Due to the confusion and the inability to locate/confirm R1's accurate code status, the facility failed to call a Code Blue and to initiate CPR timely, resulting in an approximate 45 minute delay. R1 was pronounced by the Paramedics at 3:42 AM. The facility's failure placed R1 in situation with a serious adverse outcome, a potential [CONDITION(S)]. The Immediate Jeopardy (IJ) was identified on [DATE] at 2:13 PM and was abated on [DATE] at 4:00 PM. Findings include: Review of R1's clinical record revealed: [DATE] - An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] - R1 was admitted to hospice services, but remained a Full Code. [DATE] - During the 11 PM to 7 AM shift, R1 had an acute change of condition in the facility. Based on review of the 911 calls, the Prehospital Care Report and R1's Hospice call notes, the following timeline captures how the facility responded: -at 2:27 AM - A call from the facility was placed to 911 stating that a resident was found unresponsive and had no pulse. -at 2:32 AM - A second call by the facility was placed to 911 canceling the first call for Emergency Medical Services (EMS) as the patient was on hospice care and had a DNR. The 911 dispatch canceled the call and notified the responding EMS personnel. -at 2:40 AM - A call was placed by E4 (RN Supervisor) to the 24 hour Hospice provider call line. The Hospice call note documented, Purpose of Call . Patient found unresponsive. Action Taken: Caller (E4) states patient does not have a pulse and not responding. Caller asking if patient is a DNR. Informed caller that no record of DNR status on the chart and documentation states patient has life sustaining order with the facility. Caller asking if hospice can contact family and let them know of patient status . -at 3:03 AM - A call was placed by E4 (RN Supervisor) to the 24 hour Hospice provider call line. The Hospice call note documented, Purpose of Call . Wanting ETA (estimated time of arrival) of call from (Hospice) Nurse. Action Taken: On call nurse (from Hospice) made aware facility wants an update. (Hospice nurse name) states he is trying to contact the (Emergency Contact) and will call them once he reaches them. Facility states they will call back at 3:15 AM if they haven't heard anything . -at 3:13 AM - A third call by the facility was placed to 911 stating that the resident was unresponsive. -at 3:23 AM - The 911 dispatch documented that Medic . CPR at the family request. -at 3:42 AM - R1 was pronounced by the Paramedics. -at 5:20 AM - The Prehospital Care Report by the Paramedics documented, . Facility called around 2:30 AM for a [CONDITION(S)]. Facility then called back and recalled all responding units because the patient was a hospice patient with a DNR. An hour later the facility reactivated 911 for a [CONDITION(S)] because the patient was actually found to be full code. Family was contacted and wanted care to be provided despite the patients downtime and hospice status . ALS found the patient supine (on her back) in her bed, unresponsive, pulseless, and apneic (not breathing). She was warm to the touch and still pliable . Care was provided for approximately 20 minutes . Dependent lividity began to appear on the back of the patients legs . Patient was pronounced at 3:42 hours . [DATE] at 8:25 AM - During an interview, E5 (LPN) confirmed that she was R1's assigned nurse during the 11 PM - 7 AM shift on [DATE]. E5 stated that E6 (CNA) called for assistance with R1 and that she responded behind E4 (RN Supervisor) to R1's room. E5 stated that R1 was unresponsive and still warm. When E5 was asked if she knew R1's code status, she stated no. [DATE] at 8:50 AM - During an interview, E4 (RN Supervisor) stated that between 2:25 AM to 2:30 AM, E6 (CNA) called them (E4 and E5, LPN) to come to R1's room. E4 stated that she assessed R1; no respirations and no pulse for three minutes. E4 stated she called 911 from the bedside. E4 stated that she knew R1 was receiving hospice services. E4 stated that she looked in R1's EHR first before looking in the physical chart, but the code status wasn't clear on the face sheet. E4 confirmed that she did not see the Full Code status documented at the top of R1's profile page in the EHR. E4 also confirmed that she did not check the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E4 stated that she looked in R1's physical chart for her code status and found R1's code status form. E4 stated the code status form was confusing and described it by drawing what she saw as an additional marking on the code status form. E4 stated that she called E2 (DON), told her what she found and that she canceled 911. E4 stated that she called hospice and they told her that R1 was a full code. E4 stated that she then called 911 again and the 911 operator asked if it was the same resident. E4 stated yes, it was the same resident and they came immediately. E4 stated before I finished one cycle of compressions, EMS personnel arrived. [DATE] at 2:13 PM - During a meeting with E1 (NHA), E2 (DON) and E3 (ADON), the facility was notified that an IJ was identified with respect to the incident involving R1 on [DATE]. [DATE] at 6:37 PM - The facility submitted the following abatement plan that included education and training on the location of residents code status' and how to respond to an unresponsive resident: Specifically, E4 (RN Supervisor) and E5 (LPN) would receive the following immediate in-person remediation and education on: - the residents code status located on the residents care profile in the electronic health record; - the Supervisor must have accurate code status on the report sheet at all times; - the nurse MUST obtain code status for each resident in their assignment during bedside shift report and check the electronic health record for accuracy once per shift; - in-person education and review of how to the respond to an unresponsive resident and the facility's CPR policy; - E4 and E5 signed a Nurse Responsibility Statement (completed by [DATE] at 11 PM). In addition, E2 (DON) immediately initiated a facility-wide education and training (including mock drills) with all Nurses, Supervisors and Unit Managers on the residents code status location, how to respond to an unresponsive resident and the facility's CPR policy. [DATE] at 3:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON). [DATE] at 1:45 PM - Based on the survey team's multiple interviews with nursing staff and review of the education and training provided, the IJ was abated on [DATE] at 4:00 PM.

