Every finding on record at Manhattan Community Care Center

Based on observations, interviews, record review and facility policy review, the facility failed to ensure residents received snacks at designated times and that diabetic residents received appropriate nighttime snacks as required for three (3) of (33) sampled residents. Resident #92, Resident #104, and Resident #141.Findings include:A record review of the facility, Exhibit D Resident [NAME] of Rights no date, reveals, Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life .The resident council meeting was convened on 8/17/26 at 2:00 PM with 11 residents present. Residents reported they were not aware snacks were available to them. They explained that a hydration cart occasionally came around with water and juice, but not consistently. They noted staff sometimes gave snacks to residents in the day room but did not bring snacks to residents' rooms or offer them in passing. Residents reported snacks were mainly provided during council meetings and activities. Resident #104 mentioned that, as a diabetic, receiving a snack at night would help because he is usually hungry after dinner. He added he did not know snacks were available, so he never asked staff. Resident #92 explained that residents receive only three meals a day, and snacks between meals would be beneficial because the time between meals can feel long. She added she saves her orange juice from breakfast to have something at night if her blood sugar drops, noting no one informed her snacks were available in the evenings.On 8/17/27 at 3:17 PM, Licensed Practical Nurse (LPN) #1 explained that Certified Nursing Assistants (CNAs) are usually responsible for going room to room and passing out snacks at 10 AM, 2 PM, and 6 PM. She noted the hydration cart had been sitting in its current location for at least an hour.On 8/17/26 at 3:27 PM, the State Agency (SA) observed a hydration cart on the second floor at the nurse's desk filled with snacks, but no staff were passing out the snacks.On 8/17/26 at 3:49 PM, the SA again observed the hydration cart across from the nurse's desk with no staff distributing snacks.On 8/17/26 at 4:01 PM, Resident #141, who is a diabetic, explained she cannot remember the last time staff gave her a snack or passed them out to residents. She noted she received a bag of chips today and believed it was because the SA was in the building.On 8/18/26 at 9:25 AM, Resident #104 reported he did not receive any snacks the night before on 8/17/26.On 8/19/26 at 9:04 AM, Resident #104 reported he did not receive a snack the night before on 8/18/26 and said he was very hungry.During a phone interview on 8/19/26 at 9:28 AM, CNA #1 (House Coordinator, day shift) explained that the dietary department provides snacks such as sandwiches, cakes, chips, and juice. She confirmed snacks are supposed to go out at 10 AM, 2 PM, and 6 PM. She indicated she assigns CNAs to pass out the cart, but sometimes CNAs cannot complete the task. She acknowledged that no communication system exists for other staff to take over if the assigned CNA does not pass out snacks.In a phone interview on 8/19/26 at 10:06 AM, CNA #2 (House Coordinator, evening shift) reported she does not assign a specific person to pass out snacks and believes it is a team effort. She explained she did not focus on ensuring snacks and sandwiches were distributed because she assumed someone else would handle it. She acknowledged she dropped the ball and added that no one informed her it was a specific responsibility. She noted it is important for all residents, especially diabetics, to receive snacks after dinner because their blood sugar could drop, and residents should not have to ask since dietary provides them.On 8/19/26 at 11:14 AM, Resident #141 reported she did not receive a snack or anything after dinner the previous night.On 8/20/26 at 11:57 AM, the Director of Nursing (DON) explained that the House Coordinator is responsible for assigning the task of passing out snacks. She reported that diabetic residents should receive a snack every night at 8 PM to prevent their blood sugar from dropping during the night. She added that staff are expected to go room to room with the cart and provide snacks to residents who are in their rooms.Resident #92A record review of the admission Record revealed the facility admitted Resident #92 on 8/22/23 with diagnoses that included Major Depressive Disorder Recurrent and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/26 reveals a Brief Interview for Mental Status (BIMS) score of (15) indicating Resident #92 is cognitively intact.Resident #104A record review of the admission Record revealed the facility admitted Resident #104 on 5/10/25 with diagnoses that included Type 2 Diabetes Mellitus with Chronic Kidney Disease.A record review of the MDS with an ARD of 7/29/26 revealed a BIMS score of (15) indicating Resident #104 is cognitively intact.Resident #141A record review of the admission Record revealed the facility admitted Resident #141 on 10/28/22 with diagnoses that included End Stage Renal Disease and Type 2 Diabetics Mellitus with Chronic Kidney Disease and Nutritional Deficiency.A record review of the MDS with an ARD of 6/17/26 revealed a BIMS score of (14) indicating the resident was cognitively intact.

Based on observation, interview, record review and facility policy review the facility failed to properly store medications, as evidenced by not removing expired insulin vials within the manufacturer's 28-day in-use period for two (2) of four (4) medication carts inspected.Findings Include:Record review of the facility's policy titled Insulin Administration, dated 2001, revealed to provide guidelines for the safe administration of insulin to residents with diabetes. Check the expiration date, if drawing from an opened multi-dose vial.On 08/18/2026 at 2:55 PM, during an observation of medication cart #2 on the second-floor front hall with Licensed Practical Nurse (LPN) #4, one opened vial of Lantus insulin, 100 units per milliliter, was dated 07/19/2026. The vial had been open for 30 days and exceeded the 28-day in-use period. During an interview at that time, LPN #4 confirmed the vial should have been removed from the medication cart. LPN #4 stated insulin should be discarded after 28 days because administering insulin beyond the designated period could be dangerous to residents. LPN #4 also confirmed she had not checked the insulin stored on her medication cart that day. On 08/18/2026 3:10 PM, in an observation and interview cart check on the second-floor cart #1 with LPN #5 confirmed that two bottles of Lantus that were opened on 7/16/26, should have destroyed on 8/12/26. She also confirmed that Lispro opened on 7/16/26 should have been destroyed on 8/12/26 and one dated 7/18/26 should have been destroyed by 8/14/26. She stated she started to glance over the cart this AM but did not check the cart completely. She stated insulin should not be given after 28 days as it would not be effective after 28 days.On 08/19/2026 at 4:05 PM, during an interview, the Director of Nursing (DON) stated nurses were responsible for removing opened insulin from medication carts after 28 days. The DON stated nurses should inspect the medication cart for expired medications when assuming responsibility for the cart. The DON confirmed insulin kept beyond its designated in-use period might not effectively reduce elevated blood glucose levels.

Based on observation, interview, record review and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to a resident that was dependent for personal hygiene for one (1) of seven (7) care observations. Resident #119Findings Include:Record review of the facility policy Activities of Daily Living (ADLs), Supporting, with a revision date of 3/2018 revealed ,Policy Statement: Residents will be provided with care, treatment and service as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral care .On 08/17/2026 at 11:57 AM, Resident #119 is in bed watching TV. He has moderate facial hair. He stated he has not been shaved in the last 4 days. He states they shave him once a week. He stated he would like to be shaved every other day. He stated he does not like all hair on his face.On 08/18/2026 at 12:06 PM, an observation and interview revealed Resident #119 was in bed and watching tv. He remained unshaven. Resident #119 stated he likes to be clean shaved.On 08/19/2026 at 9:38 AM, during an observation and interview revealed Resident #119 was in bed watching tv with moderate facial hair. Certified Nursing Assistant (CNA) #3 was present in the room and was assigned to Resident #119 today. Resident #119 confirmed he wanted to be shaved. On 08/19/2026 09:42 AM, an interview with CNA #3 stated Resident #119 usually like a trim down. He stated he does not ask residents on bath days if he would like to be shaved. He stated he assumes that he would like a trim down. CNA#3 confirmed that Resident #119 wants to be clean shaved. He stated that a resident that prefers to be shaved, it could cause him not to feel good about himself when he is left unshaved. On 08/19/2026 2:36 PM, in an interview and observation with Resident #119 revealed he clean shaved and smiling. He verbalized he is pleased with getting shaved.On 08/19/26 at 3:59 PM, in an interview with the Director of Nursing (DON) stated Resident #119 has designated days for showering and shaving. She stated she expects CNA #3 to do ADL care in a timely manner which included shaving.On 08/20/2026 at 10:36 AM, during an interview, the Assistant Director of Nursing (ADON) stated she usually shaved Resident #119 and gave him a facial hair trim. She confirmed she had never asked Resident #119 whether he wanted a different type of shave and stated she should have asked him about his preference.Resident #119Record review of Resident #119's admission Record revealed the facility admitted the resident on 08/30/2022 with diagnoses that included restlessness and agitation and unspecified cataracts.Record review of Resident #119's Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. Section GG documented that Resident #119 was dependent on staff for personal hygiene.

Based on record review, interviews, and facility policy review the facility failed to honor the stated food preferences as evidenced by not serving residents with a variety of choices of fresh fruits, as evidenced by the facility continued to provide only bananas or no fresh fruit for three (3) of (33) sampled residents. Resident # 114, Resident #50 and Resident #166. This failure limited the residents' food choices and resulted in dissatisfaction with the meals provided. Findings included:A review of the facility policy titled Resident Food Preferences, revised July 2017, revealed, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diets will be ordered only with the resident's or representative's consent .Policy Interpretation and Implementation .8. If the resident refuses or is unhappy with his or her diet, staff will create a care plan the resident is satisfied with .Resident #114During the Resident Council meeting on 8/17/26 at 2:30 PM, Resident #114 stated she had repeatedly requested more fresh fruit on her meal trays but received only bananas. She stated she preferred a variety of fresh fruits and vegetables. She reported that she ate the food provided because she felt she had no choice of healthier options.During an interview on 8/17/26 at 3:28 PM, the Dietary Manager acknowledged he was aware Resident #114 wanted more fresh fruit, specifically strawberries and grapes. He stated several residents had requested a greater variety of fresh fruit. He explained that he had to follow the facility's current ordering list and remain within the dietary budget. He acknowledged the facility should honor residents' food preferences.Record review of the admission Record revealed the facility admitted Resident #114 on 3/5/21 with diagnoses that included Type 2 diabetes mellitus without complications.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/26 revealed Resident #114 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.Resident #50During an interview on 8/20/26 at 12:04 PM, Resident #50 stated dietary staff periodically asked about his food preferences, but his meal trays did not reflect those preferences. He stated the facility did not provide the fruit he preferred. He reported that the facility previously served bananas, but the bananas were often overly ripe or rotten. He stated he had not received a banana or other fresh fruit in several months.Record review of the admission Record revealed the facility admitted Resident #50 on 5/22/24 with diagnoses that included unspecified hyperlipidemia.Record review of the MDS with an ARD of 7/1/26 revealed Resident #50 had a BIMS score of 13, indicating the resident was cognitively intact.Resident #166During an interview on 8/20/26 at 10:55 AM, Resident #166 stated she had been admitted a few weeks earlier and was already burned out on bananas. She stated bananas were the only fresh fruit she had received. She stated she would like other fresh fruit options, including strawberries or grapes.During an interview on 8/20/26 at 12:53 PM , the Administrator stated the Dietary Manager assessed residents' food preferences upon admission and quarterly. She stated the Dietary Manager could adjust the menu to meet residents' needs and preferences. She acknowledged residents had the right to choose the foods they received and that the facility should accommodate their needs and preferences.Record review of the admission Record revealed the facility admitted Resident #166 on 8/11/26 with diagnoses that included unspecified hyperlipidemia and essential hypertension.Record review of the MDS with an ARD of 8/15/26 revealed Resident #166 had a BIMS score of 14, indicating the resident was cognitively intact.

Based on observation, interview, record review and facility policy review the facility failed to provide appropriate treatment and services during incontinent care, as evidenced by failure to fully clean the perineal area and only cleaning the buttocks area for one (1) of seven (7) care observations. Resident #12.Findings Include:Record review of the facility's Perineal Care with a revision date of 2/2018 revealed, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident skin condition . Steps in the procedure . For a female resident .9. c. Clean the perineal area using a fresh wipe for each downward cleaning motion from front to back Ensure the labia is open for through cleaning. d. Clean the buttocks perineum thoroughly, moving from inside outwards to the thighs.f. Remove gloves perform hand hygiene and replace them with clean set of gloves. Place a clean brief on the resident.On 08/17/2026 at 3:15 PM, observed Resident #12 in bed watching tv. There was a foul smell of urine in the room.On 08/19/2026 at 9:09 AM, an observation of Resident #12 receiving peri care by Certified Nursing Assistant (CNA) #4 and assisted by CNA #5. CNA #4 did not perform hand hygiene upon entry. She applied clean gloves and removed the brief and turned resident on her left side. Resident #12 had feces in the brief and a protective dressing on the sacrum. CNA #4 wiped front to back and back to front several times. She stated that she will inform the nurse the dressing needs to be changed. After cleaning the buttocks, she placed a clean brief under the resident and turned her over and fastened the brief with dirty gloves on. On 08/19/2026 at 9:20 AM, an interview with CNA #5 confirmed that CNA #4 did not complete peri care. She stated CNA #4 wiped the buttocks front to back and back to front several times. She stated CNA #4 did not do peri care in the front. She stated the resident was placed at risk for infection.On 08/19/2026 at 9:25 AM, an interview with CNA #4 confirmed that she did not provide care in the vaginal area and wiped back to front and front to back. She stated Resident#12 could get an infection or urinary tract infection (UTI) when care is not done correctly.On 08/19/26 at 3:55 PM, in an interview the Director of Nursing (DON) stated that CNA #4 should have provided peri care by wiping front to back only. She stated peri care should have been done in the vaginal area as well. She stated not doing it completely can cause Resident #12 to get an infection or UTI. She stated she expects CNAs to use the clean technique and the inside out technique doing peri care.On 08/20/2026 10:09 AM in an interview with Licensed Practical Nurse (LPN) #3/Infection Preventionist (IP) stated CNA #4 should have started in the front. CNA#4 should wipe front to back and clean the vaginal area. She stated CNA #4 should not have touched clean brief and bed linens with dirty gloves on. She stated Resident #12 could get an infection from care she received.On 08/20/2026 at 10:26 AM, in an interview with the Assistant Director of Nursing (ADON) stated CNA #4 should have wiped from front to back. CNA #4 should have started care in the front. She stated CNA #4 exposed Resident #12 to UTI, and bacterial infection. She stated her expectations are for CNAs to care for residents as if they have their own family. She stated she expects staff to take pride in their work and treat residents with respect.Record review of Resident #12's admission Record revealed an admission date of 7/18/25 with diagnoses that included Unspecified Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.Record review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 09 which indicates the resident had moderate cognitive impairment.

Based on observation, interview, record review and facility policy review the facility failed to follow infection prevention guidelines for two (2) of seven (7) residents observed during medication administration and care observations. Resident #12 and Resident #138 Findings Include: Record review of the facility policy Handwashing/Hand Hygiene with a revision date of 8/2015 revealed, Policy Statement: This facility considers hand hygiene the primary, means to prevent the spread of infections .7b. Before and after contact with residents .7h. Before moving from a contaminated body site to a clean body site during resident care .7m. After removing gloves . Record review of the facility policy Infection Prevention revised April 2019 revealed, Staff follows established facility infection control procedures (E.g. handwashing, antiseptic technique, gloves, isolation precautions, etc. for the administration of medications, as applicable. Resident #12 On 08/17/26 at 3:15 PM, Resident #12 was observed in bed watching television. A foul odor of urine was present in the resident's room. On 08/19/26 at 9:09 AM, an observation revealed Certified Nursing Assistant (CNA) #4, assisted by CNA #5, provided perineal care to Resident #12. CNA #4 did not perform hand hygiene upon entering the room. CNA #4 applied gloves, removed the resident's soiled brief, and turned the resident onto the left side. CNA #4 did not change gloves or perform hand hygiene during the care. CNA #4 touched the clean brief and bed linens with the same gloves used during the contaminated portion of the care. CNA #4 did not perform hand hygiene after completing the care. During an interview on 08/19/26 at 9:20 AM, CNA #5 confirmed CNA #4 did not perform hand hygiene throughout the perineal care. CNA #5 stated the failure placed Resident #12 at risk for infection. During an interview on 08/19/26 at 9:25 AM, CNA #4 confirmed she did not perform hand hygiene or change gloves during the care. CNA #4 stated Resident #12 could develop an infection or urinary tract infection when perineal care was not performed correctly. During an interview on 08/19/26 at 3:55 PM, the Director of Nursing (DON) stated CNA #4 should have performed hand hygiene upon entering the room, during care when her hands became contaminated, and upon leaving the room. The DON stated the failure to perform hand hygiene could cause Resident #12 to develop an infection or urinary tract infection. The DON stated she expected CNAs to use clean technique and an inside-out technique when providing perineal care. During an interview on 08/20/26 at 10:09 AM, Licensed Practical Nurse (LPN) #3, the facility's Infection Preventionist (IP), stated CNA #4 should have performed hand hygiene upon entering the room, during care, and after completing care. LPN #3 stated CNA #4 should have changed gloves and performed hand hygiene during the care and should not have touched the clean brief or bed linens with contaminated gloves. LPN #3 stated Resident #12 could develop an infection because of the care provided. During an interview on 08/20/26 at 10:26 AM, the Assistant Director of Nursing (ADON) stated CNA #4 should have performed hand hygiene upon entering the room, changed gloves and performed hand hygiene during the care, and performed hand hygiene after completing the care. The ADON stated CNA #4 exposed Resident #12 to the risk of a urinary tract infection or bacterial infection. Record review of Resident #12's admission Record revealed an admission date of 07/18/25 with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Record review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/19/26, revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Resident #138 On 08/19/26 at 8:59 AM, while preparing medications for Resident #138, LPN #2 used her bare, ungloved hand to remove an Acidophilus tablet. LPN #2 placed the tablet into a medication cup with the resident's other morning medications. LPN #2 then administered the medications to Resident #138, who ingested them. During an interview immediately following the observation, LPN #2 confirmed she touched the medication with her bare hand. LPN #2 stated nurses should avoid touching medications or anything a resident might ingest with their bare hands because pathogens could be transmitted to the resident. LPN #2 stated failure to follow medication administration and infection prevention practices could increase the resident's risk for infection. During an interview on 08/19/26 at 3:37 PM, LPN #3, the facility's IP, stated nurses should never touch medications with their bare hands. LPN #3 stated touching medications with bare hands could expose residents to pathogens, even if hand hygiene was performed before medication administration. LPN #3 stated she expected staff to follow the facility's infection prevention practices when caring for residents. During an interview on 08/19/26 at 3:58 PM, the DON stated nurses should avoid touching medications with their bare hands to prevent transmitting pathogens to residents. The DON stated she expected staff to follow infection prevention practices during medication administration. The DON stated failure to follow infection prevention practices increased residents' risk for infection. Record review of Resident #138's admission Record revealed the facility admitted the resident on 11/1/24 with diagnoses that included hemiplegia and hemiparesis. Record review of Resident #138's Order Summary revealed an order for Acidophilus Probiotic Oral Tablet, Lactobacillus, one tablet by mouth once daily for irritable bowel syndrome, with a start date of 07/14/26. Record review of Resident #138's Medication Administration Record revealed Acidophilus was documented as administered at 9:00 AM on 08/19/26. Record review of Resident #138's MDS with an ARD of 07/3/26, revealed a BIMS score of 15, indicating the resident was cognitively intact.

Based on observation, facility policy review, record review and interviews, the facility failed to provide adequate bed linens to maintain a comfortable, homelike environment for one (1) of three (3) floors. Second Floor.Findings Included:Record review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen Revised January 2014, revealed, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen .On 5/12/26 at 3:30 PM, observation and interview revealed the Resident Representative (RR) for Resident #4 was assisting Resident #4 by changing the linens on her bed and there were no pillowcases available on the second floor. Interview with the RR revealed that she had experienced lack of clean linens available for the care of Resident #4 several times in the past. On 5/12/26 at 3:55 PM, observation revealed Resident #2 had no top sheet on his bed. He was laying on a fitted sheet under a bedspread.On 5/12/26 at 3:58 PM, interview with Certified Nursing Assistant (CNA) #1 revealed she was aware that Resident #2 had no top sheet on his bed. She stated that he did not have one because there were not any available. She confirmed that the facility did not use clean linen carts and that the CNAs retrieved clean linens from the linen closet as needed. She stated that it was not unusual for the linen closet to be empty of clean linens. She stated that resident's call lights were supposed to be within reach to provide a way for them to summon assistance as needed.On 5/12/26 at 4:00 PM, observation revealed there were no clean pillowcases, fitted or flat sheets, towels or wash clothes in the second-floor linen closet.On 5/12/26 at 4:05 PM, interview with the Director of Nurses (DON) revealed that there had been issues with maintaining clean linens in the clean linen closet.On 5/12/26 at 4:52 PM, interview with the Laundry Supervisor stated, We had emergency linen and an employee was supposed to put it out and didn't. He stated that he was aware that it was the responsibility of the laundry staff to ensure adequate clean linens were delivered to the clean linen closets on each floor for the care of the residents.On 5/12/26 at 4:57 PM, interview with the Administrator revealed he confirmed that it was the responsibility of the laundry staff to ensure adequate clean linens were delivered to the clean linen closets on each floor and he expected them to provide adequate clean linens for the care of the residents. Record review of the admission Record for Resident #2 revealed the resident was admitted on [DATE] with diagnoses including dysphagia following cerebral infarction (stroke), diabetes mellitus, gastrostomy status, heart disease, pressure ulcer of the sacral region, and malignant neoplasm of the prostate.Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/27/26 revealed the resident had no Brief Interview for Mental Status (BIMS) score recorded, had memory impairment and severely impaired cognitive skills for daily decision making, and was dependent on staff for all activities of daily living (ADLs) and functional abilities.Record review of the admission Record for Resident #4 revealed the resident was admitted on [DATE] with diagnoses including dysphagia following nontraumatic subarachnoid hemorrhage, hypertension, and pressure ulcer of the sacral region.Record review of the Quarterly Minimum Data Set (MDS) assessment for Resident #4 with an Assessment Reference Date (ARD) of 12/29/23 revealed the resident had no Brief Interview for Mental Status (BIMS) score recorded, had memory impairment and severely impaired cognitive skills for daily decision making, and was dependent on staff for all activities of daily living (ADLs) and functional abilities.