Based on observations, record review, interviews and review of facility documentation, it was determined that for one (R14) out of 23 Stage 2 sampled residents, it was determined that the facility failed to provide appropriate treatment and services to address R14's mental and psychosocial well-being after displaying and verbalizing [MEDICAL CONDITION]. Findings include: The facility policy, entitled Suicide Threats, last revised 10/12, stated, 1. Staff shall report any resident threats of suicide immediately to the Nursing supervisor/Unit Manager. 2. The Nurse Supervisor/Unit Manager shall immediately assess if the resident has a plan. This will assist in the determination of the immediate course of action. The Nurse Supervisor/Unit Manager will notify the Director of Nursing or designee of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Unit Manager or designee arrives to evaluate the resident. 4. After assessing the resident in more details, the Nurse Supervisor/Unit Manager or designee shall notify the resident's attending physician and resident representative and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation in the resident's medical record. Review of R14's clinical record revealed the following: R14 had [DIAGNOSES REDACTED]. 1/22/17 at 12 PM - A Follow Up Psychiatric Assessment stated, .Resident seen, chart reviewed and discussed with nursing staff. Resident endorses feeling sad and everything upsets me .feels hopeless and worthless. She has history of MDD which has been stable on [MEDICATION NAME] up until now .start [MEDICATION NAME] .Will continue to monitor . 1/31/17 (untimed) - In a [MEDICAL CONDITION] reduction meeting - [MEDICAL CONDITION] medication: [MEDICATION NAME] .current behavior: striking out, accusatory .oriented to self and unaware of circumstances .refusing care .illogical, depressed, anxious .medication benefits outweigh risks .Labile, at times; The recommendation was to discontinue [MEDICATION NAME] and start Klonopin. 2/7/17 - A physician's orders [REDACTED]. 2/20/17 at 10:37 AM - A facility social worker note stated, Family informed me that .her pastor visited with R14 .over the weekend. R14 told her pastor that she frequently lies in bed, thinking about how she could end it (her life). Referral was made to psych nurse practitioner and nursing to review medications. There was no evidence that R14 was seen by the psych NP or a medication review was completed. 2/22/17 (untimed) - A hospice social worker note stated, . R14 states she is tired & wishes 'all of this could be over' .knows she is going to see a psychiatrist & is ready to talk to her about her feelings .has appt. to see psychiatric nurse to assess patient's need for medicine to address symptoms of depression. 3/1/17 at 4:02 PM - A facility social worker note stated, .son and daughter-in-law told me that on their last visit, (R14) was asking them where she should cut herself to 'bleed out'. At this time, it seems she does not have the means or strength to hurt herself. In addition, she was just diagnosed with [REDACTED]. Nursing was made aware. 3/1/17 at 4:45 PM - A facility nurse's note stated that R14's urine culture results were received and an antibiotic was ordered for 7 days for a urinary tract infection. 3/8/17 (untimed) - A hospice social worker's note stated, .Psychiatric assessment completed. Pt. being monitored. No danger to self . 3/9/17 at 2:17 PM - A facility nurse's note stated, .noted with increase (sic) agitation and combative behavior hitting, kicking and screaming. 'I would rather to die than to live in this place. I want to stab myself in the heart with a knife'. Hospice made aware requested order for [MEDICATION NAME] gel. E3 (medical doctor) gave a one time order for [MEDICATION NAME] gel . The note further stated that E3 ordered urine testing and the supervisor was made aware to continue to monitor. 3/9/17 at 4:22 PM - A facility social services note stated that R14 was agitated trying to hit staff and refusing meds. Additionally, R14 tried to slide out of her geri-chair 3 times. R14 stated that she wished she had a knife so she could stab herself in the heart and that she wished she was dead. The note also stated that redirection and support were not effective. 3/13/17 at 1:30 AM - A facility nurse's note stated, .yelling out loud and attempted to throw herself on the floor . 3/14/17 at 9:34 PM - A facility nurse's note stated that R14 was found on the bedroom floor and R14 stated, It was a good idea gone bad after the fall. The nurse's note also stated that She was unable to explain further. R14 sustained a small red mark to the left eye. 3/17/17 (untimed) - A hospice social worker note stated, .Pt. also believes she has nothing to live for but told her pastor that she wasn't going to hurt herself . 3/21/17 (untimed) - A hospice chaplain note stated, .Pt reports purposely falling out of bed in an attempt to kill herself. Pt. reports being ready .Chaplain collaborated with pt's staff nurse regarding pt's depression and desire to die. Facility reports being aware. Pt receiving medication . 3/30/17 at 9:10 AM - A facility nurse's note stated that R14 attempted to throw self from Geri-chair. 3/30/17 at 4:35 PM - A nurse's note stated that R14 was found on bedroom floor and R14 stated, I changed my mind but wouldn't make any further clarification. R14 sustained a hematoma to her left forehead. 3/31/17 at 7:00 AM - A facility nurse's note stated that R14 repeatedly attempted to throw herself on the floor. 4/3/17 at 3:46 PM - surveyor observed R14 in the garden room with purple discoloration on her left forehead and left cheek. 4/4/17 at 3:34 PM - During an interview, E6 (RN/UM) confirmed that the last note from the psych NP was on 1/22/17. E6 stated that nurses can contact E3 (medical doctor) and E7 (psych NP) anytime if there are issues or concerns with a resident. 