Based on observations, interviews, record reviews and facility policy review the facility failed to ensure call lights were within reach for one (1) of six (6) residents sampled. Resident #2.Findings Included:Record review of the facility policy titled, CALL LIGHT/CALL PAGER SYSTEMS with Revision Date 9/09/22, revealed, Purpose To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.All staff.The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.On 5/11/26 at 12:40 PM, observation revealed the call light for Resident #2 was placed under his bed and came up and over the headboard of his bed, so that the call button was behind the headboard and out of the resident's reach.On 5/11/26 at 2:00 PM, interview with Certified Nursing Assistant (CNA) #2 revealed that each resident was to have their call light in reach to summon assistance as needed.On 5/12/26 at 4:05 PM, an interview with the Director of Nursing (DON) revealed that she expected call lights to be left within reach of residents and answered in a timely manner. On 5/12/26 at 4:10 PM, an interview with the Administrator revealed that he expected call lights to be left within reach of residents and answered in a timely manner.Record review of the admission Record for Resident #2 revealed the resident was admitted on [DATE] with diagnoses that included dysphagia following cerebral infarction (stroke), diabetes mellitus, gastrostomy status, heart disease, pressure ulcer of the sacral region, and malignant neoplasm of the prostate.Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/27/26 for Resident #2 revealed the facility assessed the resident as severely cognitively impaired skills for daily decision making, with memory problems and was dependent for all activities of daily living (ADLs) and with all functional abilities.

Based on observations, record review, and interviews the facility failed to implement the comprehensive, person-centered care plan for one (1) of six (6) sampled residents. Resident #1. Findings Included:Record review of the Care Plan Detail report for Resident #1 revealed Problem: I have stage 4 pressure ulcer to sacrum.Approaches.that included cleanse sacrum with normal saline pat dry apply Santyl cover with dry dressing daily.An additional care plan revealed Problem: I have a stage 4 pressure ulcer to left lower leg.Approaches. cleanse left lateral leg with normal saline pat dry apply Santyl cover with calcium alginate secure with dry dressing daily. On 5/11/20/26 at 2:00 PM, during an observation of Resident #1 and interview with Licensed Practical Nurse (LPN) #1 and Nurse Practitioner (NP) #1 revealed Resident #1 had wound dressings on his sacrum, left lateral calf and left ankle dated 5/09/26. LPN #1 confirmed she had provided wound care for Resident #1 and that the dressings were those she had applied on 5/09/26. LPN #1 confirmed that the resident's care plan specified that the dressings were to be changed daily. Following the removal of the dressings, NP #1 stated that the sacral wound appeared to have more slough than it usually did, when it was changed every day according to the resident's care plan.Record review of the Treatment Administration Record (TAR) for May 2026 for Resident #1 revealed no documentation of any wound care for 5/10/26.On 5/12/26 at 4:05 PM, during an interview the Director of Nurses (DON) stated that there were adequate licensed nurses on duty on 5/10/26, including two (2) wound care nurses and a Registered Nurse (RN) Supervisor. She confirmed that based on the dressings identified by LPN #1 dated 5/09/26 and lack of documentation on May 2026 TAR for Resident #1 wound care was not provided for Resident #1 on 5/10/26. She confirmed that the wound care would have triggered on the TAR, to notify the wound care nurse for the second floor that the resident required wound care on 5/10/26 and that all nurses had access to each resident's care plan. She confirmed she expected nurses to follow each resident's care plan in the delivery of care. On 5/12/26 at 4:57 PM, during an interview the Administrator said he expected nurses to follow each resident's care plan. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 4/01/26 and he had diagnoses of dysphagia, hemiplegia and hemiparesis following cerebral infarction (stroke), and stage 4 pressure ulcer of sacral region.Record review of the 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Further MDS review revealed the resident had impairment of both arms and legs (upper and lower extremities) and was dependent for all activities of daily living.

Based on observation, record review, facility policy review and interviews the facility failed to ensure ordered wound treatments were administered as prescribed by the physician for one (1) of six (6) residents reviewed for existing skin impairments. Resident #1.Findings Included:Record review of the facility policy titled, Wound Care dated 1/09/22 revealed the policy stated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.After completing a thorough evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of PU/PIs with appropriate interventions.Orders should include.Frequency of dressing change.Document dressing change in medical record .During an interview and observation on 5/11/20/26 at 2:00 PM, an observation with Licensed Practical Nurse (LPN) #1 and Nurse Practitioner (NP) #1 revealed Resident #1 had wound dressings on his sacrum, left lateral calf and left ankle dated 5/09/26. LPN #1 confirmed she had provided wound care for Resident #1 and that the dressings were those she had applied on 5/09/26. LPN #1 confirmed that physician orders specified that the dressings were to be changed daily. Following removal of the dressings, NP #1 stated that the sacral wound appeared to have more slough than it usually did, when it was changed every day.Record review of the Treatment Administration Record (TAR) for May 2026 for Resident #1 revealed no documentation of any wound care for 5/10/26.During an interview on 5/12/26 at 4:05 PM, the Director of Nurses (DON), stated that there were adequate licensed nurses on duty on 5/10/26, including two (2) wound care nurses and a Registered Nurse (RN) Supervisor. She confirmed that based on the dressings identified by LPN #1 dated 5/09/26 and lack of documentation on May 2026 TAR for Resident #1 wound care was not provided for Resident #1 on 5/10/26. She confirmed that the wound care would have triggered on the TAR, to notify the wound care nurse for the Second Floor that the resident required wound care on 5/10/26. She confirmed she expected wound care nurses to monitor the TARs and provide wound care as ordered by each resident's physician and care plan, and that nursing staff would follow each resident's care plan in the delivery of care. During an interview on 5/12/26 at 4:57 PM, the Administrator revealed he expected wound care nurses to monitor the TARs and provide wound care as ordered by each resident's physician and care plan, and that nursing staff would follow each resident's care plan in the delivery of care. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 4/01/26 and he had diagnoses of dysphagia, hemiplegia and hemiparesis following cerebral infarction (stroke), and stage 4 pressure ulcer of sacral region.Record review of the 5 Day Minimum Data Set (MDS) With Assessment Reference Date (ARD) 3/17/26 for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Further MDS review revealed the resident had impairment of both arms and legs (upper and lower extremities) and was dependent for all activities of daily living.Record review of the Order Summary Report for Resident #1 revealed the resident had physician orders to Clean stage 4 to (L) (left) lateral ankle .every day shift for wound with a start date of 4/30/26; Clean stage 4 to (L) lateral calf . every day shift for wound with a start date of 4/30/26 and Santyl External Ointment 250 Unit/GM (Collagenase) apply to sacrum topically every day shift . daily. with a start date of 4/26/26.

Based on interview and record review, the facility failed to implement its abuse prevention policy to protect residents from potential abuse, ensure proper reporting procedures were followed, and prohibit continued staff contact with residents following credible allegations. Specifically, the facility failed to (1) remove the Certified Nursing Assistant (CNA) from all resident care following multiple potential abuse allegations, (2) conduct a timely and complete investigation into resident and family reports of abuse, and (3) implement interventions to protect residents from further potential abuse. This deficient practice affected two (2) of four (4) residents reviewed for abuse (Residents #1 and #2).Findings include:A review of the facility's Abuse Components Plan Elder Just Act and Affordable Care Act, dated 10/24/22, revealed, .The purpose of this policy is to facilitate appropriate. investigation.of actual and/or suspected incidents of abuse.Investigation: Any report of suspected and/or actual resident mistreatment.abuse.will be promptly and thoroughly investigated by facility Administrator or their designee.If an accusation.of resident abuse.is reported, the Administrator or designee will.Identify and interview all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.Providing complete and thorough documentation of the investigation.Defining how care provision will be changed and/or improved to protect residents receiving services .At 11:29 AM on 12/29/25, in a phone interview with the Resident Representative (RR) revealed when entering the room on 11/13/25 Resident #1 was very upset indicating he is tired of the people pushing and pulling on him when he asked them to stop. She said he told her the CNA who came to get him up that morning was hurting him, and she that she was pushing on him and hit him in the chest. RR#1 explained that she went to the desk and informed the Licensed Practical Nurse (LPN) Charge Nurse #1 who called the CNA's assigned to him and he then identified the CNA who had done it. She left the facility shortly after and revealed no one from the facility ever followed up to let her know anything about the allegation.At 11:52 AM on 12/29/25, in an interview with the niece of Resident #1, she revealed being in the room when Resident #1 identified CNA #1 as being the one that hit him. She points out that before leaving the facility she asked the nurse to call Rr#1 to give her an update about the incident but says no one called them.At 12:34 PM on 12/29/25, in an initial interview with the LPN Charge Nurse, revealed that when a resident makes any type of complaint about a CNA, her role requires that she moves that CNA away from the resident especially in instances of alleged abuse. She said there are no circumstances that would warrant her not removing the CNA from the resident and allowing them to go back in the resident's room. She said it is important to remove the CNA during the initial allegation even before an investigation because it shows that you respect the resident and makes them feel safe. She said allowing the resident to still have contact with the CNA can cause them to feel afraid as it is the residents right to feel safe.At 12:50 PM on 12/29/25, in an interview with Resident #2 she revealed there is one CNA, who she can't remember her name, that was rough and mean with her on more than one occasion and she has asked that that CNA does not come back to her room because she is afraid the CNA will do something to her. She added, she thought the CNA was banned completely since it was reported to the nurse. However, the CNA still comes in to assist the roommate. Therefore, Resident #2 says she does not sleep while the CNA is in the room caring for her roommate because she does not know what she may try to do to her. At 1:01 PM on 12/29/25, in an interview with Resident #1 he revealed that CNA #1 with the red hair came in his room that morning being rough and mean to him. He said he was cussing at her and getting smart and she was doing the same thing. He said he was telling her that he is tired of the way she keeps pulling and jerking on him when getting him up. He said that is when the CNA balled up her fist and jumped at him like she was going to hit him trying to intimidate him. He said he did not like that and she should not be doing that to him as it is just not right. He adds he weighs only like fourteen pounds and she is much bigger so he can't fight her off of him. He points out that she did not hit him but explained that she motioned she like she was going to as trying to scare him. He says that CNA#1 does still come in his room.At 1:15 PM on 12/29/25, in another interview with the LPN Unit Nurse revealed that it is CNA#1 that Resident #2 said she does not want back in her room. She explained that she can tell when talking with the resident that she afraid of CNA #1.At 1:27 PM on 12/29/25, in an interview with CNA #1 revealed later during her shift, the LPN Charge Nurse called her to Resident #1 room stating the family said she hit him. CNA #1 said although that happened, she is currently still going in the resident room to help him. During this same conversation she revealed that she stills goes into Resident #2 room despite how that resident feels to help the roommate.At 1:47 PM on 12/29/25, in a follow-up interview with the LPN Charge Nurse she confirmed that she reported to the Director of Nursing (DON) that the resident and his family indicated CNA #1 was being mean to him. In the same in interview, she confirmed that CNA#1 was still going in Resident #1's room because the resident had not made any more complaints. She also confirmed with the State Agency (SA) that it is part of her role to make the daily CNA assignments, and that she was not aware that CNA #1 was still going into Resident #2's room.At 3:34 PM on 12/29/25, the DON in an interview said does recall that the LPN Charge Nurse reported to her that the resident said the CNA #1 was mean to him like she was in a rush when transferring him to the bed. She indicated that since there are two residents complaining about the same CNA, it should have been better addressed.At 4:00 PM on 12/29/25, in an interview with the RR#2 who is the daughter of Resident #2 she revealed that her mom reported to her that CNA#1 on two separate occasion was rough and mean to her. She added, she asked the LPN Charge Nurse to no longer allow the CNA to enter room and she agreed to do so. RR#2 reports that her mom said CNA#1 is still going in there despite their wishes.At 2:08 PM on 12/30/25, in an interview with CNA #2 she recalled on 11/13/25 while standing up at the nurse's desk with CNA#1 the niece of Resident #1 came up saying Resident #1 told her he was being abused or that we were hitting him.On 12/30/25 at 5:03 PM, In an interview with the Administrator he explained that he encourages all staff to call in reportable allegations. However, he is the facility abuse coordinator. He added that the facility wants their residents to be happy and feel they have a good quality of life so if they feel intimated, afraid or mistreated it is not right.Resident #1A record review of the admission Record reveals the facility admitted the resident on 8/19/25 with diagnosis including Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Pain unspecified and Gout. A review of the Minimum Date Set (ARD) with Assessment Reference Date (ARD) of 11/24/25 revealed a Brief Interview Mental Score (BIMS) of three (3).Resident #2A record review of the admission record reveals the facility admitted the resident on 7/14/25 with diagnoses including Flaccid Hemiplegia Affecting Right Dominant Side and Osteoarthritis of Hip, Unspecified.A review of the Minimum Date Set (ARD) with Assessment Reference Date (ARD) of 10/10/25 reveals a Brief Interview Mental Score (BIMS) of ten (10).A record view of the written statement regarding the allegations from Resident #1 of CNA#1 that was dated 11/13/25 revealed .Later that evening he told a family member I hit him .

Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #9.On 9/08/25 a newly admitted respite resident with diagnoses of restlessness and agitation, dementia and senile degeneration of brain and history of exit seeking behaviors and falls was assisted to exit the facility by staff, was outside unsupervised for twenty-five (25) minutes until a staff member observed the resident lying on the ground next to the iron fence that encircled the facility premises, approximately three hundred seventy-five (375) feet from the facility entrance.The facility's failure to provide adequate supervision to prevent the elopement of Resident #9 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. While Resident was out of the facility unsupervised in the parking lot and driveway area of the facility at shift change, she was observed laying on the ground.The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to Resident #9's elopement and placed all residents who were admitted with or developed wandering/exit seeking behaviors at risk. This failure resulted in Immediate Jeopardy and Substandard Quality of Care (SQC) which began on 9/08/25. The SA notified the facility's Administrator of the IJ and SQC on 09/17/2025 at 4:15 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 9/9/25, the State Agency (SA) determined the IJ and SQC to be Past Non-compliance (PNC) and the IJ removed on 9/10/25, prior to the entrance of the SA on 9/15/25. Findings include:Record review of the facility policy titled, MISSING RESIDENT/ELOPEMENTS with a review date of 1/15 (January 2015) revealed POLICY: The Unit charge Nurse is responsible for knowing the location of their residents.RESPONSIBILITY: The Charge Nurses and all other staff. PROCEDURE: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge nurse/CMT as soon as practical. 2. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure; b. Obtain assistance from other staff members in the immediate vicinity, if necessary.Record review of the Progress Notes for Resident #9 dated 9/08/25 revealed that the Director of Nurses (DON) documented, Resident assisted outside by staff.Resident is a new admission to facility 9/08/25. MD/RP notified. New order for wander guard and one on one monitoring.Record review of the Supervisor Investigation Summary Form: (facility investigation) and 9/16/25 observation at 2:06 PM during interview with Certified Nurses' Aide (CNA) #1 revealed that on 9/08/25 at approximately 2:53 PM the (former) Receptionist assisted Resident #9 out the front door. The resident walked around the grounds, sat on a bench for a while and then walked to and up the northwestern driveway toward the street and was located at approximately 3:30 PM laying on the ground on the west side of the northwest driveway, next to the iron fence that circumvented the facility property, approximately fifty-five (55) feet from the street and approximately three hundred seventy-five feet from the facility's front entrance. According to CNA #1 and the facility investigation, Resident #9 was assisted to stand and walk up the incline to a grassy area on the side of the driveway with a wheelchair brought to return the resident into the facility. On 9/16/25 at 2:06 PM, during an observation of the area Resident #9 was located in on 9/8/25 and interview with CNA #1 revealed that on 9/08/25 at approximately 3:15 PM she had gotten into her car after clocking out and was leaving the premises when she observed what she described as looked like a pile of clothes at first laying on the ground inside the northwest corner of the black metal fence that encircled the facility. She stated that as she looked, she realized it was a person lying on the ground. She stated she stopped and summoned assistance. She and CNA #2 assisted Resident #9 to stand and walk to the grassy area uphill and next to the driveway from the area she initially saw her. CNA #1 said that she and CNA #2 routinely worked on the second floor of the facility and were not familiar with the resident, so they asked questions to determine if she was a facility resident. She said that Resident #9 told them that she did not live at the facility, had driven herself to the facility and that her car was on the second floor with her daughter. CNA #1 said that she then summoned the DON and Assistant Director of Nursing (ADON), who identified Resident #1. Staff assisted the resident to return to the facility at approximately 3:25 PM. CNA #1 reported that the weather was clear, dry and warm temperature. CNA #1 described Resident #9 as wearing blue pants, a red/white/blue stripped shirt and a red sweater and house slippers. She said she received in-service training provided by the facility following the elopement and participated in elopement drills.On 9/16/25 at 2:30 PM during observation of the area Resident #9 was located on 9/08/25 and interview with CNA#2 stated that she had just clocked out following the 7:00AM to 3:00 PM (7-3) shift and got into her car in the front parking lot when she saw CNA #1 waving her hands and calling for assistance. She said she went toward CNA #1 and observed someone laying on the ground inside the northwest corner of the black metal fence that encircled the facility. She said she had not recognized the person on the ground, and she and CNA #1 talked with the woman and determined based on her appearance and confusion to summon the DON. CNA #2 said that the weather was clear, dry and warm. On 9/17/25 at 9:34 AM, during an interview the DON confirmed that she had participated in the facility investigation into the elopement of Resident #9 on 9/08/25. She stated that on 9/08/25 the facility had placed the resident on one-on-one supervision, and the primary healthcare provider (PHP) had issued new orders for application and monitoring of a safe wandering device. She stated that during her investigation she interviewed the receptionist who reported that he had entered the code and escorted the resident outside and then returned inside without knowing if she was a resident. The DON said that CNA #1 had clocked out and was leaving the premises and observed the resident and she and CNA #2 summoned her (the DON) and assisted the resident back into the facility. On 9/17/25 at 2:36 PM, during a telephone interview the Resident Representative (RR) for Resident #9 revealed that she had brought the resident to the facility on 9/08/25 for respite care. She said she was notified by the DON on the same day that Resident #9 had been assisted outside by staff and a short while later was observed by another staff member lying on the ground. She confirmed that she was notified of new orders for a safe wandering device and one-on-one supervision to prevent future elopements. She confirmed that the resident remained at the facility as planned throughout the respite period and returned home as planned. She confirmed that the resident had not been injured and said she had noted no physical or psychosocial changes in the resident following the incident.On 9/17/25 at 3:23 PM, observation revealed the front entrance opened to a front porch under a portico which led to the paved front parking lot which was well-maintained. There was a well-maintained cement sidewalk that spanned the front of the building. Observation revealed all parking spaces were full. The facility had an upper and lower driveway which led to the street. The speed limit of the street was twenty-five (25) miles per hour. There were eleven (11) vehicles observed traveling through the parking lot and an additional four (4) vehicles observed traversing the street in a five-minute period.On 9/17/25 at 3:50 PM, during an interview Executive Director revealed that the facility had investigated the 9/08/25 elopement of Resident #9, and he and the interdisciplinary team determined that the root cause was that the Former Receptionist had unlocked the door and escorted and left Resident #1 outside without determination of the resident's identity as a resident, for which the Receptionist's employment at the facility had been terminated. The resident's RR and PHP were notified and the facility received new orders for a safe wandering device, and the resident was placed on one-on-one supervision until her discharge. He said in-service training and elopement drills were initiated for all staff and that the incident was reviewed during a Quality Assessment and Performance Improvement (QAPI) meeting on 9/09/25 and reported to state agency per state and federal requirements. On 9/18/25 at 10:40 AM, during an interview LPN #3, the assigned Unit Manager for Resident #9 on 9/08/25 on first floor, stated that Resident #9 arrived on the unit accompanied by her RR at approximately 9:30 AM on 9/08/25. She stated that the resident was able to participate in Brief Interview for Mental Status (BIMS) but was only oriented to self (able to supply her own name). She stated that the RR had reported history of falls, but not wandering or elopement and that report coupled with the resident's dependence on wheelchair for locomotion resulted in an assessment of no risk for elopement. She stated that she last observed the resident around lunch time when she had assisted the resident to the first-floor dayroom for lunch. She stated that she was made aware of the elopement by the DON. LPN #3 confirmed that Resident #9's PHP had issued new orders for a safe wandering device with monitoring, and the resident was provided with one-on-one supervision for the remainder of her respite stay at the facility.On 9/18/25 at 11:00 AM, a telephone interview with the former facility Receptionist revealed he manned the desk at the front entrance and there was a keypad in the receptionist office and one next to the front entrance door. He said he was able to enter the code into either and unlock the front entrance. He reported that he was not aware that Resident #9 had been admitted because he arrived late at work and was not at the desk and had not witnessed her arrival. He explained that he released the lock on the front door and allowed Resident #9 to exit after seeing her push on the entrance door. He stated that he did not know who she was and had not asked. He said he had not noticed what type of footwear the resident was wearing. He said that he had worked at the facility as receptionist for a few weeks and confirmed that he had received training during orientation regarding keeping security codes confidential, residents at risk for wandering/elopement and dementia. He confirmed that his employment at the facility had been terminated because of the elopement.Record review of the Category One Violation Employee Corrective/Counseling Memorandum dated 9/09/25 for the former Receptionist revealed documentation that his employment was terminated on 9/09/25 due to Employee let a resident outside the facility without determining if resident was safe to exit or identify if this was a resident or not.Record review of the local weather history according to WWW.Wunderground, Copyright the Weather Channel, for the facility for 12:00 PM on 9/08/25 revealed the high temperature for the day was eighty-four (84) degrees Fahrenheit, with zero precipitation, four to twelve (4-12) mile per hour winds and clear. Record review of the admission Record for Resident #9 revealed the facility admitted the resident on 9/08/25 and the resident had diagnoses of restlessness and agitation, dementia with anxiety, senile degeneration of brain and heart failure.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/13/25 for Resident #9 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Manhattan Corrective Action Plan validated by SA on 9/18/25:On 9/08/25 around 2:53 pm, the receptionist assisted Resident #9 out the front door after which the resident was located approximately twenty-five minutes later laying on the ground in the northwest corner of the facility property. Resident #9-1. A second at risk for elopement assessment completed for Resident #9 on 9/8/25 at 3:15pm2. Resident 9's Instant care plan and Kardex were updated on 9/8/25 at 3:15pm3. One-on-one supervision orders received, and monitoring implemented on 9/8/25 at 3:15 pm4. Resident #9's Instant care plan and Kardex were updated-9/8/25 at 3:15pm5. Resident #9's Responsible Party (RP) and Primary Healthcare Provider were notified of the incident with safe wandering device bracelet orders received with bracelet applied on Resident #9 with orders for nurses to check placement and functioning every shift-9/8/25 at 3:15pm6. Head to toe body audit was conducted for Resident #9 on 9/8/25 at 3:20pm7. Temperature outside 9/8/25 at 3:00pm-clear and lower 80s8. Distance from front door 375 feet - 9/8/25On 9/08/25 nursing staff completed 100% head count of all residents not signed out on pass with all residents accounted forEmployee corrective counseling completed with former Receptionist on 9/9/25 at 8:00 am (Category 1 offence, employment terminated)100% At risk for elopement evaluations completed on all residents on 9/8/25 through 9/9/25100% in-service training started for all staff prior to working on - Elopement/Wandering, Abuse/Neglect, Behaviors, Adequate monitoring, Supervision- completed 9/09/25Safe wandering devices for all residents wearing them are checked every shift for placement and functioning on 9/8/25Elopement Drills were conducted on all shifts beginning on 9/8/25, 3:00 pm-11:00 pm (3-11) shift100% audit of elopement books completed on 9/8/25All doors checked for proper functioning on 9/8/25Security specialist contractor visited and checked doors for functioning on 9/9//25Quality Assurance (QA) Meeting attended by all key personnel, which included but not limited to Executive Director, Director of Nurses, Infection Preventionist and Medical Director was held 9/9/25 with root cause analysis conducted and interdisciplinary team developed strategy to prevent future elopement incidentsResident #9 to remain on 1:1 until discharge from facility; discharged [DATE] at 1:10pmResident photos will be taken at the time of admission, regardless of elopement risk assessment results, and posted at the receptionist desk beginning 9/9/25The facility alleges all corrective actions were completed on 9/9/25 and the Immediate Jeopardy was removed on 9/10/25Monitoring included one-on-one monitoring/supervision of Resident #9 through discharge on [DATE] and the Admissions Coordinator to monitor the communication board in the reception office to ensure the board's accuracy and currently with all new admissions' photographs posted; continued elopement assessments of all newly admitted residents at the time of admission by nursing staff; continued monitoring of positioning and functioning of safe wandering devices worn by residents at risk of elopement every shift by nursing staff; continued daily monitoring of the safe wandering system functionality by the maintenance director; review of and development of care plans for all newly admitted residents with family/resident to evaluate for history of wandering/elopement for three (3) months with monitoring results and corrective actions reviewed at QA meetings for three (3) months (first QA meeting held following incident was 9/09/25 with subsequent QA meeting held 9/18/25)On 09/18/25, SA validations were completed onsite during the complaint investigation through interviews, observations and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 09/10/25.