4/4/17 at 4:09 PM - During an interview, E2 (DON) reviewed R14's chart of recent statements and falls. When shown the 3/21/17 hospice chaplain's note, E2 stated that I didn't know and was very surprised that R14 was not seen as the psych NP was here once a week. 4/5/17 at 9:55 AM - During an interview, E10 (RN) stated that R14's behaviors have increased since her admission to hospice on 2/4/17. E10 stated that on one occasion during change of shift report, she was told that R14 had fallen and stated a plan gone wrong or bad decision. When asked what would you do if a resident expressed a desire to hurt themselves, E10 stated that she would document in the psych communication book for the psych NP to see the resident and would inform the unit manager. When asked if the hospice chaplain ever spoke to her about R14's desire to hurt herself, E10 stated no. 4/5/17 at 10:56 AM - During an interview with E6 (UM/RN), when asked if the hospice chaplain ever spoke to her about R14's desire to hurt herself, E6 stated no. When asked what she would do if a resident wanted to hurt herself, E6 stated that she would ask the resident if they had a plan, determine if they could carry out the plan and had the means and would have contacted the facility medical doctor and/or psych doctor. E6 stated that I can't say for sure that E7 (psych doctor) was aware of R14's statements to harm herself. E6 stated that E8 (psych NP) was in the facility last night, 4/4/17, and did not see the R14. 4/5/17 at 11:36 AM - During an interview, E9 (facility social worker) stated that on 2/20/17 she communicated to facility staff during nursing rounds regarding R14's statement to her family. E9 stated that R14's threats of hurting herself were known to the family before she was admitted to the facility. However, E9 confirmed that none of the above was documented. 4/5/17 at 1:14 PM - During an interview, E3 (medical doctor) stated that he last saw R14 on 3/30/17. He further stated that his practice was to ask nursing if there are any changes or updates prior to seeing the resident. E3 stated he was not aware of any of R14's statements about wanting to hurt herself and/or die and he stated, it was disturbing to hear. 4/5/17 at 1:32 PM - Met with E1 (NHA), E2 (DON) and E4 (ADON), reviewed findings and notified them that this is Immediate Jeopardy. 4/5/17 at 2:31 PM - E2 (DON) informed the survey team that R14 was placed on a 1:1 supervision and E8 (psych NP) was summoned to the facility to see R14. E7 (psychiatrist) was in route to the facility to see R14. 4/5/17 at 3:18 PM - During a combined interview with E7 (psychiatrist) and E8 (psych nurse practitioner) following their assessment of R14, E8 stated that she was on leave and did not see R14 in response to the 2/20/17 psych referral written in the psych communication book. E7 stated that R14 had no history of suicidality (suicide attempts). E7 stated that previous falls were not attempts to hurt herself but the last fall (3/30/17) was an attempt to hurt herself but not kill herself and she stated that she would not try to hurt herself again. E7 confirmed that a psych consult was not completed until today, 4/5/17. E7 stated that R14 was on [MEDICATION NAME], an anti-depressant medication, however the surveyor informed him that it was discontinued on 2/7/17. E7 stated that he had discussed with the facility management about providing suicide risk assessment education to the staff. E7 confirmed that he did not see R14 until today, 4/5/17. E7 stated that although R14 expressed a desire to die, he does not believe it is her intent to kill herself. E7 confirmed that while he was here on 3/14/17 for a [MEDICAL CONDITION] Reduction Meeting for other residents, R14 was discussed after the meeting. E7 stated that what was brought up was R14's agitation and he was not told about her suicidality. E7 confirmed that he did not see R14 on 3/14/17. When E7 was asked if he had known about R14's statements, would that have warranted further assessment. E7 stated that if he had known he would have had the suicidality assessed further. For R14, the facility failed to do the following: - to obtain a psych consult after the 2/20/17 facility social worker referral; - to follow the facility's Suicide Threats policy; and - to notify the medical doctor and the psychiatrist of R14's statements of suicide threats.

Based on record review and interview, it was determined that the facility failed to ensure that two residents (R15, R5) out of 34 sampled were free from any physical restraints. The facility failed to ensure that R15 was free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. R15 had a history of [REDACTED]. The facility failed to develop a systematic and gradual process toward reducing the use of the lap buddy. The facility failed to use alternatives, such as a less restrictive device for the least amount of time per day. The facility lacked documented evidence that the lap buddy was released every 2 hours for 10 minutes as per the care plan. The record indicated that R15 was resistant to the use of the lap buddy and indicated that R15 made attempts to slide under the lap buddy on 3 occasions. The facility's response was to immediately administer [MEDICATION NAME] gel to her wrist. The facility failed to recognize that when seated in the wheelchair with a lap buddy, the lap buddy became a stressor to R15 and contributed to her increased agitation/anxiety, depression, emotional outbursts, physical and verbal abusiveness to staff. Additionally, during lunch time observation, R5's lap buddy was not removed from her wheelchair and the wheelchair did not fit under the table. At this time the lap buddy restrained R5 from reaching her food on the table. Findings include: The facility's "Restraint Policy" and the "Restraint Reduction Policy " were reviewed. 