Based on interview, record review, and policy review the facility failed to provide needed care and services that would meet the resident's physical needs as evidenced by wound care not provided in one (1) of two (2) sampled residents with wounds. Resident #4. Findings include:Record review of the facility policy titled Wound Care Treatment Protocol (no review date) revealed the policy instructed staff to: Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document/Report Findings. Provide treatment as per physician's order.On 09/17/2025 at 9:22 AM, during an interview Resident #4 stated My wound care should be done every 3 days. It was done on 09/11/25 but not on 09/14/25. They just wipe it with wet gauze and cover it up. It's supposed to be irrigated with Dial soap. There's a doctor who sees wounds, but he's never looked at mine.Record review of Resident #4's electronic Treatment Administration Record (eTAR) for September 2025 revealed a physician order for treatment with a start date of 9/8/2025 Mupirocin External Ointment 2% Apply to left lateral ankle topically every day shift every (3) days for wound. Clean left lateral ankle with normal saline, pat dry, apply Mupirocin, cover with Mepilex every 3 days. The eTAR indicated wound care was provided on 09/11/2025, but not documented as provided on 09/14/2025, as evidenced by the absence of staff initials in the designated treatment box for that date.On 09/17/2025 at 9:34, during an interview the Director of Nursing (DON) revealed that the facility physician typically evaluates wounds, however, Resident #4 refuses the facility physician and instead is seen weekly at the Wound Clinic.On 09/17/2025 12:12 PM, in an interview Licensed Practical Nurse (LPN) #1/ Unit Manager reported that a as needed (PRN) order had been obtained for the prescribed wound care and that she administered the dressing on 09/15/2025. She added that the dressing she removed was not signed, dated, or timed, contrary to protocol.During an interview on 09/17/2025 at 3:15 PM, LPN #2/Treatment Nurse revealed that she was unaware why the wound care was missed on 09/14/2025 and stated that she only works weekdays.During a joint interview on 09/18/2025 at 3:15 PM, the Administrator and Director of Nurses (DON) acknowledged that wound care had not been completed on 09/14/2025 and confirmed their understanding of the importance of adhering to physician orders.Record review of Resident #4's admission Record revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Non-pressure Chronic Ulcer of Unspecified Lower Limb, and Vascular Dementia. Record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/2025 indicated in Section M the presence of a non-pressure ulcer. Section C indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.

Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents and failed to ensure continuous one-on-one supervision resulting in a fall that caused an acute transverse fracture of the lower sacrum, leading to hospitalization for one (1) of two (2) residents reviewed for falls. Resident #1. Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. Facility residents shall have the right to: 1 .34. A safe environment. A record review of the facility ' s Supervisor Investigation Summary Form, dated 1/31/25, revealed, Briefly describe event: On 1/30/25 around 3:30 PM, (Proper Name of Resident #1) was found sitting in the day room, with his clothes on, in front of his wheelchair. The Licensed Practical Nurse (LPN) evaluated (proper name) with no injuries noted. (Proper name) did not reveal any pain. The (LPN) and a therapist assisted resident off the floor and placed him in his wheelchair. (Proper Name) continued to be confused and combative with staff attempting to bite them .The licensed nurse called and notified nurse practitioner regarding the fall with new orders to send to the ER for evaluation. While the nurse was on the phone with Nurse Practitioner (NP), (Proper Name) stood up from his wheelchair and started taking his clothes off . (Proper Name) pulled out his catheter with the bulb intact and started walking out of the day room and into the hallway with no clothes on and, with blood noted to bilateral legs and penis without his Foley catheter .The LPN sat with (Proper Name) never reported pain and showed (no) signs or symptoms of pain. On 1/31/25, the facility requested a copy of the ER paper .admitted .with diagnosis emphysematous cystitis, prostate enlargement, and a nondisplaced transverse fracture of the sacrum between S4 and S5 .Investigation .On 1/30/25, around 3:00 PM .wife and son had just left the facility from visiting .The speech therapist then began working with (Proper Name) in the dining room, and reported he was agitated, hitting the table, and attempting to stand up. The therapist would redirect him to sit back down. After completing her therapy session, the therapist left him sitting at a table with his wheelchair moved close to the table. When the therapist walked down the hall and returned walking by the day room .was standing up with his shirt off. The therapist stopped by day room, put his shirt back on, and moved him back to the table. The nurse had started her medication pass. The therapist left the day room and when she walked back past the day room, (Proper Name) was sitting on the floor in the corner of the room. She alerted the nurse and they assisted him back into his wheelchair . A record review of a handwritten statement, dated 1/30/25 at 3:30 PM and signed by LPN #1, revealed, Resident had a fall in dayroom .DON was called and stated that staff was suppose to be on way to do a one on one with resident. A record review of the acute hospital information for Resident #1, dated 1/30/25, revealed, Impression .3. Acute transverse fracture of the lower sacrum . A record review of Resident #1's Admission Record revealed that the facility admitted him on 01/17/2025 and his admitting diagnoses included Dementia with behavioral disturbances and Osteoarthritis. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2025 revealed that Resident #1 required a staff assessment for cognition, and he had short- and long-term memory problems. On 02/26/2025 at 10:54 AM, during an interview, the Speech Therapist stated that she encountered Resident #1 at approximately 3:00 PM on 1/30/25 and observed him agitated, yelling, attempting to hit, and attempting to get up from his chair. She stated that she redirected him, which was sometimes effective, but upon finishing therapy, she noted that he remained in an agitated state and continued exhibiting the same behaviors. She explained that she did not notify staff about his behaviors before leaving because she assumed they were observing him through the window and that supervision was being provided. On 02/26/2025 at 12:20 PM, during a phone interview, Certified Nursing Assistant (CNA) #1 stated that when she arrived for her shift on the morning of 01/30/2025, the staffing coordinator assigned her to one-on-one supervision with Resident #1 on the first floor due to increased agitation and behavioral disturbances. She was later informed that Resident #1 would be moved to the second floor and continued her one-on-one supervision until the end of her shift. CNA #1 stated that before leaving for the day, she informed LPN #1 on the second floor that Resident #1 needed continuous one-on-one supervision, as per instructions from the staffing coordinator. On 02/26/2025 at 12:55 PM, during a phone interview , LPN #1, who was working the 3:00 PM to 11:00 PM shift on 1/30/25, stated that upon first observing Resident #1, he was in the dayroom with other residents and was supposed to be on one-on-one supervision. However, she did not see any staff member supervising him. She stated that she called the Director of Nursing (DON) to inquire about his assigned staff and was informed that CNA #2 was scheduled to provide one-on-one supervision but had not yet arrived. While she was observing the dayroom through the window, she witnessed Resident #1 fall. On 02/26/2025 at 2:14 PM, during a phone interview, CNA #2, who normally worked the 11:00 PM to 7:00 AM shift, stated that he was asked to come in early for the 3:00 PM to 11:00 PM shift to provide one-on-one supervision for Resident #1. However, he did not arrive until 4:08 PM. He stated that another CNA was supposed to stay with Resident #1 until he arrived to ensure continuous supervision, but no staff remained with the resident. On 02/27/2025 at 12:02 PM, during an interview, the DON stated that the fall occurred around or before 3:30 PM on 01/30/2025 in the dayroom on the second floor. She confirmed that Resident #1 was assigned to one-on-one supervision on the first floor earlier that day and that staff were supposed to monitor him in the dayroom until CNA #2 arrived. The DON acknowledged that CNA #2 was late, and no other staff remained to supervise Resident #1, resulting in a lapse in supervision at the time of his fall.

Based on staff interview, record review, and facility policy review, the facility failed to implement a care plan intervention regarding one-on-one supervision for a severely cognitive impaired resident which resulted in an unsupervised fall, leading to an acute transverse fracture of the lower sacrum for one (1) of two (2) care plans reviewed for falls. Resident #1 Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. Facility residents shall have the right to: 1 .7 .d. The right to receive the services and/or items included in the plan of care . A record review of Resident # 1's Comprehensive Care Plan, dated 1/27/25, revealed . one-on-one observation when family was not present . A record review of the facility's Supervisor Investigation Summary Form, dated 1/31/25, revealed, Briefly describe event: On 1/30/25 around 3:30 PM, (Proper Name of Resident #1) was found sitting in the day room, with his clothes on, in front of his wheelchair. The Licensed Practical Nurse (LPN) evaluated (proper name) with no injuries noted. (Proper name) did not reveal any pain. The LPN and a therapist assisted resident off the floor and placed him in his wheelchair. (Proper Name) continued to be confused and combative with staff attempting to bite them .The licensed nurse called and notified nurse practitioner regarding the fall with new orders to send to the ER for evaluation. While the nurse was on the phone with Nurse Practitioner (NP), (Proper Name) stood up from his wheelchair and started taking his clothes off . (Proper Name) pulled out his catheter with the bulb intact and started walking out of the day room and into the hallway with no clothes on and, with blood noted to bilateral legs and penis without his foley catheter .The LPN sat with (Proper Name) never reported pain and showed (no) signs or symptoms of pain. On 1/31/25, the facility requested a copy of the ER paper .admitted .with diagnosis emphysematous cystitis, prostate enlargement, and a nondisplaced transverse fracture of the sacrum between S4 and S5 .Investigation .On 1/30/25, around 3:00 PM .wife and son had just left the facility from visiting .The speech therapist then began working with (Proper Name) in the dining room, and reported he was agitated, hitting the table, and attempting to stand up. The therapist would redirect him to sit back down. After completing her therapy session, the therapist left him sitting at a table with his wheelchair moved close to the table. When the therapist walked down the hall and returned walking by the day room .was standing up with his shirt off. The therapist stopped by day room, put his shirt back on, and moved him back to the table. The nurse had started her medication pass. The therapist left the day room and when she walked back past the day room, (Proper Name) was sitting on the floor in the corner of the room. She alerted the nurse and they assisted him back into his wheelchair . A record review of a handwritten statement, dated 1/30/25 at 3:30 PM and signed by LPN #1, revealed, Resident had a fall in dayroom .DON was called and stated that staff was suppose to be on way to do a one on one with resident. A record review of the acute hospital information for Resident #1, dated 1/30/25, revealed, Impression .3. Acute transverse fracture of the lower sacrum . A record review of Resident #1's Admission Record revealed that the facility admitted him on 01/17/2025 and his admitting diagnoses included Dementia with behavioral disturbances and Osteoarthritis. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2025 revealed that Resident #1 required a staff interview to assess cognition and his short-term and long-term memory was impaired. During an interview on 02/26/2025 at 10:54 AM, the Speech Therapist stated that she encountered Resident #1 at approximately 3:00 PM and observed him agitated, yelling, attempting to hit, and attempting to get up from his chair. She stated that she redirected him, which was sometimes effective, but upon completing therapy, she noted that he remained in an agitated state and continued exhibiting the same behaviors. She admitted that she did not notify nursing staff about his behaviors before leaving because she assumed they were observing him through the window, leaving him unattended despite his documented care plan for one-on-one supervision. During an interview on 02/27/2025 at 12:02 PM, the Director of Nursing (DON) stated that the Speech Therapist should have informed staff about Resident #1's increased agitation before leaving the dayroom. She acknowledged that Resident #1 was assigned one-on-one supervision on the first floor earlier that day, and staff were expected to continue monitoring him in the dayroom until Certified Nursing Assistant (CNA) #2 arrived. However, CNA #2 was late, and no one else was assigned to supervise him. During a follow-up interview on 02/27/2025 at 1:01 PM, the DON stated that the care plan is intended to serve as a roadmap for providing care, and failure to follow it means the resident is not receiving the planned interventions necessary for their safety and well-being. During an interview on 02/27/2025 at 1:29 PM, the MDS Coordinator /LPN #3 emphasized that the care plan is essential for guiding staff in delivering appropriate care. She stated that failure to follow the care plan places the resident at risk for harm, particularly in cases requiring close supervision.

Based on interview, record review, and policy review, the facility failed to ensure residents received a diet that was according to the resident preferences for one (1) of seven (7) sampled residents. Resident #1 Findings include: Review of the Facility policy titled Resident Interview and Foot Preferences, dated 2016, revealed, Resident food preferences will be recorded and consistently utilized . On 11/07/24 at 2:30 PM, in an interview with Resident #1, she stated that she hated oatmeal and dietary services put oatmeal on her tray multiple times weekly. Resident #1 stated that she had made staff aware of preferences multiple times. On 11/08/24 at 2:52 PM, an interview with the facility Dietician, she stated that she had stressed the importance of resident food preference to dietary staff and cooks. The Dietician stated she had been made aware that Resident #1 had complained that she did not like oatmeal, and that she had continued to receive oatmeal on her breakfast trays. On 11/08/24 at 5:10 PM, during an interview, the acting Administrator confirmed that whenever possible, he expected dietary staff to accommodate resident food preferences. Record review of the Admission Record for Resident #1 revealed the facility admitted the resident on 9/05/24. The resident had diagnoses that included End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. Record review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date of (ARD) 9/04/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact.

Based on observation, interview, record review, and policy review, the facility failed to accommodate resident preferences for two (2) of seven (7) residents reviewed. Residents #3 and #4 Findings include: Review of the facility policy titled A.M. Care, dated 10/09, revealed, A.M. Care will be given to residents daily . Procedure: . 11. Provide/assist with shaving (male and female) as needed . Review of the facility policy titled Hydration Cart, dated 2016, revealed, Water or other fluids shall be offered to all residents throughout the day. Fluids are typically offered during meals, snacks. A hydration cart or location may be used to enhance access and encouragement of fluids for residents. Procedure: 1. The Hydration Cart will be offered or refreshed each day at mid morning, mid afternoon, and bedtime . Resident #4 On 11/06/24 at 3:30 PM, an observation and interview with Resident #4 and his Resident Representative (RR)revealed that water was only provided upon request, and then the resident had to wait for delivery. They stated they would rather the resident have water available at the bedside. An observation of the resident revealed the resident had a short, gray beard and mustache. The RR said that the resident preferred to be shaved daily, however, the resident's preference was not accommodated and she sometimes shaved the resident when she visited. The resident and RR indicated that their concern was not that the staff did not assist with shaving, but that the resident's preference of daily shaving was not accommodated. Record review of the Admission Record for Resident #4 revealed the facility admitted the resident on 12/14/22. The resident had diagnoses that included Parkinson's Disease and Alzheimer's Disease. Record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/24, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #3 On 11/06/24 at 4:10 PM, an observation and interview with Resident #3 revealed she did not have water at the bedside. The resident stated that sometimes when she requests water, she has to wait. She stated that she would prefer to have a water pitcher, a glass or bottle of water at the bedside. Record review of the Admission Record for Resident #3 revealed the facility admitted the resident on 3/05/24. The resident had diagnoses that included Congestive Heart Failure, Type 2 Diabetes Mellitus, and Essential (Primary) Hypertension. Record review of the Quarterly MDS with an ARD of 8/21/24 for Resident #3, revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. On 11/08/24 at 5:10 PM, during an interview, the acting Administrator confirmed that he expected staff to accommodate resident preferences to the extent possible considering the resident's physical condition, care plan and care instructions based on assessment of needs and abilities.

Based on observation, interview, and record review, the facility failed to provide a safe environment for residents as evidenced by unlocked biohazard rooms on two (2) of four (4) days of survey. Findings Included: During an observation on 07/22/24 at 12:00 PM, there was an unlocked door marked Biohazard on the second floor of the facility. Inside, a red biohazard can was open with red biohazard bags visible, alongside housekeeping chemical dispensers containing Vindicator (a type of disinfectant) and Super Shine All (a type of floor cleaner). A record review of the Safety Data Sheet (SDS), dated 02/04/21, revealed Vindicator had a health hazard for acute oral toxicity and skin corrosion/irritation. A record review of the Safety Data Sheet, dated 10/22/21, revealed Super Shine had a health hazard for serious eye damage/eye irritation. On 7/23/24 at 10:30 AM, during an observation and interview with the Housekeeping and Laundry Supervisor, she observed the biohazard room door was not secured on the second floor of the facility. She stated that biohazard doors should always remain closed and securely locked to ensure the safety of residents. In an interview on 07/24/24 at 9:05 AM, the Assistant Nursing Home Administrator (ANHA) acknowledged that biohazard room doors should always be closed and locked to ensure the safety of residents and visitors. The ANHA emphasized that it is the responsibility of all employees to ensure these doors are secure, highlighting the potential risks posed by exposure to medical waste or chemicals.

Based on observation, staff interviews, and facility policy review, the facility failed to maintain sanitary practices within professional standards for food service safety related to hand hygiene for one (1) of two (2) kitchen observations. Findings Included: A review of the facility's policy, Proper Hand Washing and Glove Use, dated 2016, revealed, Guideline: All employees will use proper hand washing procedures .Procedure .4. Employees will wash hands before and after .touching any part of their uniform, face, or hair . On 07/22/24 at 10:29 AM, an observation of the Registered Dietitian (RD) revealed on two (2) occasions while she stood adjacent to the steam table, she picked up an ink pen from the kitchen floor and placed it back on the steam table. After placing the ink pen on the steam table, the RD proceeded to handle a food service utensil which was placed in a pan of pureed pork chops on the steam table, the food thermometer, and the menu book. The RD was observed licking her fingers and flipping through the resident's meal cards that were placed on each tray. On 07/22/24 at 11:00 AM, during an interview with the RD, she acknowledged picking the pen up from the floor and placing it back on the steam table on two (2) occasions during the lunch mealtime. The RD confirmed that she would not want her food to be contaminated with items that had been on the floor or exposed to saliva. On 07/22/24 at 11:05 AM, during an interview with the Dietary Manager (DM), she acknowledged observing the RD licking her fingers and flipping through meal tickets meant to be placed on residents' trays and twice picking up an ink pen from the floor, placing it back on the steam table, and proceeding to touch other items in the kitchen without using hand hygiene. The DM stated she expected staff to use hand hygiene in the kitchen. The DM stated the staff were trained yearly regarding infection control. On 07/24/24 at 03:40 PM, during an interview with the Assistant Administrator (AA), she acknowledged the incidents as reported. The AA revealed she expected her staff to always follow safety protocols and to use hand hygiene whenever they touched a contaminated surface. The AA reported the staff received in-service training on infection control annually.

Based on interviews, record reviews, and facility policy reviews, the facility failed to develop/implement the comprehensive care plan for six (6) of thirty (30) sampled residents. Residents #53, Resident #57, Resident #68, Resident #80, Resident #121, and Resident #122 Findings Included: A review of the facility's policy titled, Care Plan Policy, dated 01/15, revealed POLICY: Each resident would have a plan of care to identify problems, needs, and strengths that will identify how the team will provide care The care plan contained services provided, preferences, abilities, and care level guidelines. Procedure: 1. The Care Plan will be developed within two days. Subsequent meetings would take place yearly and as needed. 2. The team along with the resident and/or family members, will identify services needed, preferences, ability, and care level guidelines. 3. The Care plan will be reviewed and/or revised yearly with the completion of the Admission/Readmission/Yearly Evaluation and with changes in the resident's condition as needed . During the initial tour on 07/22/24 at 10:31 AM, a general observation of the third floor revealed several residents sitting across from the nurse's station in wheelchairs and Geri chairs. Some of the residents were asleep, and some were awake with no activities. There were three residents in the activity room watching television with no activities noted. Record review of the July 2024 third floor Activity Calendar. revealed the facility had one (1) activity scheduled for each morning and two (2) activities scheduled for each afternoon. Throughout the days of observation (July 22, 2024 through July 23, 2024), none of the scheduled activities were observed, nor were there appropriate individualized activities provided for residents on the third floor. Three (3) of the sampled residents (Resident # 57, #121, and #122) were located on the third floor. Resident #53: A record review of the Care Plan with a problem onset date of 9/25/17 revealed Problem/Need: .Receives adaptive equipment (built-up utensils) to assist with self -feeding .Approaches Built up utensil with meals for self-feeding . During an observation and interview on 07/22/2024 at 12:11 PM, with Resident #53 he stated he needed a built-up fork because he was unable to use a conventional fork when eating due to his hand disability. He stated the kitchen staff often forgets to put one on his tray for every meal, forcing him to eat with his hands. He continued by saying when one did in rare instances end up on his tray, he kept it in his room for a day or two until it got dirty, at which point he sent it back to the kitchen to be cleaned, but it would take several days to get another one. Resident #53 added he had asked the kitchen staff several times to place the right fork on his tray, but he thought that whether they followed the instructions on his meal ticket depended on the person working the kitchen that day. He mentioned he also asked the Certified Nursing Assistant (CNA) who brought the tray to get him the appropriate fork, but a lot of the time they nodded, said alright, and never brought one back to his room. At this point, he said he was just tired of asking, so he did the best he could when eating his meals. An observation of the lunch meal tray revealed no built-up fork was provided, only regular silverware. On 07/23/24 at 12:15 PM, during a lunchtime observation of Resident #53's meal, no built-up fork was provided. Only plastic ware was given due to a COVID-19 outbreak. On 07/24/24 at 8:11 AM, observation of the breakfast tray revealed no built-up fork was provided, only plastic ware due to a COVID-19 outbreak. A record review of the meal ticket dated 07/24/2024 revealed, Adap Equip (Adaptive Equipment): Built-up Utensils x 2. Resident #57: A record review of Resident #57'sCare Plan revealed Problem/Need: Resident will need reminders and encouraging to participate in OOR (out of room) group activities of interest . Approaches: Staff will give resident opportunity to express opinions about activities attended. Staff will give the resident verbal reminders of activities before the commencement of the activity. Staff will engage resident in all group activities. .A record review of Resident #57's Face Sheet revealed an admitted [DATE] with diagnoses that included Pulmonary Hypertension, Chronic Kidney Disease, and Vascular Dementia. Resident #68: A record review of Resident #68's care plan revealed the facility had developed a baseline care plan; however, as on 7/25/24, the facility had not developed a comprehensive care plan for the resident. A record review of Resident #68's Face Sheet revealed an admitted [DATE] with diagnoses that included Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, and Bipolar Disorder. Resident #80: A record review of the Resident #80's Care Plan with a problem onset date of 6/12/24 revealed . Actual skin impairment .Approaches .Clean right buttocks .apply zinc oxide daily; Clean left back .apply zinc oxide daily .Clean left upper thigh .apply zinc oxide daily . The role specified for this approach was coded as N for nurse. Record review of the July 2024 Physician Orders revealed orders dated 6/13/24 for Pressure ulcer of right buttock .apply zinc oxide daily; Rash .left back .apply zinc oxide daily .Rash .left upper thigh .apply zinc oxide daily . A record review of Resident #80's Face Sheet revealed a re-admitted [DATE] with diagnoses that included Primary Hypertension and Rheumatoid Arthritis. Resident #121: A record review of Resident #121's Care Plan with a problem on set date of 3/29/23 revealed Long-term resident with potential for decline in psychosocial well-being related to being away from family .Approaches .visit with the resident as needed for encouragement .encourage participation in activities for socialization/stimulation. The Resident enjoys listening to music, dancing, and being involved in social events. Staff will engage the resident in group activities . A record review of Resident #121's Face Sheet revealed an admitted [DATE] with diagnoses of Hypertension, Moderate Intellectual Disabilities, and Anxiety Disorder. Resident #122: A record review of the Resident #122's Care Plan revealed (Proper name of Resident #122) has the inability to plan own leisure-time activities related to cognitive impairment and needs encouragement to actively participate in small group activities on the unit . Approaches: Initiate conversation as frequently as possible, Engaging .in group activities, Assist in planning leisure time activities, Visit with him and assist as needed with selecting the activities .interested in and will plan to attend . A record review of Resident #122's Face Sheet revealed an admitted [DATE] with diagnoses that included Mood Disorder, Parkinson's, and Depression On 07/25/24 at 11:13 AM, in an interview, Licensed Practical Nurse (LPN) #3, who managed care plans, mentioned that Resident #68 had been admitted on [DATE]. She explained that the baseline care plan was completed upon admission, but the comprehensive plan should have been finalized by now. She pointed out that the comprehensive care plan provided detailed and specific guidance for the staff on how to care for the resident and emphasized that it was overdue. On 07/25/24 at 11:19 AM, in an interview, Registered Nurse (RN) #1, responsible for care plans and MDS, acknowledged there was no reason for the delay in completing the comprehensive care plan. She took responsibility for ensuring it was done, noting that it provided essential details and interventions for nurses and CNAs to care for residents properly. On 07/25/24 at 3:10 PM, in an interview, the Assistant Executive Director (AED) expressed her expectation for care plans to be completed promptly and in accordance with federal guidelines. She stressed that these plans were crucial for staff to deliver appropriate care to the residents. During an interview on 07/25/24 at 3:30 PM, the Director of Nursing (DON) confirmed the facility failed to follow the residents' care plans by not adhering to the calendar and providing activities to the residents. The DON emphasized that activities were important, and she expected the staff to meet the residents' needs by offering daily activities. The DON also highlighted the importance of staff following care plans, ensuring CNAs only applied barrier cream provided by the facility, and that nurses were responsible for applying zinc oxide as a medication. She further explained that care plans were essential for guiding staff in taking care of the residents, including assisting with meals and managing behaviors. 41680 48669

Based on record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan which provided sufficient water intake to provide adequate hydration for one (1) of (16) residents who require enteral feedings. Resident #2 On 9/04/21 the Registered Dietician (RD) #1 reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2. The Physician (MD #1) reviewed the recommendations and approved them and issued physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, the Care Plan was not developed to provide adequate hydration for Resident #2. As a result, Resident #2 was transferred by emergency services to the local hospital emergency department, intubated, placed on a ventilator, required resuscitation, and was admitted to the local hospital critical care unit for eight (8) days. The State Agency (SA) notified the facility's Administrator the Immediate Jeopardy (IJ) on 11/03/21 at 3:30 PM. The facility's failure to implement and develop a comprehensive care plan, for Resident #2 with a history of Gastrostomy and Dysphagia placed this resident at risk for serious injury, harm, impairment, or death. The facility submitted an acceptable Removal Plan on 11/4/21 in which they alleged all corrective actions to remove the IJ were completed on 11/4/21 and the IJ removed on 11/4/21. The SA determined the IJ was removed on 11/4/21 prior to exit, and the scope and severity for 42 CFR 483.21 (b)(1)( Comprehensive Care Plans (F656) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy titled CARE PLANS dated 1/15 revealed the policy stated, Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care .The Care plan will be reviewed and/or revised yearly with the completion of the Admission/Readmission/Yearly Evaluation and with changes in the resident's condition as needed. Record review of the Face Sheet for Resident #2 revealed the resident had been admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/02/21 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #2 had moderate cognitive impairment. Record review of the Care Plan for Resident #2 revealed he had a Problem/Need with problem onset date 1/20/20 Resident receives medications and hydration via peg tube . Goal and Target date Will show no s/s (signs or symptoms) of fluid volume deficit thru 1/2022 .Approaches .NPO (nothing by mouth) .Report S/S of fluid volume deficit as needed to MD (Medical Doctor); such as, sunken eyes, poor skin turgor, decrease urine output, dry brittle hair/nails, etc .Glucerna 1.5 @ 60ml/hr (milliliters per hour) every 24 hrs (hours). Resident #2 also had Care Plan Problem/Need with onset date listed 12/13/13 Swallowing difficulties R/T (related to) mechanical causes evident by acute respiratory failure with dysphagia resulting in Peg tube placement .Approaches . NPO .Assess tube feeding orders for adequate daily intake for protein, calories, RDA's (recommended daily allowances) and fluids .Glucerna 1.5 @ 60 cc (cubic centimeters). 0n 11/02/21 at 3:40 PM, an interview with the Director of Nurses (DON) revealed when asked How do you monitor the resident's fluid intake, including enteral feeding if applicable, the DON responded Follow physicians orders. Actual measurement is usually documented on the Medication Administration Record (MAR). When asked how do you ensure the resident is provided with adequate fluids, the DON stated, Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked who from the dietary staff attends the Interdisciplinary team (IDT) meetings, the DON responded, the Registered Dietician and Dietary Manager. the DON reported that if care plan concerns were noted, the Unit Manager, Minimum Data Set (MDS) nurse, the Charge Nurse, the Registered Dietician, the Social Worker and the Activity Director, and sometimes the Dietary Manager, based on residents' annual review date or if there were a significant change in condition, reviewed care plans within 14-21 days. The DON stated she was aware the resident was due for a Care Plan review due to the ARD date but was not aware of a planned care plan review related to significant change. The DON stated she felt the care plan for Resident #2 was followed as it was, but the care plan did not address free water flushes. On 11/02/21 at 2:24 PM, an interview with Licensed Practical Nurse (LPN) #4, Charge Nurse revealed the Care Plan for Resident #2 was followed but there was no intervention specific to free water flushes. On 11/03/21 at 1:25 PM, an interview with LPN #1 revealed care plans were supposed to be updated according to physician orders. On 11/03/21 at 4:10 PM, an interview with the physician for Resident #2, MD #1, revealed he was familiar with the resident and his care. He stated he had been called on the evening of 10/26/21 and notified of signs and symptoms of level of consciousness change, elevated temperature and tachypnea for Resident #2 and had issued an order to send Resident #2 to the hospital for evaluation. MD #1 stated he was not aware Resident #2 was not receiving water flushes via his peg tube. MD #1 stated Resident #2 had a Registered Dietician (RD) assessment which resulted in new dietary recommendations in September 2021. MD #1 stated he had been apprized by RD #1 of the new dietary recommendations and agreed to the recommended changes without modification. MD #1 stated after he had issued new orders based on the RD recommendations, they would be sent to Nursing for the order to be transcribed. MD #1 confirmed he expected the care plan to reflect physician orders. When asked how much he felt the lack of water had contributed to the hospitalization of Resident #2, MD #1 responded It would be nice to be able to say it would have a neutral effect, but I cannot deny it would have had a significant effect. Record review of the History and Physical from the hospital admission for Resident #2 dated 10/27/21 revealed Resident #2 was admitted to the hospital with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Active Problems included Acute kidney injury, [CONDITION(S)], Hyperchloremia. The hospital records indicated Resident #2 was nonresponsive, tachypneic .intubated and given 1 Liter of Normal Saline. Shortly after patient had a brief PEA (Pulseless Electrical Activity) arrest .with ROSC (return of spontaneous circulation) after one round of compressions. Labs were significant . Sodium (Na+) greater than 180, Chloride greater than 140, Blood Urea [MEDICATION(S)] (BUN) 187, Cr (Creatinine) 3.23.Physical Exam .General: ill appearing, poorly cared for elderly male . The Assessment and Plan section of the hospital record revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .status post [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] slightly improved with fluids. Hyperchloremic [CONDITION(S)] Na greater than 180, chloride greater than 140. Patient PEG tube dependent. Lactic acid 8.-obvious lack of free water, most likely due to lack of FWF (Free Water Flushes) administration for prolonged period of time .fluid resuscitated with [MEDICATION(S)] fluids initially, now will start D5w 125 ml/hr (milliliters per hour) .difficult to establish goal as current value too high to record. Acute renal failure Bs (base line) Cr (Creatinine) 0.6, last value recorded from April. Cr on admission 3.23, BUN 187. UA very concentrated specific gravity 1.034 .-received [MEDICATION(S)] fluid resuscitation-Foley (catheter) placed from strict I's and O's (intake and outputs)-will monitor closely .Disposition: continue to manage shock and correct [CONDITION(S)]. Resident #2 was admitted for inpatient care at 8:01 on 10/27/21. REMOVAL PLAN 11/3/21 Manhattan Nursing and Rehabilitation Removal Plan - IJ - Residents with tube feeding formula, water flushes, care plans The facility was informed by state agency 11/3/21 3:30pm of an immediate jeopardy and substandard quality of care. The state agency provided the facility with IJ templates for F692, F693, F656. The facility failed to transcribe the dietary registered dietitian recommendations correctly resulting in omission of free water flushes for resident number two. The facility failed to provide resident # 2 sufficient fluid intake to maintain proper hydration and health by failing to transcribe the dietary recommendations correctly resulting in omission of free water flushes from 9/14/21 through 10/27/21 when resident was admitted to hospital for hypovolemic shock. The facility failed to fully develop and implement a comprehensive care plan for resident # 2 as 10/6/21 care plan states resident receives medication and hydration. Goal states will show no signs and symptoms fluid volume deficit through 1/2022 but had no approach for free water flushes as recommended by registered dietitian; with order start date of 9/14/21 to provide total free water of 2144cc. Corrective actions: 1. On 11/3/21 at 10:00a.m. 100% audits sixteen of sixteen residents with enteral feedings and water flushes were initiated and completed on 11/04/2021 at 10:00am. to ensure accuracy of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The audits were completed by supervisory registered nurses. There are 16 residents with feeding tubes in the facility on 11/4/21. Zero of 16 residents needed revision and/or corrections. 2. On 11/3/21 at 2:30pm licensed nurses and certified nursing assistants were in-serviced by supervisory registered nurses related to signs and symptoms of dehydration, residents with enteral feeding, orders for enteral formula, water flushes, documentation of enteral formula and water flushes on the medication administration record(MAR) with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings as physician ordered and recommended amount of feedings and flushes to equal the daily ordered and recommended amounts. Licensed nurses and certified nursing assistants will not be allowed to work until they have been in-serviced. 3. On 11/4/21 at 12:00pm the sixteen residents with enteral feeding/water flushes plan of care have been reviewed by the Director of Nursing and MDS Coordinator. No revision was needed. and was completed 11/4/21 at 12:00pm related to residents enteral feeding physician ordered formula and water flushes. 4. On 11/3/21 at 3:45 pm. the Quality Assurance (QA) committee met to include Executive Director, Director of Nurses (also Infection Preventionist at present), Regional Clinical Operation nurse, Vice President of Operations, and Medical Director in regard to Immediate Jeopardy cited for failure to provide sufficient fluid intake, failure to provide resident enteral feeding as physician ordered, and failure to develop and implement a comprehensive person centered care plan to meet the resident needs. Corrective actions will ensure that residents are receiving enteral feedings per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Two (2) policies were reviewed- (1. Tube Feeding and 2. Care plan policy. No revisions were made to the policies. QA Committee decided to implement collection of registered dietitian recommendations upon completion by nursing staff per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Director of Nursing Services/RN supervisory nurses will complete an enteral feeding audit on all residents with enteral feedings physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. On 11/3/21 at 3:30pm all sixteen residents (16) residents with enteral feedings were assessed for signs and symptoms of dehydration by supervisor registered nurses, completed 11/04/2021 at 10:00am with no residents found with concerns of dehydration. Dehydration risk assessments have been reviewed, updated, and completed on each resident with enteral feedings by supervisory registered nurses on 11/4/21 at 12:00pm. 6. On 11/3/21 at 8:00pm the Director of Nursing audited enteral feedings and evaluated sixteen (16) residents who are receiving enteral feeding per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Facility alleges relieving the immediacy of this immediate jeopardy on 11/4/21 at 2:00pm. On 11/05/2021 SA entered facility for validation of the Removal Plan for Immediate Jeopardy. Validation: 1. On 11/05/2021 interview with Director of Nursing indicated audits were completed for all residents who resided in the facility which ensured accuracy of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . SA validated through interview and record reviews for Residents #2, #3, #4, and #5 (along with all the other residents in facility on this date with feeding tubes) accuracy of feeding tube orders with water flushes on medication administration records with no revisions or corrections necessary. 2. On 11/05/2021 through interviews with Director of Nursing and Acting Director of Nursing, and record review of facility Educational In-Service Record titled Tube Feedings / Care Plans / S/S Dehydration / Transcription of Tube Feeding Orders / Free Water Flushes for tube feeders sign-in sheet, the SA validated that in-service was conducted for all nurses and certified nursing assistants related to signs and symptoms of dehydration, residents with enteral feedings, orders for enteral formula, water flushes, documentation of enteral feedings and flushes on the medication administration record with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings and flushes as ordered by physician and recommended by the dietician to equal the daily ordered and recommended amounts. Through interviews with LPN #3, LPN #5, LPN #6, and CNA # 2 and CNA #3, SA validated that nursing staff was not allowed to work until they had been properly in-serviced. 3. On 11/05/2021 SA validated through interview with Director of Nursing that care plans of Residents #2, #3, #4, and #5 (and the other residents in facility on this date with feeding tubes) were reviewed related to residents' enteral feedings and water flushes as physician ordered and dietary recommendations. Record review of residents #2, #3, #4, and #5 (and the other residents in facility on this date with feeding tubes) care plans indicate enteral feeding orders, flush orders, and observation for signs and symptoms of dehydration. 4. On 11/05/2021 through interviews with four (4) members of the Quality Assurance committee including the Director of Nursing (also the Infection Preventionist), the Acting Director of Nursing, the Administrator and the Registered Dietician and record review of facility Monthly Facility QA & A Minutes sign-in sheet dated 11/03/2021 at 3:45pm; the SA validated a meeting of the QA & A committee regarding the Immediate Jeopardy for failure to provide sufficient fluid intake, failure to provide residents enteral feedings as physician ordered, and failure to fully develop and implement a comprehensive, person-centered care plan to meet the resident needs. Two (2) policies were reviewed: 1) Tube feeding Policy and 2) Care Plan Policy. No revisions were formulated to the policies. The committee did, however, decide to implement collection of Registered Dietician recommendations upon completion by nursing staff per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also added will be an enteral feeding audit daily on all residents with enteral feedings and water flushes by Director of Nursing and RN supervisory nurses to ensure accuracy and documentation of enteral feedings and water flushes on the medication administration record. 5. On 11/05/2021 through interview with Director of Nursing and record review of facility Evaluation of Dehydration Risk assessment forms for Residents #2, #3, #4, and #5, (and the other residents in facility on this date with feeding tubes) dated 11/04/2021, and observation of Residents #2, #3, #4, and #5 for signs and symptoms of dehydration, SA validated that 100% of residents in facility with feeding tubes were assessed for signs and symptoms of dehydration with no resident found with signs or symptoms of dehydration. 6. On 11/05/2021 through interview with Director of Nursing and record review of facility Physician Orders, facility Department Notes - Category - Dietary, and facility Daily Care Guide, SA validated 100% of residents requiring tube feedings are receiving enteral feedings and water flushes per Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. The SA validated on 11/05/2021 all corrective actions were completed as of 11/04/2021 and Immediate Jeopardy was removed on 11/04/2021 prior to exit.