1. R15 was admitted to the facility with [DIAGNOSES REDACTED]. According to R15's annual Minimum Data Set (MDS) assessment dated [DATE], her cognitive skills for daily decision-making were "modified independence-some difficulty in new situations only " . R15 was independent with ambulation, bed mobility and transfer, and needed limited assistance of one person with her other ADLs (activities of daily living) such as toilet use, personal hygiene and physical help with bathing. She had no indicators of depression, anxiety and sad mood but exhibited "verbally abusive (to staff) behavioral symptoms ,[DATE] days in the last 7 days " which was easily altered, and " socially inappropriate/disruptive behavioral symptoms (rummaging through her belongings, screaming, making false accusations, anger/agitation) ,[DATE] days in the last 7 days" and not easily altered. Review of R15's nurse ' s notes revealed that this resident was alert and confused. A Psychiatry follow-up (f/u) dated [DATE], stated "Today, resident alert and pleasant. Oriented to person only. Free of expressions of [MEDICAL CONDITION]". [DATE] Psychiatry f/u stated, "Nursing reports on-going agitation, confusion difficulty with redirection...Met with resident who is alert and very pleasant...Seems to have positive response to present meds (medications- Klonopin, [MEDICATION NAME] 10 mg; [MEDICATION NAME] 0.5 mg Q 12 hrs. prn (used last [DATE])[MEDICATION NAME] D/C (discontinued) [DATE] r/t family's request". [DATE] Psychiatry f/u evaluation stated, "Was asked to see due to increased agitation especially in evening. Delusional. Unable to be redirected. Becomes panicked...Today resident alert and pleasant...Spoke with family member #1...agreeable to restarting [MEDICATION NAME]". [DATE] Psychiatry f/u..."Nursing reports on-going confusion and agitation especially in evening hours...Met with resident...Displaying mild to moderate anxiety...Continued dementia related mood and behavioral sx (symptoms). Will increase [MEDICATION NAME] to 25 mg 4 PM & HS (bedtime). Review of R15's clinical record revealed that this resident had 8 unwitnessed falls without injury from [DATE] through [DATE]. On [DATE], the physician ordered " Lap buddy for safety" but did not include the medical diagnosis/symptoms that warranted the use of the lap buddy. R15's quarterly MDS assessment dated [DATE] indicated changes in her cognitive skills for daily decision making to "moderately impaired- decisions poor; cues supervision required." The facility initiated a care plan dated [DATE] entitled "Restraint: Potential for discomfort, injury R/T (related to) use of lap buddy". The care plan goal was "Will be free from discomfort and injury x 90 days. The approaches included "Ensure proper placement of the lap buddy, release q 2 hours for at least 10 min., PT/OT as indicated, Attempt reduction, Explain procedure to family and provide support to resident and her family." In an interview with E2 (Director of Nursing/DON) on [DATE] at 12:15 PM, she stated that they discussed use of the lap buddy with the resident's Court appointed guardians (family member #1 and #2) and had obtained verbal permission. On [DATE] at 1:00 PM, E9 (Social Service Director) confirmed that there was no signed consent. The facility lack documented evidence that the family members were fully informed and aware of the potential risk (negative outcomes which included "increase in confusion and agitation " and may constitute harm/accident hazard such as strangulation and entrapment associated with restraints), and the benefits and the use of other alternatives. R15 was initially evaluated by PT (Physical Therapy) on [DATE] as related to her frequent falls with a short term goal to "ambulate with RW(roller walker"/ww (wheeled walker) within facility setting only" and a care giver goal to "ambulate independently with AD (assistive device) 3x a week for 30 days" to increase safety. R15 was receiving skilled PT until [DATE] when she was placed on Hospice Care per the family's request due to her declining clinical condition. R15 was then placed on a "Functional Maintenance Program" (FMP) on [DATE] (approximately 3 weeks after the lap buddy was initiated) to ambulate up to 150 ft with roller walker "assist x 2" and W/C follow 7 x week during the ,[DATE] PM shift. In an interview with E31 (PT) on [DATE] at 11:45 AM revealed that this program was done once a day on the ,[DATE] PM shift only and the 150 ft ambulation could take 5 minutes for some residents or more minutes depending on the resident's tolerance. Review of R15's FMP record revealed that from [DATE] through ,[DATE], R15 was on FMP with a 1 staff person assist instead of 2 assist as indicated. The ,[DATE] FMP record indicated that 16 days out of 24 days, she tolerated 150 ft ambulation, refused 3 x and only ambulated 100 ft 4x. The ,[DATE] FMP record indicated that R15 tolerated the procedure 95% of the time. The ,[DATE] FMP record showed a 95% declined in participation. During an interview with E30 (PTA) and E31(PT) on [DATE] at 9:30 AM, they stated that they were aware that R15 was ordered a lap buddy for safety. However, the nursing staff never requested a follow-up to revaluate and/or recommend an alternative for the lap buddy. According to the ,[DATE] through ,[DATE] MAR (Medication Administration Record), the staff signed off placement of lap buddy every shift. However there was lack of documented evidence in the CNAs ADL (activities of daily living) flow sheets , MAR's, TAR's (Treatment Administration Record), and nurse's notes to indicate that R15's lap buddy was consistently released every 2hr for at least 10 minutes as per care plan. Review of R15's clinical record revealed the following sequence of events: [DATE] chest X-ray results (due to cough to r/o aspiration) result revealed " Right lower lobe infiltrate". R15 was being treated with Antibiotics for URI (upper respiratory infection). [DATE] Psychiatry F/U stated, "...Nursing reports recent falls, increased sedation...met with resident who is asleep and difficult to arouse...". [DATE] nurse's note, timed 10:30 AM stated, ... " In w/c (wheelchair) lap buddy in place. Repeating asking ' How do you get this off " referring to lap buddy ' ...alert with confusion...Resident continues with agitation and repeating same sentences given PRN (as needed) [MEDICATION NAME] @ 11:00 without significant changes ... ". [DATE] nurse's note and timed 1430 stated, "Resident continues with agitation and repeating same sentences, given PRN [MEDICATION NAME] @ 1100 without significant changes ... " [DATE] nurse's note timed 1145 stated, "Resident extremely agitated ...yelling and screaming at this nurse when tried to give Res PRN [MEDICATION NAME] po. Lifting up whole w/c to stand up, yelling at this nurse ...called (Name of MD #1) ...N/O (new order) [MEDICATION NAME] 0.5 mg/0.1 ml Gell (sic) Apply top (topical) to wrist x 1 now " . [DATE] nurse's note timed 2245 stated, " ...In w/c with lap