Based on record review, facility policy review, and staff interview the facility failed to ensure Resident #2 received free water flushes through his Percutaneous Endoscopic Gastrostomy (PEG) tube to maintain adequate hydration status which resulted in Resident #2 becoming Hypovolemic (Dehydrated), resulting in Resident #2 being transferred to the local hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2. On 9/04/21 the Registered Dietician (RD #1) reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2 which included 175 milliliter free water flushes every four (4) hours. The physician (MD #1) reviewed the recommendations and approved them and issued physician orders based on the recommendations. On 9/14/21 the facility failed to include free water flushes in the transcription of the physician orders which led to inadequate hydration for Resident #2 after 9:00 AM on 9/14/21.As a result, Resident #2 was transferred by emergency services to the local hospital emergency department, intubated, placed on a ventilator, required resuscitation, and was admitted to the local hospital critical care unit for eight (8) days. The facility's failure to provide adequate hydration for forty-three (43) days for Resident #2 with a history of Gastrostomy and Dysphagia caused Resident #2 serious harm and placed other residents who received enteral feedings in a situation that is likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/14/21 when the facility failed to ensure the physician ordered dietary recommendations were implemented to provide adequate hydration for Resident #2. The facility Administrator was notified of the IJ on 11/03/21 at 3:30 PM. The facility provided an acceptable Removal Plan on 11/04/21, in which the facility alleged all corrective actions were completed to remove the IJ on 11/04/21, and the IJ removed on 11/04/21. The SA determined the IJ was removed on 11/04/21 prior to exit, and the scope and severity for 42CFR 483.25(g)(1)(2) Assisted nutrition and hydration (F692) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled TUBE FEEDING dated 7/18 revealed Residents with a .Gastrostomy . tube will be provided nutrition and hydration via the feeding tube. Record review of the Face Sheet for Resident #2 revealed Resident #2 was admitted to the faciility on 12/13/13 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He currently has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/02/21 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #2 had moderate cognitive impairment. Record review of 'Medical Nutrition Recommendations' for Resident #2 dated 9/04/21, revealed RD#1's recommendation was listed as .Give Glucerna 1.5 continuous at 60ml/hr (milliliters per hour) for 24 hours. Flush 175 ml every 4 hours. Provides: 2160 kcal/118 gm (kilocalories/gram) PRO (protein)/2144 free water. Record review of Departmental Notes dated 9/16/2021 at 9:39 AM, Role: Dietary revealed .Flush 175ml (milliliters) q (every) 4 hrs (hours) to provide total free water 2144ml. Record review of Electronic Medication Administration Record (EMAR) for the month of September 2021 for Resident #2 revealed he had Free water flush 150 cc six (6) times a day through 9:00 AM on 9/14/21. Record review of EMAR for the months of September and October 2021 for Resident #2 revealed he had no Free water flush after 9:00 AM on 9/14/21. Record review of RESIDENT ISSUES FOR (MD #1), (Nurse-Physician communication binder) revealed an entry dated 10/19/21 for Resident #2, Behavior seems normal but resident appears pale and weak. The entry was signed by Nurse Practitioner (NP#1) for the resident's primary physician on 10/22/21. There was also an entry dated 10/26/21 for Resident #2 which indicated weak, pale, eyes sunken. This entry was crossed out with a note indicating that the resident had been transferred to the hospital on 10/27/21. Record review of the Physician Orders for October 2021 for Resident #2 revealed orders for NPO(Nothing by Mouth) dated 4/05/21. Send resident to (Proper Name of Local Hospital) for evaluation related to respiratory distress and temperature 100.8 dated 10/27/21 at 3:05 AM. There were no Physician Orders for water flushes included in the Physician Orders. Record review of the History and Physical from the hospital admission for Resident #2 dated 10/27/21 revealed Resident #2 was admitted to the hospital with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Active Problems included Acute kidney injury, [CONDITION(S)], Hyperchloremia. The hospital records indicated Resident #2 was nonresponsive, tachypneic .intubated and given 1 Liter of Normal Saline. Shortly after patient had a brief PEA (Pulseless Electrical Activity) arrest .with ROSC (return of spontaneous circulation) after one round of compressions. Labs were significant . Sodium (Na+) greater than 180, Chloride greater than 140, Blood Urea [MEDICATION(S)] (BUN) 187, Cr (Creatinine) 3.23 .Physical Exam .General: ill appearing, poorly cared for elderly male .The Assessment and Plan section of the hospital record revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .status post [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] slightly improved with fluids. Hyperchloremic [CONDITION(S)] Na greater than 180, chloride greater than 140. Patient PEG tube dependent. Lactic acid 8.-obvious lack of free water, most likely due to lack of FWF (Free Water Flushes) administration for prolonged period of time .fluid resuscitated with [MEDICATION(S)] fluids initially, now will start D5w 125 ml/hr (milliliters per hour) .difficult to establish goal as current value too high to record. Acute renal failure Bs (base line) Cr (Creatinine) 0.6, last value recorded from April. Cr on admission 3.23, BUN 187. UA very concentrated specific gravity 1.034 .-received [MEDICATION(S)] fluid resuscitation-Foley (catheter) placed from strict I's and O's (intake and outputs)-will monitor closely .Disposition: continue to manage shock and correct [CONDITION(S)]. Resident #2 was admitted for inpatient care at 8:01 on 10/27/21. Record review of Departmental Notes dated 9/16/21 at 2:14 PM of the Role: Nursing: notes revealed, .He receives all nutritional support and hydration via peg tube . The entry was signed by Licensed Practical Nurse (LPN #1) Record review of Departmental Notes dated 10/27/21 at 3:00 AM of the Role: Nursing revealed, 2:40 AM upon entering room, resident appeared to have respiratory distress. Unresponsive. BP (blood pressure) 89/59, T (temperature) 100.8, R (respiration rate) 28, P (pulse) 125. Fingers appear swollen. Top of mouth is discolored and dry . 2:45 AM. (Formal Name of MD #1) notified of resident condition and N.O. (new order) send resident to (hospital) for evaluation . 0n 11/02/21 at 3:40 PM, an interview with the Director of Nurses (DON) revealed when asked how do you monitor the resident's fluid intake, including enteral feeding if applicable, the DON responded Follow physicians orders. Actual measurement is usually documented on the MAR. When asked what potential hydration deficits has the resident experienced, the DON states she is not aware and doesn't know. When asked what other limitations or factors impact the resident's hydration, the DON responded, Medications is the only thing I know of. When asked how do you ensure the resident is provided with adequate fluids, the DON stated, Physician orders and physician ordered lab work to be quantitative. When asked what, when, and to whom do you report changes in fluid intake, the DON responded, The floor nurse reports it to the physician. The DON explained the Registered Dietician makes recommendations in writing, which are presented to the physician and if approved by the physician they are entered into the resident's record as an order by the Unit Manager or nurse. The DON stated if the physician orders based on the Registered Dieticians recommendations appeared differently on the physicians orders and Medication Administration Record (MAR), then it was considered a transcription error by the Unit Manager or nurse. The DON acknowledged Resident #2 received a hypertonic tube feeding and did not receive free water flushes for forty-three (43) days. On 11/02/21 at 2:24 PM, an interview with LPN #4, charge nurse revealed she stated Somedays I am the Unit Manager for the second floor. I transcribed what was on the paper as far as the flushes. She could not explain why the 175 cc free water flushes listed on the 'Nutrition Recommendation' sheet was not on the physician orders or MAR. On 11/03/21 at 1:10 PM, an interview with RD #2 revealed she started work at the facility on 9/20/21. She stated RD #1 no longer worked at the facility. RD #2 stated Registered Dieticians use a clinical formula which involved residents' weight, height, diagnosis, and medications along with other factors to determine the appropriate amount for free water flushes for each resident with a feeding tube. She confirmed Resident #2 needed the free water flushes and stated the Glucerna 1.5 tube feeding would not have provided sufficient amount of water on its own. She stated she had not been notified that Resident #2 had any signs or symptoms of dehydration by the staff. On 11/03/21 at 4:10 PM, an interview with the physician for Resident #2, MD #1, revealed he was familiar with the resident and his care. He stated he had been called on the evening of 10/26/21 and notified of signs and symptoms of level of consciousness change, elevated temperature and tachypnea for Resident #2 and had issued an order to send Resident #2 to the hospital for evaluation. MD #1 stated he was not aware Resident #2 was not receiving water flushes via his peg tube. MD #1 stated he had been apprized by the RD of the new dietary recommendations and agreed to the recommended changes without modification. MD #1 stated after he had issued new orders based on the RD recommendations, they would be sent to nursing for the order to be transcribed. When asked how much he felt the lack of water had contributed to the hospitalization of Resident #2, MD #1 responded It would be nice to be able to say it would have a neutral effect, but I cannot deny it would have had a significant effect. REMOVAL PLAN 11/3/21 Manhattan Nursing and Rehabilitation Removal Plan - IJ - Residents with tube feeding formula, water flushes, care plans The facility was informed by state agency 11/3/21 3:30pm of an immediate jeopardy and substandard quality of care. The state agency provided the facility with IJ templates for F692, F693, F656. The facility failed to transcribe the dietary registered dietitian recommendations correctly resulting in omission of free water flushes for resident number two. The facility failed to provide resident # 2 sufficient fluid intake to maintain proper hydration and health by failing to transcribe the dietary recommendations correctly resulting in omission of free water flushes from 9/14/21 through 10/27/21 when resident was admitted to hospital for hypovolemic shock. The facility failed to fully develop and implement a comprehensive care plan for resident # 2 as 10/6/21 care plan states resident receives medication and hydration. Goal states will show no signs and symptoms fluid volume deficit through1/2022 but had no approach for free water flushes as recommended by registered dietitian; with order start date of 9/14/21 to provide total free water of 2144cc. Corrective actions: 1. On 11/3/21 at 10:00a.m. 100% audits sixteen of sixteen residents with enteral feedings and water flushes were initiated and completed on 11/04/2021 at 10:00am. to ensure accuracy of physician orders with documentation of enteral feeding and water flushes on the medication administration record (MAR). The audits were completed by supervisory registered nurses. There are 16 residents with feeding tubes in the facility on 11/4/21. Zero of 16 residents needed revision and/or corrections. 2. On 11/3/21 at 2:30pm licensed nurses and certified nursing assistants were in-serviced by supervisory registered nurses related to signs and symptoms of dehydration, residents with enteral feeding, orders for enteral formula, water flushes, documentation of enteral formula and water flushes on the medication administration record(MAR) with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings as physician ordered and recommended amount of feedings and flushes to equal the daily ordered and recommended amounts. Licensed nurses and certified nursing assistants will not be allowed to work until they have been in-serviced. 3. On 11/4/21 at 12:00pm the sixteen residents with enteral feeding/water flushes plan of care have been reviewed by the Director of Nursing and MDS Coordinator. No revision was needed. and was completed 11/4/21 at 12:00pm related to residents enteral feeding physician ordered formula and water flushes. 4. On 11/3/21 at 3:45 pm. the Quality Assurance (QA) committee met to include Executive Director, Director of Nurses (also Infection Preventionist at present), Regional Clinical Operation nurse, Vice President of Operations, and Medical Director in regard to Immediate Jeopardy cited for failure to provide sufficient fluid intake, failure to provide resident enteral feeding as physician ordered, and failure to develop and implement a comprehensive person centered care plan to meet the resident needs. Corrective actions will ensure that residents are receiving enteral feedings per physician orders and recommended amount of feeding and flushes to equal the daily ordered and recommended amounts. Two (2) policies were reviewed- (1. Tube Feeding and 2. Care plan policy. No revisions were made to the policies. QA Committee decided to implement collection of registered dietitian recommendations upon completion by nursing staff per physician orders and will be retained by medical records for a minimum of one year. Director of Nursing Services/RN supervisory nurses will complete an enteral feeding audit on all residents with enteral feedings physician orders for formula and water flushes to ensure accuracy and documentation of enteral feeding and water flushes on the medication administration record daily. 5. On 11/3/21 at 3:30pm all sixteen residents (16) residents with enteral feedings were assessed for signs and symptoms of dehydration by supervisor registered nurses, completed 11/04/2021 at 10:00am with no residents found with concerns of dehydration. Dehydration risk assessments have been reviewed, updated, and completed on each resident with enteral feedings by supervisory registered nurses on 11/4/21 at 12:00pm. 6. On 11/3/21 at 8:00pm the Director of Nursing audited enteral feedings and evaluated sixteen (16) residents who are receiving enteral feeding per physician orders and recommended amount of feeding and flushes to equal the daily ordered and RD recommended amounts and verifying sufficient fluid intake approaches are on the person-centered comprehensive care plan. 7. Facility alleges relieving the immediacy of this immediate jeopardy on 11/4/21 at 2:00pm. On 11/05/2021 SA entered facility for verification of Removal Plan for Immediate Jeopardy. Validation: 1. On 11/05/2021 interview with director of nursing indicated audits were completed for all residents who resided in the facility which ensured accuracy of physician orders with documentation of enteral feedings and water flushes. SA validated through interview and record reviews for Residents #2, #3, #4, and #5 (along with all the other residents in facility on this date with feeding tubes) accuracy of feeding tube orders with water flushes on medication administration records with no revisions or corrections necessary. 2. On 11/05/2021 through interviews with Director of Nursing and Acting Director of Nursing, and record review of facility Educational In-Service Record titled Tube Feedings / Care Plans / S/S Dehydration / Transcription of Tube Feeding Orders / Free Water Flushes for tube feeders sign-in sheet, the SA validated that in-service was conducted for all nurses and certified nursing assistants related to signs and symptoms of dehydration, residents with enteral feedings, orders for enteral formula, water flushes, documentation of enteral feedings and flushes on the medication administration record with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings and flushes as ordered by physician and recommended by the dietician to equal the daily ordered and recommended amounts. Through interviews with LPN #3, LPN #5, LPN #6, and CNA # 2 and CNA #3, SA validated that nursing staff was not allowed to work until they had been properly in-serviced. 3. On 11/05/2021 SA validated through interview with Director of Nursing that care plans of Residents #2, #3, #4, and #5 (and the other residents in facility on this date with feeding tubes) were reviewed related to residents' enteral feedings and water flushes as physician ordered and dietary recommendations. Record review of residents #2, #3, #4, and #5 (and the other residents in facility on this date with feeding tubes) care plans indicate enteral feeding orders, flush orders, and observation for signs and symptoms of dehydration. 4. On 11/05/2021 through interviews with four (4) members of the Quality Assurance committee including the Director of Nursing (also the Infection Preventionist), the Acting Director of Nursing, the Administrator and the Registered Dietician and record review of facility Monthly Facility QA & A Minutes sign-in sheet dated 11/03/2021 at 3:45pm; the SA validated a meeting of the QA & A committee regarding the Immediate Jeopardy for failure to provide sufficient fluid intake, failure to provide residents enteral feedings as physician ordered, and failure to fully develop and implement a comprehensive, person-centered care plan to meet the resident needs. Two (2) policies were reviewed: 1) Tube feeding Policy and 2) Care Plan Policy. No revisions were formulated to the policies. The committee did, however, decide to implement collection of Registered Dietician recommendations upon completion by nursing staff per physician orders and will be retained by Medical Records for a minimum of one (1) year. Also added will be an enteral feeding audit daily on all residents with enteral feedings and water flushes by Director of Nursing and RN supervisory nurses to ensure accuracy and documentation of enteral feedings and water flushes on the medication administration record. 5. On 11/05/2021 through interview with Director of Nursing and record review of facility Evaluation of Dehydration Risk assessment forms for Residents #2, #3, #4, and #5, (and the other residents in facility on this date with feeding tubes) dated 11/04/2021, and observation of Residents #2, #3, #4, and #5 for signs and symptoms of dehydration, SA validated that 100% of residents in facility with feeding tubes were assessed for signs and symptoms of dehydration with no resident found with signs or symptoms of dehydration. 6. On 11/05/2021 through interview with Director of Nursing and record review of facility Physician Orders, facility Department Notes - Category - Dietary, and facility Daily Care Guide, SA validated 100% of residents requiring tube feedings are receiving enteral feedings and water flushes per Physician orders per Registered Dietician recommendations and are verifying sufficient fluid intake approaches on the person-centered comprehensive plan of care. 7. The SA validated on 11/05/2021 all corrective actions were completed as of 11/04/2021 and Immediate Jeopardy was removed on 11/04/2021 prior to exit.

Based on record review, facility policy review, and staff interview the facility failed to ensure Resident #2 received free water flushes through his Percutaneous Endoscopic Gastrostomy (PEG) tube to maintain adequate hydration status which resulted in Resident #2 becoming Hypovolemic (Dehydrated), resulting in Resident #2 being transferred to the local hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident #2. On 9/04/21 the Registered Dietician (RD #1) reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2 which included 175 milliliter free water flushes every four (4) hours. The physician (MD #1) reviewed the recommendations and approved them and issued physician orders based on the recommendations. On 9/14/21 the facility failed to include free water flushes in the transcription of the physician orders which led to the tube feeding complication of inadequate hydration for Resident #2 after 9:00 AM on 9/14/21. The facility's failure to provide adequate hydration for forty-three (43) days for Resident #2 with a history of Gastrostomy and Dysphagia caused Resident #2 serious harm and placed other residents who received enteral feedings in a situation that is likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/14/21 when the facility failed to ensure the physician ordered dietary recommendations was in place to provide adequate hydration for Resident #2. The facility Administrator was notified of the IJ at 3:30 PM and provided the IJ templates. The facility provided an acceptable Removal Plan on 11/04/21, in which the facility alleged all corrective actions were completed to remove the IJ on 11/04/21, and the IJ removed on 11/04/21. The SA determined the IJ was removed on 11/04/21 prior to exit, and the scope and severity for 42CFR 483.25 (g)(5)Enteral Nutrition (F693) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled TUBE FEEDING dated 7/18 revealed, Residents with a .Gastrostomy . tube will be provided nutrition and hydration via the feeding tube. Record review of the Face Sheet for Resident #2 revealed Resident #2 was admitted to the faciilityon 12/13/13 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He currently has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/02/21 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #2 had moderate cognitive impairment. Record review of Medical Nutrition Recommendations for Resident #2 dated 9/04/21, revealed RD#1's recommendation was listed as Give Glucerna 1.5 continuous at 60ml/hr (milliliters per hour) for 24 hours. Flush 175 ml every 4 hours. Provides: 2160 kcal/118 gm (kilocalories/gram) PRO (protein)/2144 free water. Record review of Departmental Notes dated 9/16/2021 at 9:39 AM, Role: Dietary revealed .Flush 175ml (milliliters) q (every) 4 hrs (hours) to provide total free water 2144ml. Record review of Electronic Medication Administration Record (EMAR) for the month of September 2021 for Resident #2 revealed he had Free water flush 150 cc six (6) times a day through 9:00 AM on 9/14/21. Record review of EMAR for the months of September and October 2021 for Resident #2 revealed he had no Free water flush after 9:00 AM on 9/14/21. Record review of RESIDENT ISSUES FOR (MD #1), (Nurse-Physician communication binder) revealed an entry dated 10/19/21 for Resident #2, Behavior seems normal but resident appears pale and weak. The entry was signed by Nurse Practitioner (NP#1) for the resident's primary physician on 10/22/21. There was also an entry dated 10/26/21 for Resident #2 which stated weak, pale, eyes sunken. This entry was crossed out with a note indicating that the resident had been transferred to the hospital on 10/27/21. Record review of the Physician Orders for October 2021 for Resident #2 revealed orders for NPO(Nothing by mouth) dated 4/05/21. Send resident to (Proper Name of Local Hospital) for evaluation related to respiratory distress and temperature 100.8 dated 10/27/21 at 3:05 AM. There were no Physician Orders for water flushes included in the Physician Orders. Record review of the History and Physical from the hospital admission for Resident #2 dated 10/27/21 revealed Resident #2 was admitted to the hospital with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Active Problems included Acute kidney injury, [CONDITION(S)], Hyperchloremia. The hospital records indicated Resident #2 was nonresponsive, tachypneic .intubated and given 1 Liter of Normal Saline. Shortly after patient had a brief PEA (Pulseless Electrical Activity) arrest .with ROSC (return of spontaneous circulation) after one round of compressions. Labs were significant . Sodium (Na+) greater than 180, Chloride greater than 140, Blood Urea [MEDICATION(S)] (BUN) 187, Cr (Creatinine) 3.23. Physical Exam .General: ill appearing, poorly cared for elderly male .The Assessment and Plan section of the hospital record revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .status post [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] slightly improved with fluids. Hyperchloremic [CONDITION(S)] Na greater than 180, chloride greater than 140. Patient PEG tube dependent. Lactic acid 8.-obvious lack of free water, most likely due to lack of FWF (Free Water Flushes) administration for prolonged period of time .fluid resuscitated with [MEDICATION(S)] fluids initially, now will start D5w 125 ml/hr (milliliters per hour) .difficult to establish goal as current value too high to record. Acute renal failure Bs (base line) Cr (Creatinine) 0.6, last value recorded from April. Cr on admission 3.23, BUN 187. UA very concentrated specific gravity 1.034 .-received [MEDICATION(S)] fluid resuscitation-Foley (catheter) placed from strict I's and O's (intake and outputs)-will monitor closely .Disposition: continue to manage shock and correct [CONDITION(S)]. Resident #2 was admitted for inpatient care at 8:01AM on 10/27/21. Record review of Departmental Notes dated 9/16/21 at 2:14 PM, Role: Nursing: revealed, .He receives all nutritional support and hydration via peg tube . The entry was signed by Licensed Practical Nurse (LPN #1) Record review of Departmental Notes dated 10/27/21 at 3:00 AM, Role: Nursing revealed, 2:40 AM upon entering room, resident appeared to have respiratory distress. Unresponsive. BP (blood pressure) 89/59, T (temperature) 100.8, R (respiration rate) 28, P (pulse) 125. Fingers appear swollen. Top of mouth is discolored and dry . 2:45 AM. (Formal Name of MD #1) notified of resident condition and N.O. (new order) send resident to (hospital) for evaluation . 0n 11/02/21 at 3:40 PM, an interview with the Director of Nurses (DON) revealed when asked how do you monitor the resident's fluid intake, including enteral feeding if applicable, the DON responded Follow physicians orders. Actual measurement is usually documented on the MAR. When asked what potential hydration deficits has the resident experienced, the DON states she is not aware and doesn't know. When asked what other limitations or factors impact the resident's hydration, the DON responded, Medications is the only thing I know of. When asked how do you ensure the resident is provided with adequate fluids, the DON stated, Physician orders and physician ordered lab work to be quantitative. When asked what, when, and to whom do you report changes in fluid intake, the DON responded, The floor nurse reports it to the physician. The DON explained the Registered Dietician makes recommendations in writing, which are presented to the physician and if approved by the physician they are entered into the resident's record as an order by the Unit Manager or nurse. The DON stated if the physician orders based on the Registered Dieticians recommendations appeared differently on the physicians orders and Medication Administration Record (MAR), then it was considered a transcription error by the Unit Manager or nurse. The DON acknowledged Resident #2 received a hypertonic tube feeding and did not receive free water flushes for forty-three (43) days. On 11/02/21 at 2:24 PM, an interview with LPN #4, charge nurse revealed Somedays I am the unit manager for the second floor. I transcribed what was on the paper as far as the flushes. She could not explain why the 175 cc free water flushes listed on the Nutrition Recommendation sheet was not on the physician orders or MAR. On 11/03/21 at 1:10 PM, an interview with RD #2 revealed she started work at the facility on 9/20/21. She stated RD #1 no longer worked at the facility. RD #2 stated Registered Dieticians use a clinical formula which involved residents' weight, height, diagnosis, and medications along with other factors to determine the appropriate amount for free water flushes for each resident with a feeding tube. She confirmed Resident #2 needed the free water flushes and stated the Glucerna 1.5 tube feeding would not have provided sufficient amount of water on its own. She stated she had not been notified that Resident #2 had any signs or symptoms of dehydration by the staff. On 11/03/21 at 4:10 PM, an interview with the physician for Resident #2, MD #1, revealed he was familiar with the resident and his care. He stated he had been called on the evening of 10/26/21 and notified of signs and symptoms of level of consciousness change, elevated temperature and tachypnea for Resident #2 and had issued an order to send Resident #2 to the hospital for evaluation. MD #1 stated he was not aware Resident #2 was not receiving water flushes via his peg tube. MD #1 stated he had been apprized by the RD of the new dietary recommendations and agreed to the recommended changes without modification. MD #1 stated after he had issued new orders based on the RD recommendations, they would be sent to nursing for the order to be transcribed. When asked how much he felt the lack of water had contributed to the hospitalization of Resident #2, MD #1 responded It would be nice to be able to say it would have a neutral effect, but I cannot deny it would have had a significant effect. REMOVAL PLAN 11/3/21 Manhattan Nursing and Rehabilitation Removal Plan - IJ - Residents with tube feeding formula, water flushes, care plans The facility was informed by state agency 11/3/21 3:30pm of an immediate jeopardy and substandard quality of care. The state agency provided the facility with IJ templates for F692, F693, F656. The facility failed to transcribe the dietary registered dietitian recommendations correctly resulting in omission of free water flushes for resident number two. The facility failed to provide resident # 2 sufficient fluid intake to maintain proper hydration and health by failing to transcribe the dietary recommendations correctly resulting in omission of free water flushes from 9/14/21 through 10/27/21 when resident was admitted to hospital for hypovolemic shock. The facility failed to fully develop and implement a comprehensive care plan for resident # 2 as 10/6/21 care plan states resident receives medication and hydration. Goal states will show no signs and symptoms fluid volume deficit through1/2022 but had no approach for free water flushes as recommended by registered dietitian; with order start date of 9/14/21 to provide total free water of 2144cc. Corrective actions: 1. On 11/3/21 at 10:00a.m. 100% audits sixteen of sixteen residents with enteral feedings and water flushes were initiated and completed on 11/04/2021 at 10:00am. to ensure accuracy of physician orders with documentation of enteral feeding and water flushes on the medication administration record (MAR). The audits were completed by supervisory registered nurses. There are 16 residents with feeding tubes in the facility on 11/4/21. Zero of 16 residents needed revision and/or corrections. 2. On 11/3/21 at 2:30pm licensed nurses and certified nursing assistants were in-serviced by supervisory registered nurses related to signs and symptoms of dehydration, residents with enteral feeding, orders for enteral formula, water flushes, documentation of enteral formula and water flushes on the medication administration record(MAR) with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings as physician ordered and recommended amount of feedings and flushes to equal the daily ordered and recommended amounts. Licensed nurses and certified nursing assistants will not be allowed to work until they have been in-serviced. 3. On 11/4/21 at 12:00pm the sixteen residents with enteral feeding/water flushes plan of care have been reviewed by the Director of Nursing and MDS Coordinator. No revision was needed. and was completed 11/4/21 at 12:00pm related to residents enteral feeding physician ordered formula and water flushes. 4. On 11/3/21 at 3:45 pm. the Quality Assurance (QA) committee met to include Executive Director, Director of Nurses (also Infection Preventionist at present), Regional Clinical Operation nurse, Vice President of Operations, and Medical Director in regard to Immediate Jeopardy cited for failure to provide sufficient fluid intake, failure to provide resident enteral feeding as physician ordered, and failure to develop and implement a comprehensive person centered care plan to meet the resident needs. Corrective actions will ensure that residents are receiving enteral feedings per physician orders and recommended amount of feeding and flushes to equal the daily ordered and recommended amounts. Two (2) policies were reviewed- (1. Tube Feeding and 2. Care plan policy. No revisions were made to the policies. QA Committee decided to implement collection of registered dietitian recommendations upon completion by nursing staff per physician orders and will be retained by medical records for a minimum of one year. Director of Nursing Services/RN supervisory nurses will complete an enteral feeding audit on all residents with enteral feedings physician orders for formula and water flushes to ensure accuracy and documentation of enteral feeding and water flushes on the medication administration record daily. 5. On 11/3/21 at 3:30pm all sixteen residents (16) residents with enteral feedings were assessed for signs and symptoms of dehydration by supervisor registered nurses, completed 11/04/2021 at 10:00am with no residents found with concerns of dehydration. Dehydration risk assessments have been reviewed, updated, and completed on each resident with enteral feedings by supervisory registered nurses on 11/4/21 at 12:00pm. 6. On 11/3/21 at 8:00pm the Director of Nursing audited enteral feedings and evaluated sixteen (16) residents who are receiving enteral feeding per physician orders and recommended amount of feeding and flushes to equal the daily ordered and RD recommended amounts and verifying sufficient fluid intake approaches are on the person-centered comprehensive care plan. 7. Facility alleges relieving the immediacy of this immediate jeopardy on 11/4/21 at 2:00pm. On 11/05/2021 SA entered facility for verification of Removal Plan for Immediate Jeopardy. Validation: 1. On 11/05/2021 interview with director of nursing indicated audits were completed for all residents who resided in the facility which ensured accuracy of physician orders with documentation of enteral feedings and water flushes. SA validated through interview and record reviews for Residents #2, #3, #4, and #5 (along with all the other residents in facility on this date with feeding tubes) accuracy of feeding tube orders with water flushes on medication administration records with no revisions or corrections necessary. 2. On 11/05/2021 through interviews with Director of Nursing and Acting Director of Nursing, and record review of facility Educational In-Service Record titled Tube Feedings / Care Plans / S/S Dehydration / Transcription of Tube Feeding Orders / Free Water Flushes for tube feeders sign-in sheet, the SA validated that in-service was conducted for all nurses and certified nursing assistants related to signs and symptoms of dehydration, residents with enteral feedings, orders for enteral formula, water flushes, documentation of enteral feedings and flushes on the medication administration record with the plan of care reviewed/revised as indicated, and that residents are receiving enteral feedings and flushes as ordered by physician and recommended by the dietician to equal the daily ordered and recommended amounts. Through interviews with LPN #3, LPN #5, LPN #6, and CNA # 2 and CNA #3. Through interviews SA validated that nursing staff was not allowed to work until they had been properly in serviced. 3. On 11/05/2021 SA validated through interview with Director of Nursing that care plans of Residents #2, #3, #4, and #5 (and the other residents in facility on this date with feeding tubes) were reviewed related to residents enteral feedings and water flushes as physician ordered and dietary recommendations. Record review of residents #2 through #5 (and the other residents in facility on this date with feeding tubes) care plans indicate enteral feeding orders, flush orders, and observation for signs and symptoms of dehydration. 4. On 11/05/2021 through interviews with four (4) members of the Quality Assurance committee including the Director of Nursing (also the Infection Preventionist), the Acting Director of Nursing, the Administrator and the Registered Dietician and record review of facility Monthly Facility QA & A Minutes sign-in sheet dated 11/03/2021 at 3:45pm; the SA validated a meeting of the QA & A committee regarding the Immediate Jeopardy for failure to provide sufficient fluid intake, failure to provide residents enteral feedings as physician ordered, and failure to fully develop and implement a comprehensive, person-centered care plan to meet the resident needs. Two (2) policies were reviewed: 1) Tube feeding Policy and 2) Care Plan Policy. No revisions were formulated to the policies. The committee did, however, decide to implement collection of Registered Dietician recommendations upon completion by nursing staff per physician orders and will be retained by Medical Records for a minimum of one (1) year. Also added will be an enteral feeding audit daily on all residents with enteral feedings and water flushes by Director of Nursing and RN supervisory nurses to ensure accuracy and documentation of enteral feedings and water flushes on the medication administration record. 5. On 11/05/2021 through interview with Director of Nursing and record review of facility Evaluation of Dehydration Risk assessment forms for Residents #2, #3, #4, and #5, (and the other residents in facility on this date with feeding tubes) dated 11/04/2021, and observation of Residents #2, #3, #4, and #5 for signs and symptoms of dehydration, SA validated that 100% of residents in facility with feeding tubes were assessed for signs and symptoms of dehydration with no resident found with signs or symptoms of dehydration. 6. On 11/05/2021 through interview with Director of Nursing and record review of facility Physician Orders, facility Department Notes - Category - Dietary, and facility Daily Care Guide, SA validated 100% of residents requiring tube feedings are receiving enteral feedings and water flushes per Physician orders per Registered Dietician recommendations and are verifying sufficient fluid intake approaches on the person-centered comprehensive plan of care. 7. The SA validated on 11/05/2021 all corrective actions were completed as of 11/04/2021 and Immediate Jeopardy was removed on 11/04/2021 prior to exit.