buddy and chair alarm in place. Resident had increased anxiety this shift. [MEDICATION NAME] gel 0.1ml applied at 1700 (5:00 PM) with little effect. Resident kept trying to take lap buddy off of w/c most of shift ... " . [DATE] nurse's note timed 2300 stated, "Resident very agitated this shift. [MEDICATION NAME] 0.5mg given at 1600 and was not effective. Resident in w/c with lap buddy and alarm in place ...Resident out of w/c for toileting and ambulation with staff assistance. Resident able to make needs known but is very confused. Resident kept trying to remove lap buddy off of w/c and became more agitated when unable to self ambulate. Resident unable to comprehend the use of the w/c and lap buddy...". This same nurse's note also stated that the resident stated "...she was being abused...". [DATE] nurse's note timed 2200 stated,"...Resident agitated during the shift and threw 400 (unit) care plan book across the nursing station desk at the CNA because she would not take off the Resident's lap buddy. [MEDICATION NAME] given at 1600, and slowly began to take effects after dinner ... " . [DATE] nurse's note timed 1530 stated," Addendum ...Resident agitated trying to get out of w/c. [MEDICATION NAME] given at 1120." [DATE] nurse's note timed 1500 stated, ...did c/o (complaint of) not being able to remove lap buddy, did explain reason for using lap buddy to no avail; resident continued to try and have staff members remove lap buddy throughout the shift; aide assisted resident prn with continent care; at this time resident in w/c at nsg. (nursing) station for observation " . [DATE] nurse's note stated, " Resident OOB (out of bed) w/c with lap buddy. Became anxious around 1300 (1:00 PM) wanting lap buddy taken off. Given PRN [MEDICATION NAME] at 1300. CNA walked resident with walker from Nurses station to bathroom for toileting and back again. Resident unstable ambulation. Needs assistance " . [DATE] nurse's note indicated...family members #1 and #2 requests change of MD to (Physician #2). [DATE] nurse's note timed 0235 stated," Res. OOB (out of bed) in w/c with lap buddy until 1245. Alert with usual confusion ...received PRN [MEDICATION NAME] with + (positive) relief ... " [DATE] nurse's note timed 2300 stated, " Resident alert with confusion. Very anxious this shift; [MEDICATION NAME] given but was not effective. Self propelling w/c with lap buddy in place around facility ... " . [DATE] nurse's note timed 0220 stated, " OOB in w/c with lap buddy (from previous shift) very agitated ... " [DATE] Psychiatry f/u stated, "Nursing reports agitation continues, combative with care, paranoid. Today resident alert and pleasant. Mobile in wheelchair...will increase [MEDICATION NAME] to 25 mg at noon & 4 PM". [DATE] nurse's note timed 0400 stated, "Resident has been OOB and awake into w/c since 2345 (11:45 PM), did try to give [MEDICATION NAME] d/t (due to) increased agitation...propelled self around 400 lounge...". [DATE] [MEDICATION NAME] 0.5 mg po (by mouth) every 12 hours was prescribed for [DIAGNOSES REDACTED]. [DATE] nurse's note stated, "Resident attempting to get out of w/c, sliding her body under the lap buddy. CNA attempted to reposition resident and she became verbally abusive, cursing and very combative, punching, grabbing, kicking and slapping ...Did received [MEDICATION NAME] gel with little relief noted". [DATE] nurse's note timed 0215 stated, "Resident combative, fighting CNA, kicking and hitting her. Attempting to get out of wc (wheelchair) by sliding self under lap buddy (alarm on). Received PRN [MEDICATION NAME] gel at 0120; ...at nurses station sitting quietly napping off and on " . [DATE] nurse's note timed 0310 stated, " ...prior to getting in bed resident attempting to slide out of wc (under lap buddy). " [DATE] nurse's note timed 0215 stated, "...Resident placed in wc with lap buddy and began to grab things off of nursing station. Resident placed in geri chair with pillow under her head and at this time relaxed, with eyes closed. " [DATE] Psychiatry F/U stated, "Nursing reports verbal and physical abuse-staff. Confusion and agitation increases...4PM and continues throughout evening. Today resident alert and pleasant. Mobile in wheelchair...Change [MEDICATION NAME] to AM and 4 PM-same dose". On [DATE] [MEDICATION NAME] order was changed to 0.5 mg. 1 po TID at 0800, 1300 and 1800. R15, exhibited repeated resistance to the use of the lap buddy while seated in the wheelchair. She attempted to get out of the wheelchair by trying to slide out underneath the lap buddy 3 times ([DATE], [DATE], and [DATE]). The daily nurse's notes indicated that R15 had difficulty in adjusting to the presence of the lap buddy on her wheelchair. Her agitation, anxiety, emotional outburst, physical and verbal abusive behaviors continued to increase when she was in the wheelchair with the lap buddy that she could not remove. Instead of engaging in a systematic and gradual process toward reducing the restraint, the facility used PRN [MEDICATION NAME] to control her behaviors. The facility failed to recognize that the lap buddy was a stressor to R15 and contributed to her increased agitation, anxiety, depression, emotional outburst, and abusive behavior. Since [DATE], R15 was being treated with antibiotics for right lower lobe (lung) infiltrate/upper respiratory infection. R15 expired on [DATE] with the immediate cause of death as Dementia-complications of pneumonia, dysphagia and hypertension. 2. During lunch time observations at the "Satellite Dining Room" on [DATE] at approximately 12:00 PM, R5's lap tray was not removed from her wheelchair and the wheelchair did not fit under the table. R5 was left in that same position with the lap tray for approximately 30 minutes and she had difficulty accessing/reaching her food from the table. In an interview with E25 (CNA) and E19 (RN) in the dining room on [DATE], they both acknowledged that R5 was supposed to have her lap tray off during meal time. E25 immediately removed R5's lap tray and repositioned her wheelchair when addressed by the surveyor. At that time, R5 commented that her food was already cold. R5's food tray was replaced at 12:45 PM with hot food, however, R5 stated that she lost her interest to eat.

Based on record review, observation and interview, it was determined that the facility failed to provide an environment that was free of accident hazards as was possible for two (2) residents (R11 & R44) out of 34 sampled. The facility failed to ensure that a Hoyer lift did not present an accident hazard for R11. The CNA failed to ensure that the metal hook of the hoyer lift handle was secured when attempting to place the Hoyer lift's leg under the bed. The handle with the metal hook swung and hit the back of R11's head causing a laceration that required the insertion of 2 staples in the hospital emergency room . The facility failed to ensure that R44's side rail was secure. Both siderails were observed to be loose and moved back and forth when grasped posing an accident hazard. In addition, the facility failed to maintain an environment free from accident hazards as evidenced by an unlocked linen chute accessible to residents on the first floor of the facility. Findings include: 1. The facility's policy entitled "Mechanical Lifts" was reviewed. R11 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R11's cognitive skills for daily decision-making were severely impaired and she was totally dependent on staff for activities of daily living (ADLs). The facility established a care plan dated 5/10/10 entitled "Potential for pain, altered skin, decline in ROM (range of motion) R/T (related to) (L) distal femur fx (fracture)" and with the last review date of 6/10/10. The interventions included "Hoyer lift and 2 assist with all transfers". A nurse's note dated 7/4/10 (0715) stated, "At 0515 Aide alerted this nurse of resident acquiring a head injury which did result in two lacerations on the posterior side (head), aide (1 CNA) was performing hoyer setup when one of the hoyer arms (handles) hit the resident in the head, used abd (abdominal) pads to apply pressure to lacerations to halt bleeding, while acquiring vs (vital signs)...observed that resident's pox/pulse ox (oxygen saturation with the patient's blood monitored with a pulse oximeter device) was 85% (normal range 92 -100%), placed resident on O2 (oxygen) via nasal canula which before she left facility increased to 92%, bleeding was stopped before EMT's transferred resident to ER...for evaluation...neuro checks is performed prior to leaving facility". A nurse's note dated 7/4/10 (1020) stated, "Resident returned from ED (Emergency Department) at 1010 via stretcher with 2 EMTs (Emergency Medical Technicians). Resident had 2 staples applied to laceration on back of head...". Review of the facility's investigation included a written statement from E29 (CNA) dated 7/4/10 which stated, " This morning at around 5:15 AM I was giving care and preparing resident (R11) to get up. Unfortunately, one of the dangling hoyer hooks hit her on the head. This happened accidentally as I was trying to lower the hoyer handles to hook them to the lifting hoyer pads on the bed...". In an interview with E29 on 8/24/10 at approximately 3:10 PM, he confirmed that he was alone in the room. He further stated that R11's head was contracted and was always up and she could not lay flat, so the metal hooks of the dangling hoyer handle hit her on the back of her head. E29, on preparing R11's transfer to a chair with a Hoyer lift failed to call for assistance to ensure R11's safety. E29 failed to secure the hoyer lift handle to prevent it from dangling. R11 sustained a 1 inch laceration to posterior aspect of her head when it was hit by the dangling hoyer lift handle bar and was sent out to the hospital for evaluation and sutures (2 staples). The facility's policy and procedure indicated that 2 staff members must be present when preparing, positioning the sling pads underneath the resident and attaching the S-hooks of the chains to the swivel bar hooks prior to lifting and performing transfers using a mechanical lift. In an interview with E19 (RN,Staff Developer) on 8/24/10, she stated that E30 (PTA) inserviced all staff on 6/9/10 on the use of the Hoyer lift. In an interview with E30 (PTA) on 8/30/10 at 1:00 PM confirmed that the Hoyer lift taken into the resident's room must be away from the bed. One person should prepare the pad underneath the resident and the 2nd person hooks the pad to the handles of the Hoyer lift. Since there was no opportunity to observe R11 for transfer with a Hoyer lift, 2 observations of Hoyer lift transfers on 8/26/10 and 8/30/10 on R44 (another resident with a Hoyer lift transfer) was done correctly with 2 persons and according to facility policy . Review of facility's incident report and result of investigation revealed that E2 and E19 acknowledged on 7/9/10 that E29 "operated hoyer lift without a second person resulting in Resident injury. Per policy, transferring residents via hoyer lift requires two staff members at all times". E29 was "careless" and "violated safety rules". Consequently, the unsecured/dangling Hoyer lift handle bars and hook became an accident hazard to R11. 2. R44 was observed on 8/23/10 at 9:45 AM sitting up in bed with both side rails in the up position. She stated that she used them to help her turn herself in bed. Both side rails were observed to be loose and moved back and forth when grasped posing an accident hazard. During observations on 8/23/10 at 3:00 PM, with E15 (maintenance director), he agreed that R44's side rails were too loose. At 3:30 PM, E15 stated that he replaced the side rails. Observations at that time confirmed that the side rails fit properly. The facility failed to maintain an environment free of accident hazards as evidenced by loose side rails on R44's bed. 3. Observations on 8/18/10 through 8/25/10 of the first floor linen chute door revealed that the linen chute was unlocked and accessible to residents. The chute had a locking system that was in disrepair. Staff interviews with E13 (Maintenance) and E14 (Maintenance) confirmed this finding. The door to the chute was observed locked on 8/27/10 at 1:30 PM and 8/30/10 at 10:00 AM after it was repaired.

Based on record review, interview and review of facility policy and procedures, it was determined that the facility failed to ensure that three (3) residents (R88, R99 and R100) out of 34 sampled, who were incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The facility failed to re-assess R88's, R99's and R100's bladder continence status when they experienced a decline and failed to follow procedures for the management of the bladder incontinence. All three (3) resident's bladder continence status declined from continent to incontinent. Findings include: The facility's policy entitled "Bowel & Bladder Program" stated, "On admission, readmission, quarterly or in response to change (s) in the resident's condition (sic) will be evaluated for bowel and bladder continence and potential for bowel and bladder retraining in order to prevent urinary tract infection [MEDICAL CONDITION], and to maintain normal bladder function. Any resident identified as incontinent of urine will be evaluated for causal factors and appropriate actions undertaken to obtain the most effective functioning....The choice of interventions will be dependent on assessment findings including voiding patterns. PROCEDURE: 1. EVALUATE using the Bowel and Bladder Assessment tool on admission, readmission, quarterly, or in response to change in condition. 2. INITIATE Three-Day Continence Management Diary based upon the scoring of the assessment above. Scoring: 0-6 = Good candidate for individualized training; 7-14 = Candidate for toileting schedule (timed voiding); 15-24 = Poor candidate for toileting schedule or retraining...3. Evaluate impact of all medications...4. Determine if further testing is needed such as stress test, post-void residual checks...5. Develop and implement care plan...6. Evaluate response to approaches...7. Re-evaluate effectiveness at least quarterly..." 