Based on observations, staff interview, record review and facility policy review, the facility failed to follow the care plan for one (1) of six (6) residents reviewed for Activities of Daily Living (ADL) care and incontinent care. The faciilty's failure to follow the individualized care plan for Resident #6, for incontinent check/care every two (2) hours and as needed resulted in Resident #6 developing Moisture Associated Skin Damage to her sacral area. The facility also failed to clean fingernails and rinse the soap from a resident during a bed bath. Resident #6. Findings include: Record review of the facility policy titled Comprehensive Person Centered Care Plans with a history date of 3/18, revealed, POLICY: Each resident will have a person centered care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Record review of Resident #6's Care Plan, updated 8/3/21, Problem/Need: Resident is incontinent of bowel and bladder, and requires assistance with immobility, Risk for impaired skin integrity related to incontinence, immobility and wears large brief, nutritional deficiency. Goal and Target Date: Resident will have no complications to episodes of incontinence thru 10/2021. Skin will remain intact without reddened or open areas thru 10/2021. Approaches: . incontinent checks/care every 2 hours and prn (as needed) . Record review of Resident #6's Care Plan, updated 8/3/21, Problem/Need: Risk for further decline in self care r/t (related to) dx (diagnosis) of arthritis.Goal and Target Date: Resident will have no further decline in ADLs thru 10/2021. Approaches: Shower M (Monday), W (Wednesday), F (Friday) 7-3 .Provide incontinent check/care every two (2) hours and as needed . Observation on 8/10/21 at 1:17 PM, revealed Certified Nursing Assistant (CNA) #4 check and provide incontinent care for Resident #6. CNA #4 opened the front of the brief. The resident was wet and dirty with bowel movement (BM). The resident was noted with two (2) briefs on. Resident #6 entire buttocks appeared red. Interview on 8/10/21 at 1:32 PM, with CNA #4 confirmed that the Resident #6 had on two (2) briefs and that her bottom was red. Interview on 8/10/21 at 2:30 PM, with Registered Nurse (RN) #2 revealed that it is unacceptable for a resident to have two (2) briefs on because that can cause skin issues. She stated all residents get a bath or shower on the 7/3 shift and that Resident #6 should have gotten a bed bath today. Interview on 8/10/21 at 2:33 PM, with CNA #3 revealed that she was the CNA for Resident #6 today. She stated she did not put 2 briefs on the resident and that the 11/7 shift must have done it. She stated she went in the resident's room this morning and she did not look wet, and that the resident told her that she did not need anything. She stated she just pulled the cover back and looked at her brief and she did not realize she had 2 briefs on. CNA #3 admitted that she had not changed the resident or given her a bath today. Stated she has been at work all day. CNA #3 stated that not changing and turning the resident and not giving her a bath could cause her to have more breakdown. CNA #3 did not respond when the SA asked if she considered not providing incontinent care, turning the Resident, and not bathing the Resident to be neglect of the resident. Observation on 8/11/21 at 8:25 AM, revealed CNA #3 provided ADL care for Resident #6. CNA #3 prepared a pan of soapy water and placed it on the over bed table. CNA #3 used a soapy cloth to wash the resident's face. CNA #3 put the cloth back in the same pan and squeezed the cloth and washed the resident's upper arms, axilla, and the upper chest area. CNA #3 placed the cloth back in the pan of water and took a towel and dried the resident's arms, CNA #3 did not rinse the soapy water off Resident #6's face, arms, axilla, and upper chest area. CNA #3 opened the brief and folded the brief down between the resident's legs. CNA #3 used the same cloth and squeezed the soapy water out and began to wash the resident's front peri area. CNA #3 told the resident that she needed her to turn to the right and the resident turned with physical help from CNA #3 and held onto the siderail. CNA #3 used a couple of wipes to clean BM off the rectal area. CNA #3 used the same cloth and squeezed the soapy water off and washed the buttocks area. After CNA #3 washed the resident's buttocks, she placed a clean brief on the resident and did not rinse or dry her skin. CNA #3 then placed a clean gown on the resident. CNA #3 confirmed that she had completed the resident's bath and care for the morning, when asked by the SA. Interview on 8/11/21 at 8:40 AM, with CNA #3 confirmed that the bath she gave just now to Resident #6 was a complete bath. She stated she thought she washed everything when she gave the bath. She stated the water had very little soap in it and she used the towel to dry her off. She stated she guessed that the soap could irritate the skin if not rinsed off. On 8/11/21 at 8:45 AM, the SA asked RN #2 would she come look at Resident #6's bottom with the SA and she stated that she had looked at it yesterday after she had observed CNA #4's care for Resident #6 and she had on two (2) briefs. RN #2 stated that she saw that Resident #6's bottom was red. The SA asked RN #2 for us to go look at Resident #6's bottom today as she had just been changed. CNA #3 and RN #2 turned Resident #6 over and opened the brief and RN #2 stated that she could see how red her bottom was and the two (2) open areas on the right buttock. RN #2 stated that the wound doctor was scheduled to see her this afternoon. RN #2 agreed that the dried scaly skin that was around the open areas appeared as dried cream. Observation on 8/11/21 at 3:24 PM, revealed the Wound Physician present to perform a wound assessment on Resident # 6. The Wound Physician said the entire buttocks is Moisture Associated Skin Damage (MASD) with a denuded area on the right buttock. He recommended to consult with the attending physician to place a foley catheter in the resident to keep the urine from this area and to stop the calazinc treatment and begin using [MEDICATION(S)] to the entire bottom area. He stated he would not do a separate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 9:10 AM, with the Administrator revealed he terminated CNA #3 yesterday afternoon, 8/11/21, due to her negligence to provide adequate care to the Resident #6. Observation on 8/12/21 at 9:35 AM of Resident #6 fingernails remain with dirty substance under all her fingernails. Interview on 8/12/21 at 9:36 AM, with RN #2 revealed that any nurse can do nail care. RN #2 stated the CNA should ensure the nails are cleaned during their bath. She stated the RN is responsible for keeping the nails trimmed. Observation on 8/12/21 at 9:40 AM, with RN #2 as she examined Resident #6's fingernails. She stated all her fingernails have a dirty substance under them and need to be cleaned. Interview on 8/12/21 at 9:42 AM, with CNA #5 while in Resident #6's room revealed she had already completed the bed bath on Resident #6. CNA #5 confirmed that Resident #6's fingernails have a dirty substance under every one of them. She stated she does need to have them cleaned and that she should have done this with her bath. Interview on 8/12/21 at 11:40 AM, with the Director of Nursing (DON) revealed that nail care is part of the AM care, and that no resident should have dirty fingernails, especially after their bath. Phone interview on 8/12/21 at 12:10 P.M. with the wound physician related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound physician confirmed that being left double briefed and wet and soiled for a long period of time could have caused the MASD to the resident's sacrum. Stated he recommended to apply [MEDICATION(S)] and to consult with the attending physician to place a foley catheter for a few days to allow the area to be free of as much moisture as possible. Phone interview on 8/12/21 at 12:34 P.M. with the attending physician for Resident #6. The attending physician confirmed and agreed with the wound physician's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 12:40 PM, with DON revealed that ADL care and incontinence care is part of the CNA orientation and that it is part of the resident's care plan. She stated they are taught bed baths and incontinence care in orientation. Interview on 8/12/21 at 1:05 P.M. with DON revealed that she is aware of the MASD diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Stated this is unacceptable care. Record review of the facility Weekly Skin Audit dated 8/11/21 revealed Resident #6 with a new skin issue on her sacrum compared to the weekly skin audit documented on 8/4/21. Record review of the facility Wound Evaluation Form dated 8/11/21 revealed, a circle on the body diagram of the sacrum, Wound Type: MASD .Treatment reviewed and ordered clean with normal saline (NS), apply [MEDICATION(S)] oxide every (q) shift Size: length 24 centimeters by width of 24 centimeters .Comments: MASD noted during care .Document care plan interventions: incontinent care as needed, weekly body audit, and turn every two (2) hours and PRN (as needed). Record review of the Physician Orders on Resident #6 revealed a new order dated 8/11/21 to clean MASD to bilateral buttock with normal saline, pat dry, apply [MEDICATION(S)] oxide every shift until healed. Record review of the (Proper Name) Surgical Note dated 8/11/21 by wound physician under wound location: sacrum, under etiology; Moisture Associated Skin Damage, under provider comments: area of central denudation. Record review of the Face Sheet for Resident #6 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/13/21 for Resident #6 revealed, Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating Resident #6 had moderate cognitive impairment. Section G for Functional Status revealed requires limited assist of one (1) person for bed mobility with 1 person physical assistance; and extensive assistance of 1 person for personal hygiene. The MDS revealed that toilet use occurred only once or twice during the lookback period and required 1 person physical assistance.

Based on observations, staff interviews, record review, and facility policy review, the facility neglected to provide incontinent checks/care that resulted in Moisture Associated Skin Damage to the sacral area for one (1) of seven (7) residents reviewed for abuse and neglect. Resident #6. Findings include: Record review of the facility policy titled Abuse Prevention with revised date of 11/2017 revealed, Definitions . f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain . Observation on 8/10/21 at 1:17 PM revealed Certified Nursing Assistant (CNA) #4 check and provide incontinent care to Resident #6. CNA #4 opened the front of the brief. Resident #6 was wet and dirty with bowel movement (BM). The resident was noted with two (2) briefs on. When CNA #4 opened the brief, she rolled the 2 briefs down and BM was noted all over Resident #6's perineal area. CNA #4 cleaned Resident #6's buttocks using wipes. Resident #6's entire buttocks appear red. Interview on 8/10/21 at 1:32 PM, with CNA #4 confirmed that Resident #6 had on two (2) briefs and that her bottom was red. Interview on 8/10/21 at 2:30 PM, with Registered Nurse (RN) #2 revealed that it is unacceptable for a resident to have two (2) briefs on because that can cause skin issues. She stated all residents get a bath or shower on the 7/3 shift and that Resident #6 should have gotten a bed bath today. Interview on 8/10/21 at 2:33 PM, with CNA #3 revealed that she was the assigned CNA for Resident #6 today. She stated she did not put 2 briefs on the resident and that the 11/7 shift must have done it. CNA #3 stated she went into the resident's room this morning and she did not look wet, and that the resident told her that she did not need anything. She just pulled the cover back and looked at her brief and she did not realize she had 2 briefs on. CNA #3 admitted that she had not changed the resident or given her a bath today. She stated she has been at work all day. CNA #3 stated that not changing and turning the resident and not giving her a bath could cause her to have more breakdown. CNA #3 did not respond when the SA asked if she considered not providing incontinent care, turning the Resident, and not bathing the Resident to be neglect of the resident. On 8/11/21 at 8:45 AM, the SA asked RN #2 would she come look at Resident #6's bottom with the SA and she stated that she had looked at it yesterday after she had observed CNA #4's care for Resident #6 and she had on two (2) briefs. RN #2 stated that she saw that Resident #6's bottom was red. The SA asked RN #2 to go look at Resident #6's bottom today as she had just been changed. CNA #3 and RN #2 turned Resident #6 over and opened the brief and RN #2 stated that she could see how red her bottom was and the two (2) open areas on the right buttock. RN #2 stated that the wound doctor is scheduled to see her this afternoon. RN #2 agreed that the dried, scaly skin that was around the open areas appeared as dried cream. Observation on 8/11/21 at 3:24 PM, revealed the Wound Physician was present to perform a wound assessment on Resident # 6. The Wound Physician confirmed the entire buttocks is Moisture Associated Skin Damage (MASD) with a denuded area on the right buttock. He stated he recommended to consult with the attending physician to place a foley catheter in the resident to keep the urine from this area and to stop the calazinc treatment and begin using [MEDICATION(S)] to the entire bottom area. He stated he would not do a separate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 9:10 AM, with the Administrator (ADM) revealed he terminated CNA #3 yesterday afternoon, 8/11/21, due to her negligence to provide adequate care to Resident #6. Phone interview on 8/12/21 at 12:10 PM, with the Wound Physician related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he recommended to apply [MEDICATION(S)] and to consult with the attending physician to place a foley catheter for a few days to allow the area to be free of as much moisture as possible. Phone interview on 8/12/21 at 12:34 PM, with the attending physician for Resident #6 revealed the attending physician confirmed and agreed with the wound physician's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 12:40 PM, with the Director of Nursing (DON) revealed that ADL care and incontinence care is part of the CNA orientation. Record review of the personnel record for CNA #3 revealed competencies completed on 10/14/2020 for the following: Bath/shower, Bed bath, Handwashing, Incontinence care. Interview on 8/12/21 at 1:05 PM, with the DON revealed that she is aware of the MASD diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated this is unacceptable care and this is the reason why CNA #3 was terminated. Record review of the facility Weekly Skin Audit dated 8/11/21 revealed Resident #6 with a new skin issue on her sacrum compared to the weekly skin audit documented on 8/4/21. Record review of the facility Wound Evaluation Form dated 8/11/21 revealed, a circle on the body diagram of the sacrum, Wound Type: MASD .Treatment reviewed and ordered clean with normal saline (NS), apply [MEDICATION(S)] oxide every (q) shift Size: length 24 centimeters by width of 24 centimeters .Comments: MASD noted during care .Document care plan interventions: incontinent care as needed, weekly body audit, and turn every two (2) hours and PRN (as needed). Record review of the Physician Orders dated August 2021 for Resident #6 revealed a new order dated 8/11/21 to Clean MASD to bilateral buttock with normal saline, pat dry, apply [MEDICATION(S)] oxide every shift until healed. Record review of the (Proper Name) Surgical Note dated 8/11/21 by the Wound Physician revealed, Wound Location: sacrum, Etiology: Moisture Associated Skin Damage . Provider comments: area of central denudation. Record review of Resident #6's Care Plan, updated 8/3/21, Problem/Need: Resident is incontinent of bowel and bladder, and requires assistance with immobility, Risk for impaired skin integrity related to incontinence, immobility and wears large brief, nutritional deficiency. Goal and Target Date: Resident will have no complications to episodes of incontinence thru 10/2021. Skin will remain intact without reddened or open areas thru 10/2021. Approaches: . incontinent checks/care every 2 hours and prn (as needed) . Record review on 8/11/21 of the Daily Unit Management, revealed CNA #3 was assigned to care for Resident #6. Record review of the Face Sheet for Resident #6 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/13/21 for Resident #6 revealed, Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating Resident #6 had moderate cognitive impairment. Section G for Functional Status revealed requires limited assist of one person for bed mobility with 1 person physical assistance; and extensive assistance of 1 person for personal hygiene. The MDS revealed that toilet use occurred only once or twice during the lookback period and required 1 person physical assistance.