1. R99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R99's admission Minimum Data Set (MDS) assessment, dated 3/29/10 indicated the resident had short and long term memory problems and her cognitive skills for daily decision making were moderately impaired. The MDS indicated that R99 required one person limited assistance for transfers and one person extensive assistance for toileting and hygiene. The resident was assessed as being continent of urine (scored "0") and as not being on any scheduled toileting plan. The facility's Bowel and Bladder Assessment, completed on 3/22/10 identified R99's score as "8" indicating the resident was a candidate for toileting schedule (timed voiding) per facility policy. The care plan for "ADL (activities of daily living) function rehab potential self care deficit," dated 3/23/10 stated the resident required moderate assistance of one person for hygiene, toileting and transfers and that R99 was continent of B&B (bowel and bladder). A care plan for the problem "Pressure Ulcers at risk for altered skin integrity..." dated 3/24/10 included the approach, "Requires mod (moderate) assist of one with toileting Uses pull-ups for occasional urinary incontinence, provide inc (incontinence) care PRN (as necessary)..." Review of the CNA (certified nurse aide) Flow Sheets from 3/22/10 through 5/11/10 revealed that R99 had eight (8) episodes of urinary incontinence documented. Nurse's notes from 3/22/10 through 5/8/10 stated the resident was continent of urine and was assisted to the bathroom by CNAs. A nurse's note, dated 5/9/10 and timed 3:30 PM, stated the resident was alert with some confusion and at times incontinent at hour of sleep. A nurse's note, dated 5/10/10 and timed 10 PM, stated the resident was able to make her needs known, transferred independently, ambulated with a rolling walker and was continent of bowel and bladder with occasional incontinence. On 5/13/10 at 6:50 AM, the nurse's note stated that R99 was "assist (with) toileting by CNA. Noted to be incontinent of urine..." A nurse's note, dated 5/14/10 and timed 3:30 PM, stated that the CNA reported that the resident was having more incontinence of urine and that it would be passed onto the next shift to check the urine for bacteria (possible infection). On 5/15/10 at 9:45 PM, the nurse's note stated that a urine dipstick (test strip used to check for infection) was completed and was within normal limits. Review of the CNA Flow Sheets from 5/12/10 through 8/23/10, revealed that R99 was now incontinent of urine daily. Nurse's notes during this same time period indicated that the resident was at times toileting independently and at other times required assistance with incontinence care. There was no evidence in the clinical record that the facility re-assessed R99 at the time of her increased incontinence (mid May) or that a voiding diary was completed in order to determine voiding patterns in an attempt to improve and/or maintain continence. A quarterly Bowel and Bladder Assessment, completed on 6/12/10, listed a score of "7" which indicated R99 was a "candidate for toileting schedule (timed voiding)." There was no evidence that a voiding diary was completed at this time. A quarterly MDS assessment, dated 6/14/10 indicated that R99 was dependent for transfers and totally dependent for toilet use. The MDS also indicated the resident was incontinent of urine (scored "4" - "had inadequate control Bladder, multiple daily episodes") and was not on any scheduled toileting plan. The care plan for "ADL function" was revised on 6/24/10 and listed the problem, "Incont of bladder, requires extensive assistance (with) incont care. The approaches were revised to indicate that R99 now required extensive assistance of one person with toileting. There was no evidence that a voiding diary was completed at this time or that any new interventions were implemented in an attempt to improve R99's continence status. On 8/23/10 at 9 AM an interview was conducted with R99, who was mildly confused. R99 was asked if she had any difficulty using the bathroom and if she needed help. R99 stated that she had no problems. When asked if she had any problem with incontinence she stated that sometimes when she gets up from bed she has to go "fast" and at times "doesn't get there in time." During an interview with E21 (CNA) on 8/23/10 at 4:05 PM, she stated that she has worked with R99 since the end of May and that the resident was both continent/incontinent. E21 stated that the resident toileted herself independently and would call for assistance if she needed help with incontinence care. E21 stated that she knew the resident was incontinent because she throws her briefs in the bathroom trash can. On 8/24/10 at 11:30 AM, E20 (CNA) was interviewed and stated that the resident used to be continent of urine and that she recalled when R99 became incontinent. E20 also stated that the resident was still incontinent, but she would take/remind her to use the bathroom throughout her shift. E20 stated the resident was forgetful and needed reminders. E20 also stated that she had never completed a voiding diary for the resident. In an interview with E18 (nurse) on 8/24/10 at 2:25 PM, E18 stated that the resident "has always been incontinent." E18 acknowledged that a voiding diary was never completed and subsequently no planned toileting scheduled. E18 stated that R99's day shift aide always took her to the bathroom, however, she agreed that this aide was not on duty around the clock. On 9/3/10 at 9:45 AM, during an interview with E19 (nurse) this surveyor was provided with copies of attendance records for a bowel and bladder inservice conducted on 4/1/10. The "self learning inservice" consisted of staff reading the facility policy and signing off that they read it. E19 acknowledged that when a resident became incontinent after being continent this would constitute a change in status and warrant implementation of an assessment, a voiding diary and a subsequent scheduled toileting plan. E19 stated that the nursing Unit Manager/Supervisor should initiate a voiding diary or inform the floor/medication nurse of the need for one. The floor/medication nurse should monitor that the CNAs are completing the diary. Although the facility had policies and procedures pertaining to a bladder program, the facility failed to ensure that systems were in place for the staff to identify a decline in bladder continence and then activate the appropriate interventions. The facility failed to ensure that R99 received appropriate treatment and services to restore as much normal bladder function as possible. R99, who became increasingly incontinent after having been assessed as continent of bladder upon admission, was not provided with these services. R99 experienced a decline in her continence status which resulted in harm to the resident. 