Based on observations, staff interviews, record review and facility policy review, the facility failed to provide incontinent care in a manner to prevent the occurrence of Moisture Associated Skin Damage (MASD), and failed to ensure fingernails were cleaned and skin was rinsed after a bed bath for one (1) of six (6) residents reviewed for Activities of Daily Living (ADL). Resident #6. Findings include: Record review of the facility policy titled Bed Bath with a date of 8/11 revealed POLICY: Bedfast residents will receive a bed bath daily. A bed bath also provides a mild form of exercise and allows observation of the resident to meet his psychosocial and physical needs . Procedure: .10. Bathe, rinse and dry face, ears, and neck. Ask resident if soap is desired. Give special attention to eyes, nose, and corners of mouth. After washing one eye, fold the washcloth over before washing other eye. 11.Remove gown. 12. Bathe, rinse, and dry farther arm, axilla, and hand; pay particular attention to nail beds and between fingers. 13. Bathe, rinse, and dry nearer arm, axilla and hand. 14. Place bathe towel over chest and fold bath blanket to abdomen. Avoid exposing resident. 15. Place bath towel, wash, rinse, and dry chest. 16. Fold blanket to pubis region. 17. Bathe rinse and dry abdomen. Give special care to umbilicus and deep folds of skin 19. Wash legs and feet. Bathe, rinse and dry .21. Bathe, rinse, and dry back from hairline to waist, then buttocks. Record review of the facility policy titled A.M. Care with a History: Comm 10/09 policy E. 1 revealed POLICY: A.M. Care will be given to residents daily. RESPONSIBILITY: All nursing assistants . PROCEDURE: .10. Provide nail care as needed. Observation on 8/10/21 at 1:17 PM, revealed Certified Nursing Assistant (CNA) #4 check and provide incontinent care to Resident #6. CNA #4 opened the front of the brief. Resident #6 was wet and dirty with bowel movement (BM). The resident was noted with two (2) briefs on. When CNA #4 opened the brief, she rolled the 2 briefs down and BM was noted all over Resident #6's perineal area. CNA #4 cleaned Resident #6's buttocks using wipes. Resident #6's entire buttocks appear red. Interview on 8/10/21 at 1:32 PM, with CNA #4 confirmed that the Resident #6 had on two (2) briefs and that her bottom was red. Interview on 8/10/21 at 2:30 PM, with Registered Nurse (RN) #2 revealed that it is unacceptable for a resident to have two (2) briefs on because that can cause skin issues. Stated all residents get a bath or shower on the 7/3 shift and that Resident #6 should have gotten a bed bath today. Interview on 8/10/21 at 2:33 PM, with CNA #3 revealed that she was the assigned CNA for Resident #6 today. She stated she did not put 2 briefs on the resident and that the 11/7 shift must have done it. CNA #3 stated she went into the resident's room this morning and she did not look wet, and that the resident told her that she did not need anything. She just pulled the cover back and looked at her brief and she did not realize she had 2 briefs on. CNA #3 admitted that she had not changed the resident or given her a bath today. She stated she has been at work all day. CNA #3 stated that not changing and turning the resident and not giving her a bath could cause her to have more breakdown. CNA #3 did not respond when the SA asked if she considered not providing incontinent care, turning the resident, and not bathing the resident to be neglect of the resident. Observation on 8/11/21 at 8:25 AM, revealed CNA #3 provided ADL care for Resident #6. CNA #3 prepared a pan of soapy water and placed it on the over bed table. CNA #3 used a soapy cloth to wash the resident's face. CNA #3 put the cloth back in the same pan and squeezed the cloth and washed the resident's upper arms, axilla, and the upper chest area. CNA #3 placed the cloth back in the pan of water and took a towel and dried the resident's arms, CNA #3 did not rinse the soapy water off Resident #6's face, arms, axilla, and upper chest area. CNA #3 opened the brief and folded the brief down between the resident's legs. CNA #3 used the same cloth and squeezed the soapy water out and began to wash the resident's front peri area. CNA #3 told the resident that she needed her to turn to the right and the resident turned with physical help from CNA #3 and held onto the siderail. CNA #3 used a couple of wipes to clean BM off the rectal area. CNA #3 used the same cloth and squeezed the soapy water off and washed the buttocks area. After CNA #3 washed the resident's buttocks, she placed a clean brief on the resident and did not rinse or dry her skin. CNA #3 then placed a clean gown on the resident. CNA #3 confirmed that she had completed the resident's bath and care for the morning, when asked by the SA. Interview on 8/11/21 at 8:40 AM, with CNA #3 confirmed that the bath she gave just now to Resident #6 was a complete bath and she thought she washed everything when she gave the bath. She stated the water had very little soap in it and she used the towel to dry her off. She stated she guessed that the soap could irritate the skin if not rinsed off. On 8/11/21 at 8:45 AM, the SA asked RN #2 would she come look at Resident #6's bottom with the SA and she stated that she had looked at it yesterday after she had observed CNA #4's care for Resident #6 and she had on two (2) briefs. RN #2 stated that she saw that Resident #6's bottom was red. The SA asked RN #2 for us to go look at Resident #6's bottom today as she had just been changed. CNA #3 and RN #2 turned Resident #6 over and opened the brief and RN #2 stated that she could see how red her bottom was and the two (2) open areas on the right buttock. RN #2 stated that the wound doctor is scheduled to see her this afternoon. RN #2 agreed that the dried scaly skin that was around the open areas appeared as dried cream. Observation on 8/11/21 at 3:24 PM, revealed Wound Physician present to perform a wound assessment on Resident # 6. The Wound Physician said the entire buttocks is Moisture Associated Skin Damage (MASD) with a denuded area on the right buttock. He recommended to consult with the attending physician to place a foley catheter in the resident to keep the urine from this area and to stop the calazinc treatment and begin using [MEDICATION(S)] to the entire bottom area. He stated he would not do a separate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 9:10 AM, with the Administrator revealed he terminated CNA #3 yesterday afternoon, 8/11/21, due to her negligence to provide adequate care to Resident #6. Observation on 8/12/21 at 9:35 AM, of Resident #6's fingernails remain with dirty substance under all her fingernails. Interview on 8/12/21 at 9:36 AM with RN #2 revealed that any nurse can do nail care. RN #2 stated the CNA should ensure the nails are cleaned during their bath. She stated the RN is responsible for keeping the nails trimmed. Observation on 8/12/21 at 9:40 AM, with RN #2 as she examined Resident #6's fingernails, she stated all her fingernails have a dirty substance under them and need to be cleaned. Interview on 8/12/21 at 9:42 AM, with CNA #5 while in Resident #6's room revealed she had already completed the bed bath on Resident #6. CNA #5 confirmed that Resident #6's fingernails have a dirty substance under every one of them. She stated she does need to have them cleaned and that she should have done this with her bath. Interview on 8/12/21 at 11:40 AM, with the Director of Nursing (DON) revealed that nail care is part of the AM care, and that no resident should have dirty fingernails, especially after their bath. Phone interview on 8/12/21 at 12:10 PM, with the Wound Physician related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he recommended to apply [MEDICATION(S)] and to consult with the attending physician to place a foley catheter for a few days to allow the area to be free of as much moisture as possible. Phone interview on 8/12/21 at 12:34 PM, with the Attending Physician for Resident #6, the Attending Physician confirmed and agreed with the wound physician's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/12/21 at 12:40 PM, with the DON revealed that ADL care and incontinence care is part of the CNA orientation and that this includes the fingernails. Interview on 8/12/21 at 1:05 PM, with DON revealed that she is aware of the MASD diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated this is unacceptable care and this is the reason why CNA #3 was terminated. Record review of the facility Weekly Skin Audit dated 8/11/21 revealed Resident #6 with a new skin issue on her sacrum compared to the weekly skin audit documented on 8/4/21. Record review of the facility Wound Evaluation Form dated 8/11/21 revealed, a circle on the body diagram of the sacrum, Wound Type: MASD .Treatment reviewed and ordered clean with normal saline (NS), apply [MEDICATION(S)] oxide every (q) shift Size: length 24 centimeters by width of 24 centimeters .Comments: MASD noted during care .Document care plan interventions: incontinent care as needed, weekly body audit, and turn every two (2) hours and PRN (as needed). Record review of Resident #6's Physician Orders revealed a new order dated 8/11/21 to clean MASD to bilateral buttock with normal saline, pat dry, apply [MEDICATION(S)] oxide every shift until healed. Record review of the (Proper Name) Surgical Note dated 8/11/21 by the Wound Physician revealed, Wound Location: sacrum, Etiology: Moisture Associated Skin Damage . Provider comments: area of central denudation. Record review of Resident #6's Care Plan, updated 8/3/21, Problem/Need: Resident is incontinent of bowel and bladder, and requires assistance with immobility, Risk for impaired skin integrity related to incontinence, immobility and wears large brief, nutritional deficiency. Goal and Target Date: Resident will have no complications to episodes of incontinence thru 10/2021. Skin will remain intact without reddened or open areas thru 10/2021. Approaches: . incontinent checks/care every 2 hours and prn (as needed) . Record review of Resident #6's Care Plan, updated 8/3/21, Problem/Need: Risk for further decline in self care r/t (related to) dx (diagnosis) of arthritis.Goal and Target Date: Resident will have no further decline in ADLs thru 10/2021. Approaches: Shower M (Monday), W (Wednesday), F (Friday) 7-3 .Provide incontinent check/care every two (2) hours and as needed . Record review on 8/11/21 of the Daily Unit Management revealed CNA #3 was assigned to care for Resident #6. Record review of the Face Sheet for Resident #6 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/13/21 for Resident #6 revealed, Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating Resident #6 had moderate cognitive impairment. Section G for Functional Status revealed requires limited assist of one (1) person for bed mobility with 1 person physical assistance; and extensive assistance of 1 person for personal hygiene and bathing. The MDS revealed that toilet use occurred only once or twice during the lookback period and required 1 person physical assistance.

Based on record review, staff interview, family interview, and complaint report review, the facility failed to ensure the safety and prevention of an accident of a resident who was discharged /transferred from the facility by dispensing medications that were prescribed for another resident upon discharge. The incorrect medications, which included Anti-hypertensive medications, were ingested by the resident during transport to the other facility, which resulted in the resident's drop in Blood Pressure (BP) and medical treatment from a local hospital. This affected one (1) of four (4) residents reviewed for discharge medications, Resident #7. Findings include: The facility did not submit a policy related to resident safety related to discharge. Review of facility's policy entitled Discharge Medications,dated 08/17, revealed medications are to be sent with the resident on discharge or out on pass based on state regulations and physician's orders [REDACTED]. The correct directions for use are written on a separate piece of paper. Discharge medications are counted or the volume of liquid estimated and the discharging nurse enters the following information on the discharge form: Date, Pharmacy name and prescription number, Name and strength of each medication, and Quantity or amount. During a telephone interview on 08/08/17 at 1:30 PM, Resident #7's daughter revealed that on 08/2/17 at approximately 08:15 AM, she arrived at the facility to pick her mom up to transfer to a facility closer to home. The resident's daughter said her mother had not received her morning medications or breakfast. The daughter revealed she signed two (2) different forms to get the medication from the nurse, which were sent in two (2) different bags. The daughter claimed the discharging nurse did not give her any instructions on the discharge medications. Resident #7's daughter stated they left the facility enroute to the other facility, which was 113 miles away, and when they were about 40 miles from the receiving facility, the daughter asked the mother to take her 9:00 AM medications and to take everything that said 9:00 AM on the package. The daughter stated that Resident #7 tore the packages open and took the medications. The daughter said, Mom knows her medicine and can see well. The daughter stated that when they arrived at the receiving facility, her mom (Resident #7) was out of it and could not stand up. The daughter revealed the receiving facility attempted to get a blood pressure on Resident #7, but thought blood pressure machine was broken because it would not register. The daughter revealed the receiving facility could not keep her mother awake. The daughter revealed the facility realized her mother was given the wrong medications after the nurse at the receiving facility reconciled the medications. Resident #7's daughter said she had the empty medication wrappers of the incorrect mediations sent with them by the facility, that her mother had ingested. The daughter stated the name on the medication wrappers was (Resident #4's name). Review of a faxed copy of the empty medication wrappers that Resident #7's daughter sent to the State Agency, revealed the medications that Resident #7 had ingested. The following medications were sent by the transferring facility with Resident #7, ingested by Resident #7, but were actually prescribed to Resident #4. These medications were verified and listed on Resident #4's Medication Administration Record, dated 08/2017. These medications included four (4) Cardiovascular/Anti-hypertensive medications, which lower the blood pressure and one (1) Thyroid medication. 1. Levothyrothyroxine 25 microgram (mcg) tablet 2. Carvedilol 12.5 mg tablet. 3. Amlodipine Besylate 10 mg Tablet 4. Clonidine 0.2 mg Tablet 5. Hydralazine 100 mg Tablet Review of the discharging facility's document entitled, Discharge Summary/Instructions, revealed under the medication section of the Discharge Summary, the discharging nurse checked a box yes that read Medication reconciliation performed of all pre-discharged meds with post discharge meds including over the counter? The Discharge summary was dated 08/02/17, and signed by Registered Nurse (RN) #2. During an interview, on 08/10/17 at 3:30 PM, RN #2 stated she filled out the discharge paper work the day before Resident #7 was discharged and also checked the yes box indicating that Resident #7's discharge medications had been reconciled. RN #2 revealed she also wrote a note on the Discharge Summary that read, See attached medication list. RN #2 revealed to her knowledge, the attached Medication List was not completed at the time and that another nurse would fill that part out. RN #2 did not verify how the medications were reconciled. During an interview on 08/09/17 at 3:15 PM, and 08/10/17 at 3:10 PM, Licensed Practical Nurse (LPN) #1 revealed on the morning of the discharge, 08/02/17 around 08:15 AM, Resident #7 came to her and said she was ready to be discharged and was in a hurry. She said she filled out the medication reconciliation form and asked LPN #2 to get Resident #7 a seven (7) day supply of medication out of the medication room. She stated that the medication comes from the pharmacy in a seven (7)-day bundle. LPN #1 said she handed the resident's daughter two (2) bags of medication and instructed her that one (1) of the bags contained this morning's medication and the other bag was the medication for the next seven (7) days and both were to be given to the facility. LPN #1 confirmed she did not count all the medications or look at the label of the bundled seven (7)-day supply handed to her. She stated that she estimated the amount of medication supply by taking the amount prescribed per day and multiplying by seven (7) days. LPN #1 said if she had counted the medications, she would have noticed the name difference on the labels. During a telephone interview on 8/25/17 at 4:05 PM, LPN #2 stated that she was asked by LPN #1 to get Resident #7's medication from the medication room to take with her to the other facility upon discharge. LPN #2 stated that she didn't normally work that floor and when she pulled the medication, she saw the resident's first name on the roll of medication and she pulled it out of the box and gave the roll of medications to LPN #1. LPN #2 stated that LPN #1 tried to explain the medication directions to Resident #7's daughter, but the daughter kept saying they were in a hurry. LPN #2 stated she pulled the morning medications for Resident #7 from the cart and put them in a zip-loc bag and gave them to LPN #1. LPN #2 stated she was not aware that she had pulled another resident's medication, instead of Resident #7's medications, until a few days after the incident occurred. Record review of facility's investigation, dated and signed by the Administrator on August 3, 2017, revealed the facility received a call from the other facility that Resident #7 had arrived with medications that had another resident's name (Resident #4). Review of a statement by LPN #1 revealed, The family kept rushing me stating she needed to leave so I asked (nurse's name) to get the meds from the room. (Nurse's Name) brought me a bundle of medications from the med room and I turned and handed to the family. A written statement from LPN #2, revealed that she pulled the wrapped sleeve of medications from the medication room and gave to LPN #1 for Resident #7 on the day of discharge to the other facility. Record review of the receiving facility's Nurse's notes, dated 8/2/17 at 1:34 PM, revealed Resident #7 arrived at the facility and would verbally respond but at the end of the assessment, she was asleep, easily aroused, and would fall back to sleep and snoring at times. Resident #7's blood pressure (BP) was 80/58. On 8/2/17 at 2:10 PM, the resident was in Trendelenburg position with a BP of 91/58. Nurses's notes on 8/2/17 at 3:42 PM, noted the resident's BP 80/58 and the physician was contacted and gave an order to give one (1) liter of Normal Saline; 500 cubic centimeters (cc's) bolus, then 100 cc's an hour to be given in the infusion lab (at the local hospital). On 8/2/17 at 4:30 PM, the Nurse's Note documented Resident #7's BP of 77/38 prior to transfer to the hospital infusion lab. The Nurse's Notes revealed on 8/2/17 at 10:30 PM, the Resident was sent back to the room with a blood pressure of 110/60 and verbally responsive. Review of a report from the local hospital, dated 8/2/17, revealed Resident #7 had a [DIAGNOSES REDACTED].#7 was noted to have a BP of 77/38 and IV fluids were infused, 500 cc bags, two (2) bags total, and the resident was sent back to the facility with a BP of 110/56 on 8/2/17 around 10:24 PM. Interview with the receiving facility's Director of Nursing (DON) on 8/10/17 at 8:40 AM, revealed Resident #7 arrived at the facility on 8/2/17 between 11:30 AM and 12:00 Noon and was slow to respond. The DON stated the resident's BP was 68/40 and when re-checked, it was 77/52. The DON stated that the Physician was notified and the resident was sent out and received IV fluids at the local hospital infusion lab. The DON stated that staff reported to her that the bundle of medications that were sent with the resident did not belong to her, they belonged to someone else and there were medications missing from the bundle. The DON confirmed the medications had Resident #4's name on the packages, which included Levothyrothyroxine, Carvedilol, Amlodipine, Clonidine and Hydralazine, which were missing for the 9:00 AM dose for 8/3/17. The DON stated she called the resident's daughter, who reported that the resident had taken nine (9) or 10 medications that were for the 9:00 AM time and a Narco (pain medication). The DON stated the name on the medications in the bundle was (Resident #4's name), and the doses for 9:00 AM were missing for 8/3/17. The DON stated that her Administrator called the discharging facility's Administrator to let her know the wrong medications were sent with Resident #7. During an interview on 08/10/17 at 2:30 PM, the discharging facility's DON revealed she was made aware of the mistake of Resident #7's medications when the RN supervisor called her on 08/02/17 about 6:15 PM. She was told that the facility had sent the wrong medication with Resident #7 to the receiving facility, that the medication belonged to (Resident #4's name). The DON said she was not told the condition of Resident #7. The DON said when a resident is discharged the Nurse fills out a form containing a list of the medications and the quantity. The DON revealed they do not count each medication. She stated the medications are in sealed packages. When asked how the medication was checked and reconciled if it was not counted, the DON replied, I don't know. The DON said the discharge summary is usually filled out the day before a planned discharge and two (2) different people usually fill out the discharge summary. The DON stated, We gave the wrong medication to the wrong person. She said she didn't know the patient ended up with emergency treatment until told by the Surveyor. During an interview on 08/08/17 at 4:15 PM, the facility Administrator acknowledged the facility gave the wrong medications to Resident #7 upon discharge to another facility, that the nurse got a stack of Resident #4's medications from the medication room and handed them to the discharging nurse, who gave them to the family of Resident #7 to take to the receiving facility. She revealed the two (2) residents had the same first names and were on the same floor but on opposite ends. The Administrator stated the facility realized they had made the mistake of giving Resident #7 the wrong medication on discharge when the daughter called. The facility admitted Resident #7 on 06/08/17, with [DIAGNOSES REDACTED]. Review of Resident #7's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 6/15/17, revealed a Basic Interview for Mental Status (BIMS) score as 15, which indicated no cognitive impairment.