2. R88 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R88's quarterly MDS assessment, dated 5/31/10, indicated that her cognitive skills for daily decision making were independent and she had no memory problems. Additionally, R88 was fully continent of bowel and bladder and was independent for toileting. The facility's Bowel and Bladder Assessment, completed on 6/2/10, identified R88's score as "1" which indicated that she was a good candidate for individualized training. Review of the CNA Flow Sheets from admission in 12/09 through 6/10 revealed that R88 was fully continent of bladder. A nurse's note, dated 6/22/10 and timed 7 AM, stated, "...noted to be incontinent of urine this AM...", however, according to the CNA flow sheet, she was fully continent of bladder on 6/22/10. A nurse's note, dated 7/14/10 and timed 8:15 AM, stated, "....requests help at times with ADL's but mostly independent, mixed incontinence of B&B..." Another nurse's note, dated 7/21/10 and timed 7 AM, stated "...May or may not toilet self. Assistance offered (every 2 hours) to toilet. Resident may be incontinent but uses toilet as well..." Review of R88's CNA Flow Sheet for 7/10, revealed that she was mostly incontinent on the 11 PM to 7 AM shift and about half of the time on the 3 to 11 PM shift. Review of a nurse's note, dated 7/31/10 and timed 5:30 AM, revealed that R88 was found lying in the doorway of her bathroom. She had been ambulating with a rolling walker. R88 complained of left shoulder pain, was sent to the hospital and was found to have sustained a fracture to her left upper arm. Review of R88's CNA Flow Sheet for 8/10, revealed that she was not only incontinent of bladder on the 11 PM to 7 AM shift, but also on the 7 AM to 3 PM shift and all but 8 times on the 3 PM to 11 PM shift. A Bowel and Bladder Assessment was completed on 8/13/10 for R88 that identified a score of "12" indicating that she was a candidate for a toileting schedule (timed voiding) per facility policy. No evidence was found in R88's clinical record that the facility initiated a three-day voiding diary. During an interview with E24 (CNA) on 8/31/10, she stated that she took R88 to the bathroom every two hours but the resident was usually already wet. She stated that R88 used to ask for help to go, but she had not been asking lately. A significant change MDS for R88 was completed on 8/23/10 (during the survey) which indicated that the resident was totally incontinent of bladder and dependent on staff for toileting. The facility failed to re-access R88's bladder continence in 7/10 when she first showed a decline. As a result, R88's continence status continued to decline until she became almost totally incontinent of bladder. The facility did not implement a voiding diary until 8/27/10 after it was brought to the facility's attention by the surveyor. 3. R100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R100's admission MDS (Minimum Data Set) Assessment, dated 4/12/10 indicated that the resident's cognitive skills for daily decision making were coded as a "1" (modified independence) with some short term memory loss. The assessment indicated that R100 was fully continent of bowel and bladder. She was not on a scheduled toileting plan but, was totally dependent for toileting and required one (1) person physical assistance. R100's care plan for "ADL function/rehab potential...", dated 4/9/10 included the approach "...Provide extensive assist of one c (with) ....grooming, hygiene, toileting..." Review of R100's clinical record lacked evidence that the Bowel and Bladder Assessment was completed on admission. However, there was a Three-day Continence Management Diary, dated 4/7/10 through 4/9/10 with no documentation for 4/8/10 and missing documentation on 4/9/10 for the 7-3 and 11-7 shifts. Available documentation indicated that R100 was found to be clean and dry or she was assisted to the toilet with positive results. CNA Flow sheets were reviewed and revealed that R100 was fully continent of bladder in 4/10. R100 was documented as both incontinent and continent on the 11-7 shift on 5/21/10, otherwise she was fully continent during 5/10. Review of the 6/10 CNA flow sheets revealed that R100 remained continent of bladder except for the 11-7 shifts on 6/27/10 and 6/28/10. A nurse's note, dated 4/8/10 and timed 6:55 AM stated, "... Res. (resident) assisted to BR (bathroom) X (times) 2. gait slow/unsteady..." A nurse's note, dated 4/9/10 and timed 11 PM stated, "... got OOB (out of bed) to the bathroom only, Continent of B&B (bowel and bladder)..." On 4/11/10, a nurse's note timed for 9 PM revealed that R100 was "...Continent of B&B..." and on 5/2/10 at 2:20 PM, a nurse documented "... Requires assistance c (with) walker & staff to bathroom..." R100's Quarterly MDS, dated [DATE] indicated that R100's cognitive skills for daily decision making were "severely impaired" with short term memory loss. Additionally, R100 remained totally dependent for toileting and was coded as "occasionally incontinent" of bladder. The facility's Bowel and Bladder Assessment, completed on 6/30/10, identified R100's score as "5" which indicated that she was a "good candidate for individualized training." Although review of the CNA flow sheets from 7/1/10 through 8/6/10 revealed that R100 was continent, a Bowel and Bladder Assessment completed on 7/16/10, listed a score of "8", which indicated that R100 was a candidate for toileting schedule (timed voiding). There was no evidence that a Three-day Continence Management Diary was done as per facility policy. Review of the 8/10 CNA flow sheets revealed that R100 was incontinent of bladder on the 11-7 shifts for 20 out of 31 nights. There was no 11-7 shift documentation on 8/28, 8/30 and 8/31/10. Otherwise, R100 was documented as being fully continent on the day and evening shifts for 8/10. There was no evidence found in R100's clinical record that another "Bladder and Bladder Assessment" was done after 7/16/10. The only voiding diary found was the incomplete diary of 4/17/10. While the care plan for "ADL function/rehab potential...", dated 4/9/10 approach for "...extensive assist of one c .... toileting..." was revised (undated) to "total" assist, the careplan was not updated to include incontinence. During an interview on 8/30/10, E25 (CNA) stated that R100 was not on a toileting schedule because the resident was able to tell staff when she needed to go to the bathroom. E25 stated that R100 was continent during the day. During an interview on 8/31/10, E26 (CNA) stated that the resident was walked to the bathroom. E26 stated that R100 sometimes gets agitated when asked if she needs to be toileted and does not always want to get up. E26 stated that frequently R100 was found to be incontinent at the beginning of the shift or a shortly afterwards. During an interview on 8/31/10, R100 stated that she used the call bell to alert staff when she needed to be toileted. R100 was asked what happens if staff do not come right away when she used the call bell. She stated, "I would try to hold it and hope I don't wet myself." When asked if that ever happened, she stated, "Yes." During an interview on 8/31/10, E27 (charge nurse) was unable to explain why R100 had a decline in continence. E27 denied ever seeing the facility's Bowel and Bladder Assessment despite it being in the resident's chart. He denied that a Three-day Continence Management Diary was completed for R100. He stated that he was not involved in R100's bowel and bladder assessment nor was he familiar with the facility's policy. After being shown the policy, E27 acknowledged that the facility policy was not followed. Findings were discussed during an interview on 8/31/10 with E2 (Director of Nursing). E2 acknowledged that the facility failed to follow their policy after assessing a change (decline) in bladder status in 6/10 when a Quarterly MDS assessment was done, they failed to follow-up on the 7/16/10 bladder assessment and failed to implement their policy (assess and follow-up with a Three-day Continence Management Diary) in 8/10 when CNA flow sheets revealed that R100 was incontinent numerous times on the 11-7 shift. Although the facility was documenting data on the CNA Flow Sheets, it was unclear as to what system was in place to analyze and act upon this data when indicated.