Based on record review, facility policy review, staff interview, complaint report review, and family interview, the facility failed to dispense the correct medications to a resident transferring to another facility for one (1) of four (4) residents reviewed, Resident #7. Failure to dispense the correct medication resulted in Resident #7 ingesting another resident's medication, and receiving outside medical services for Hypotension (a drop in blood pressure). Findings Include: Review of facility's policy titled, Dispensing Pharmacy Services, revised 10/09, revealed Pharmaceutical services are available to provide the facility and residents with medications, services and related supplies/equipment. The Dispensing pharmacy agrees to supply the following pharmaceutical services. This includes but not limited to: Dispenses prescriptions accurately based on prescribers orders; Provide medications packaged according to facility policy; Label and dispense all medications according to all applicable laws; Assist the facility, as needed to establish appropriate packaging/ equipment to meet the needs of the facility/residents; and Provide medication information to the facility's nursing staff, when requested During a telephone interview on 08/08/17 at 1:30 PM, Resident #7's daughter stated that she arrived at the facility at 8:15 AM on 08/2/17, to transfer her mother to another facility, which was 113 miles away. The daughter said her mother had not received her morning medications or breakfast. The daughter revealed she signed two (2) different forms to get the medication from the nurse, which were sent in two (2) different bags. The daughter alleged the discharging nurse did not give any specific instructions on the discharge medications. The daughter stated that they were about 40 miles from their destination, when they stopped and the resident took all of the medications that were labeled for 9:00 AM. The daughter stated that her mother tore the packages open and took the medications. The daughter said, Mom knows her medicine and can see well. The daughter stated when they arrived at the new facility, her mom was out of it, and could not stand up. She stated that the staff attempted to get a blood pressure on Resident #7, but thought the blood pressure machine was broken because it would not register. The daughter stated that the receiving facility could not keep her mother awake and realized her mother was given the wrong medications after the nurse reconciled the medications and found that the medications that were sent were for another resident with the same first name. Resident #7's daughter said she had the empty medication wrappers for the incorrect mediations dispensed by the facility that her mother had ingested, which listed another resident's name, which was Resident #4. Review of the list of medications, faxed by Resident #7's daughter, revealed four (4) Cardiovascular/Anti-hypertensive medications and a Thyroid medication that was labeled with another resident's name (Resident #4), which had the same first name as Resident #7. The following medications were sent by the transferring facility with Resident #7 and ingested by Resident #7: 1. Levothyrothyroxine 25 microgram (mcg) tablet 2. Carvedilol 12.5 milligram (mg) tablet. 3. Amlodipine Besylate 10 mg Tablet 4. Clonidine 0.2 mg Tablet 5. Hydralazine 100 mg Tablet Review of the facility's document for Resident #7, entitled Discharge Summary/Instructions, revealed under the medication section, the nurse checked a box yes that read: Medication reconciliation performed of all pre-discharged meds with post discharge meds including over the counter? The Discharge summary was dated 08/02/17, and signed by Registered Nurse (RN) #2. During an interview on 08/10/17 at 3:30 PM, RN #2 stated she filled out the discharge paper work the day before Resident #7 was discharged and also checked the yes box indicating that Resident #7's discharge medications had been reconciled. RN#2 revealed she also wrote a note on the Discharge Summary that read, See attached medication list. RN #2 stated to her knowledge, the attached Medication List was not to be completed at the time and that another nurse would fill that part out. RN #2 did not say how or if she reconciled the resident's medication. Record review of facility document entitled, Discharge/Out on Pass Medication Form,dated 08/02/17, and signed by Licensed Practical Nurse (LPN) #1, listing all of the medications that were to be discharged with Resident #7. This form list each medication, dose, administration times and quantity of each medication sent to the other facility. These are the only medications that were to be dispensed upon transfer. This discharge document listed the following medications: [REDACTED] Mobic 15 mg, 1 tablet once a day, Quantity 7 Tradjenta 5 mg, 1 tablet by mouth daily, Quantity 7 Glimeperide 4 mg, 1 tablet by mouth daily, Quantity 7 Lasix 40 mg, 1 tablet by mouth daily, Quantity 7 Lidocaine 5% patch, 1 topically every day for 12 hours then remove, Quantity 30 Vitamin D 50,000 units, 1 tablet by mouth every week on Wednesday, Quantity 1 Neurontin 300 mg, one tablet by mouth every six hours, quantity 32 Metoprolol 25 mg, 1 tablet by mouth every 6 hours, quantity 16 Norco 7.5mg/325 mg, 1 tablet by mouth every 12 hours as needed, quantity 54 Carafate 1 gram, 1 tablet by mouth before meals and bedtime quantity 54 Levothyroxine 88 microgram (mcg), 1 tablet every morning , quantity 7 Protonix 40 mg, 1 tablet every morning, quantity 7 Novalog 100 unit/milliliter (ml) vial, per sliding scale before meals and according to scale, quantity 1 vial During an interview on 08/09/17 at 3:15 PM, and 08/10/17 at 3:10 PM , LPN #1 said she filled out the medication reconciliation form and asked another nurse to get Resident #7's seven (7) day supply of medication out of the medication room, which was LPN #2. LPN #1 said she handed the resident's daughter two (2) bags of medication and instructed her that one (1) of the bags contained this morning's medication and the other bag was the medication for the next seven (7) days and both were to be given to the facility. LPN #1 confirmed she did not count all the medications or look at the label of the bundled seven (7)-day supply handed to her. She stated that she estimated the amount of medication supply by taking the amount prescribed per day and multiplying by seven (7) days. LPN #1 said if she had counted the medications, she would have noticed the name difference on the labels. During a telephone interview on 8/25/17 at 4:05 PM, LPN #2 stated that she was asked by LPN #1 to get Resident #7's medication from the medication room to take with her to another facility. LPN #2 stated that she didn't normally work that floor and when she went through the box which held about 60 other resident's medications for the week, she saw the resident's first name on a roll of medication, she pulled it out and gave the roll to LPN #1. LPN #2 stated that LPN #1 tried to explain the medication directions to Resident #7's daughter, but the daughter kept saying they were in a hurry. LPN #2 stated she was not aware that she had pulled another resident's medication, instead of Resident #7's medications, until a few days after the incident occurred. LPN #2 stated that the normal procedure was to verify the medications with the physician's orders [REDACTED]. Record review of facility's investigation, dated and signed by the Administrator on August 3, 2017, revealed the facility received a call from the receiving facility that Resident #7 had arrived with medications that had another resident's name (Resident #4). Review of a statement by LPN #1 revealed, The family kept rushing me stating she needed to leave so I asked (nurse's name) to get the meds from the room. (Nurse's Name) brought me a bundle of medications from the med room and I turned and handed to the family. A written statement from LPN #2, revealed that she pulled the wrapped sleeve of medications from the medication room and gave to LPN #1 for Resident #7 on the day of discharge to the other facility. Record review of the receiving facility's Nurse's notes, dated 8/2/17 at 1:34 PM, revealed Resident #7 arrived at the facility and verbally responded but at the end of the assessment she was asleep, easily aroused, and would fall back to sleep, snoring at times. Resident #7's blood pressure (BP) was 80/58. On 8/2/17 at 2:10 PM, the resident was in Trendelenburg position with a BP of 91/58. Nurses's notes on 8/2/17 at 3:42 PM, noted the resident's BP was 80/58 and the physician was contacted and gave an order to give one (1) liter of Normal Saline; 500 cubic centimeters (cc's) bolus, then 100 cc's an hour to be given in the infusion lab (at the local hospital). On 8/2/17 at 4:30 PM, the Nurse's Note documented Resident #7's BP of 77/38 prior to transfer to the hospital infusion lab. Documentation on 8/2/17 at 10:30 PM, revealed the Resident was sent back to the room with a blood pressure of 110/60 and verbally responsive. Review of a report from the local hospital, dated 8/2/17, revealed Resident #7 had a [DIAGNOSES REDACTED].#7 was noted to have a BP of 77/38 and Normal Saline IV fluids were infused until around 10:24 PM, when the resident was sent back to the facility with a BP of 110/56. A total of 1 liter of fluids was administered. Interview with the receiving facility's Director of Nursing (DON) on 8/10/17 at 8:40 AM, revealed Resident #7 arrived at the facility on 8/2/17, between 11:30 AM and 12:00 noon, and was slow to respond. The DON stated the resident's BP was 68/40 and when re-checked, it was 77/52. The DON stated that the Physician was notified and the resident was sent to the local hospital for IV fluids. The DON stated that Resident #7 arrived at the facility with the wrong medications that was sent from the discharging facility in a bundle. The DON stated the name on the medication wrappers belonged to (Resident #4's name). The DON stated there were medications missing from the bundle and confirmed the medications missing for the 9:00 AM dose for 8/3/17, included Levothyrothyroxine, Carvedilol, Amlodipine, Clonidine and Hydralazine. The DON stated she called the resident's daughter, who reported that the resident had taken nine (9) or 10 medications that were for the 9:00 AM time and a Narco (pain medication). During an interview on 08/10/17 at 2:30 PM, the discharging facility's DON revealed she was made aware of the mistake of Resident #7's medications when the RN supervisor called her on 08/02/17 about 6:15 PM. She was told that the facility had sent the wrong medication with Resident #7 to the receiving facility, that the medication sent belonged to (Resident #4's name). The DON said when a resident is discharged the Nurse fills out a form containing a list of the medications and the quantity. The DON revealed they do not count each medication. She stated the medications are in sealed packages. When asked how the medication was checked and reconciled if it was not counted, the DON replied, I don't know. The DON said the discharge summary is usually filled out the day before a planned discharge and two (2) different people usually fill out the discharge summary. The DON stated, We gave the wrong medication to the wrong person. She said she didn't know the patient ended up with any type of treatment until told by the Surveyor. During an interview on 08/08/17 at 4:15 PM, the facility Administrator acknowledged the facility gave the wrong medications to Resident #7 upon discharge to another facility, that the nurse got a stack of Resident #4's medications from the medication room and handed them to the discharging nurse, who gave them to the family of Resident #7 to take to the receiving facility. She revealed the two (2) residents had the same first names and were on the same floor but on opposite ends. The Administrator stated the facility realized they had made the mistake of giving Resident #7 the wrong medication on discharge when the daughter called. During a telephone interview 08/10/17 at 1:40 PM, the Director of Pharmacy for the pharmacy services provider, revealed he was not sure what the facility's policy was for discharging medication to residents. He stated, I stay in a pharmacy in a separate building, receive the facility's orders and send the medication back to them. I'm not sure what happens when they leave the facility. During an interview on 08/10/17, the Consulting Pharmacist was asked the procedure for dispensing medication for discharged or transferred residents. He revealed that they just send the medication with the resident if Medicaid or Medicare has paid for them. He stated that the nurse should reconcile the medications, count and document. He stated that the receiving party should sign out the dispensed medications. The facility admitted Resident #7 on 06/08/17, for an Artificial Shoulder, Gout, Hypertension and Diabetes Type II. Review of Resident #7's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/15/17, revealed a Basic Interview for Mental Status (BIMS) score as 15, indicating no cognitive deficit.

Based on staff interview, facility policy review, family interview, and complaint review, the facility failed to follow the plan of care related to discharge instructions and medications for one (1) of six (6) resident care plans reviewed, Resident #7. Resident #7 was given a package of another resident's medication upon discharge, which she ingested on the way to another facility, which resulted in a drop in blood pressure that was treated at a local hospital. Findings include: Review of facility policy entitled Comprehensive Person Centered Care Plans, revision ,[DATE], revealed each resident will have a plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care. Review of Resident #7's plan of care for discharge, revealed under problem onset dated [DATE], that Resident #7 has a potential for decline in psychosocial wellbeing. Discharge plans are to transfer to a facility closer to her hometown when a bed becomes available. Review of this plan of care revealed a goal listed as Residents mental, medical and psychological well-being will be maintained and resident will be discharged upon bed availability. Intervention included to give the family a copy of the discharge summary detail. Review of the care plan for Resident is receiving 9 or more medications, initiated [DATE], revealed an intervention to administer medications as ordered. Review of a complaint, received on [DATE], submitted by Resident #7's daughter, revealed the facility gave her mother the wrong medication, which belonged to another resident with the same first name, upon discharge to another facility. This caused the resident's blood pressure to drop significantly. The complaint form documented that the resident could have died from this careless mistake. During a telephone interview on [DATE] at 1:30 PM, Resident #7's daughter stated that on [DATE] at approximately 08:15 AM, she arrived at the facility to pick her mom up to transfer to a facility closer to home. The daughter said her mother had not received her morning medications or breakfast. The daughter revealed she receive medication from the nurse, which were in two (2) different bags. The daughter revealed when they were about 40 miles from their destination, Resident #7 opened the bags of medication and took all of the medications that had 9:00 AM on the package. The daughter revealed when they arrived at the new facility, her mom was out of it, and could not stand up. The daughter revealed the receiving facility attempted to get a blood pressure on Resident #7 and thought that the machine was broken because it would not register. The daughter revealed the receiving facility could not keep her mother awake. The daughter revealed the facility realized her mother was given the wrong medications after the nurse at the receiving facility reconciled the medications. Resident #7's daughter said she had the empty medication wrappers of the incorrect mediations sent with them by the facility that her mother had ingested, that were prescribed for another resident. Review of a fax, sent by Resident #7's daughter, revealed a copy of the empty medication wrappers that was sent with Resident #7 on the day of discharge from the facility, which indicated what medications the resident had ingested. The following medications were dispensed by the transferring facility for Resident #7, ingested by Resident #7, but actually were prescribed to Resident #4. (These medications are also listed on Resident #4's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 25 microgram (mcg) tablet 2. Carvedilol 12.5 milligram (MG) tablet. 3. [MEDICATION NAME] 10 MG Tablet 4. [MEDICATION NAME] 0.2 mg Tablet 5. [MEDICATION NAME] 100 MG Tablet Interview with the receiving facility's Director of Nursing (DON) on [DATE] at 8:40 AM, confirmed that Resident #7 arrived at the facility on [DATE] between 11:30 AM and 12:00 noon and was slow to respond with a BP of ,[DATE]. The DON stated that the Physician was notified and the resident was sent out and received IV fluids. The DON stated that staff reported to her that the bundle of medications that were sent with the resident did not belong to her, they belonged to someone else and there were medications missing from the bundle. The DON confirmed the medications had Resident #4's name on the packages, which included [MEDICATION NAME], Carvedilol, [MEDICATION NAME] and [MEDICATION NAME], which were missing for the 9:00 AM dose for [DATE]. The DON stated that her Administrator called the discharging facility's Administrator to let her know the wrong medications were sent with Resident #7. Record review of receiving facility's nurse's notes, dated [DATE] at 1:34 PM, revealed Resident #7 arrived at the facility and at the end of her initial assessment was asleep, easily aroused, and would fall back to sleep with snoring at times and the resident's blood pressure was ,[DATE]. The Nurse's Note revealed at 3:42 PM on [DATE], that Resident #7's blood pressure was ,[DATE] and the resident continued to be sleepy and drowsy. The physician was contacted and gave an order to give 500 cubic centimeters (ccs) of Normal Saline bolus Intravenously (IV), then 100 cc's an hour to be given in the infusion lab. The nurse's notes reveal on [DATE] at 10:30 PM, the Resident was sent back to room with a blood pressure of ,[DATE]. During an interview on [DATE] at 10:30 AM, The Minimum Data Set (MDS)/Care Plan Nurse, revealed that care plans were a guide to help caregivers of different disciplines to care for the residents. She stated, When residents arrive at the facility, we initiate the care plan process. We don't know at the time of admission the complete discharge plans of the resident. She stated the the nurses should follow the instructions on the discharge summary as part of following the care plan. The facility admitted Resident #7 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Basic Interview for Mental Status (BIMS) score as 15, which indicated no cognitive impairment. .

Based on staff interview, family interview, family complaint review, facility record review, and facility policy review, the facility failed to sufficiently prepare and carry out a safe and orderly transfer of a resident in a manner to avoid anxiety, discomfort, and outside medical treatment by not following the protocol of counting and verifying medication and reviewing the medication with the resident and/or family upon discharge/transfer to another facility. The facility sent the incorrect medications with the resident, which she ingested, resulting in the resident being treated at the local hospital for [MEDICAL CONDITION] with Intravenous (IV) fluids. This occurred for one (1) of four (4) transferred/discharged residents, Resident #7. Findings include: Review of facility policy entitled Discharge Plan/Summary-(voluntary), dated ,[DATE], revealed an interdisciplinary summary is completed on a resident upon discharge to home or other nursing facility to assure the continuum care needs of the resident are met. Upon notification, the interdisciplinary team should be notified to allow staff the opportunity to educate and implement safe discharge. The Guidelines for completion of the discharge summary includes: Nursing: Identifies continuing nursing needs. Specifies level of nursing care needed. Verified resident/family understanding of orders including all medications prescribed by the physician. Review of facility policy entitled Discharge Medications, dated ,[DATE], revealed medications are sent with the resident upon discharge only under conditions that protect the resident and ensure compliance with the law. Medications are sent with the resident on discharge or out on pass based on state regulations and the physician's orders [REDACTED]. When needed by resident or responsible party, handwritten directions may be given to the resident or responsible party, not affixed to the container and may be hand written on a separate piece of paper. If the discharging nurse is unable to answer any specific questions about these medications, the dispensing pharmacy can be contacted for the information before releasing the medications. discharged medications are counted or the volume of liquid estimated and the discharging nurse enters the following information on the discharge form: Date, Pharmacy name and prescription number, Name and strength of each medication, and Quantity or amount. Both the nurse and the recipient sign the form acknowledging communication of the information. Review of a Revised Facility Policy, dated ,[DATE], entitled: Discharge Medications, revealed the labels of discharge medications are verified for completeness and accuracy by checking them against the most recent physician's orders [REDACTED]. If current directions for use are not the same as those on the discharge label, the correct directions for use are written on a separate sheet of paper. Review of a written complaint, received on [DATE], revealed upon transfer from the facility, Resident #7 was given the wrong medication, which belonged to another resident with the same first name as Resident #7. The [AGE] year-old discharged resident (Resident #7), was given the incorrect medication that caused her blood pressure to drop. The complaint noted that the receiving facility caught the error with the mix up of medication. The complainant stated that her mother could have died from this careless mistake. During a telephone interview on [DATE] at 1:30 PM, Resident #7's daughter revealed on [DATE] at approximately 08:15 AM, she arrived at the facility to pick her mom up to transfer to another facility. Resident #7's daughter said her mother had not received her morning medications or breakfast. The Daughter revealed her mother said she was not hungry. The daughter said she had to sign two (2) different forms to get the medication from the nurse, which were sent in two (2) different bags. The daughter claimed the discharging nurse did not give any instructions on the discharge medications and she and her mom left for the other facility, which was 113 miles away. The daughter said when they were about 40 miles from their destination, the daughter asked the mother to take her 9:00 AM medications and to take everything that said 9:00 AM on the package. She stated that her mother tore the bags open and took the medications. The daughter said, Mom knows her medicine and can see well. The daughter revealed when they arrived at the new facility, her mom (Resident #7) was out of it, and could not stand up. The daughter revealed the receiving facility attempted to get a blood pressure on Resident #7, but thought the blood pressure machine was broken because it would not register. The daughter revealed the receiving facility could not keep her mother awake. The daughter revealed the facility realized her mother was given the wrong medications after the nurse at the receiving facility reconciled the medications, she said it was for another resident with the same first name as her mother. Resident #7's daughter said she had the empty medication wrappers of the incorrect mediations sent with them by the facility that her mother had ingested, that was prescribed for another resident. Review of the document that Resident #7's daughter faxed to the State Agency, which was a copy of the empty medication wrappers dispensed for and ingested by Resident #7, and review of Resident #4's Medication Administration Record [REDACTED] Resident #4, and was also documented on Resident #4's Medication Administration Record. Per faxed report, the following medications were dispensed by the transferring facility and ingested by Resident #7, which included Cardiovascular/Anti-hypertensive medications and a [MEDICAL CONDITION] medication: 1. [MEDICATION NAME] 25 microgram (mcg) tablet 2. Carvedilol 12.5 Milligram (MG) tablet. 3. [MEDICATION NAME] 10 MG Tablet 4. [MEDICATION NAME] 0.2 MG Tablet 5. [MEDICATION NAME] 100 MG Tablet Review of Discharging facility document for Resident #7, entitled Discharge Summary/Instructions revealed under the medication section of the Discharge Summary, the discharging nurse checked a box yes that read Medication reconciliation performed of all pre-discharged meds with post discharge meds including over the counter? A handwritten note read, See attached medication list. (The medications listed were medications that the resident was prescribed). The Discharge summary was dated [DATE], and signed by Registered Nurse (RN) #2. During an interview on [DATE] at 3:30 PM, RN #2 stated she filled out the discharge paper work the day before Resident #7 was discharged and also checked the yes box indicating that Resident #7's discharge medications had been reconciled. RN #2 revealed she also wrote a note on the Discharge Summary that read, See attached medication list. RN #2 revealed, to her knowledge, the attached Medication List was not completed at the time and that another nurse would fill that part out. RN #2 did not acknowledge how the medications were reconciled when she checked the yes box on the discharged for m. Record review of the facility document entitled Discharge/Out on Pass Medication Form, dated [DATE], listing all of the medications that were to be discharged with Resident #7, was written and signed by Licensed Practical Nurse (LPN) #1. This form listed each medication, dose, administration times and quantity of each medication sent to the other facility. The medications on this list were the only medications to be dispensed to the receiving facility. The discharge document listed the following medications: [REDACTED] [MEDICATION NAME] 15 mg, 1 tablet once a day, Quantity 7 [MEDICATION NAME] 5 MG, 1 tablet by mouth daily, Quantity 7 Glimeperide 4 MG, 1 tablet by mouth daily, Quantity 7 [MEDICATION NAME] 40 MG, 1 tablet by mouth daily, Quantity 7 [MEDICATION NAME] 5% patch, 1 topically every day for 12 hours then remove, Quantity 30 Vitamin D 50,000 units, 1 tablet by mouth every week on Wednesday, Quantity 1 [MEDICATION NAME] 300 MG, one tablet by mouth every six hours, quantity 32 [MEDICATION NAME] 25 MG, 1 tablet by mouth every 6 hours, quantity 16 [MEDICATION NAME] 7.5 mg/325 mg, 1 tablet by mouth every 12 hours as needed, quantity 54 [MEDICATION NAME] 1 gram, 1 tablet by mouth before meals and bedtime quantity 54 [MEDICATION NAME] 88 MCG, 1 tablet every morning, quantity 7 [MEDICATION NAME] 40 MG, 1 tablet every morning, quantity 7 Novalog 100 unit/ml vial, per sliding scale before meals and according to scale, quantity 1 vial During an interview on [DATE] at 3:15 PM, and [DATE] at 3:10 PM, LPN #1 revealed she did not give Resident #7's 9:00 AM medications because she was not the medication nurse and did not have the keys to the medication cart or medication room. LPN #1 revealed on the morning of the discharge, [DATE] around 08:15 AM, Resident #7 came to her and said she was ready to be discharged and was in a hurry. She said she filled out the medication reconciliation form and asked another nurse to get Resident #7's seven (7) day supply of medication out of the medication room. LPN #1 said the daughter came to her a second time and already had Resident #7 in the car. LPN #1 said she handed the Resident's Daughter two (2) bags of medication and instructed her that one (1) of the bags contained this morning's medication and the other bag was the medication for the next seven (7) days and both were to be given to the facility. LPN #1 said she tried to explain the medications to the Resident's Daughter for the discharge/transfer and the Daughter she did not have time and there was no need because she was going to another facility. LPN #1 confirmed she did not count all the medications or look at the label of the bundled 7-day supply handed to her. She estimated the amount of medications supply by taking the amount prescribed per day and multiplying by 7 (seven) days. LPN #1 said if she had counted the medications, she would have noticed the name difference on the labels. During a telephone interview on [DATE] at 4:05 PM, LPN #2 stated that Resident #7 refused to take her morning medications because she was in a hurry to leave, so she pulled them from the cart and put them in a zip-loc bag and gave them to LPN #1. LPN #2 stated that she didn't normally work that floor and didn't know Resident #7, but was told by a Certified Nursing Assistant (CNA) who the resident was when she brought her to the medication cart to get her medications. LPN #2 stated that LPN #1 asked her to get the weekly medications for the resident to take with her to the other facility. LPN #2 stated she went to the med room and started looking through the box where 60 resident's medications had been brought in for the week and when she saw the first name of the resident she pulled it out and handed it to LPN #1. She stated she heard LPN #1 trying to explain to the daughter about the medications and heard her tell the daughter to give the week's worth of medications to the facility and the AM medications for that days were in the zip-loc bag, but the daughter kept saying they were in a hurry. LPN #2 stated that the normal procedure for discharging a resident was to verify the medications with the physician's orders [REDACTED].#1 much chance to do that. Record review of facility's investigation, dated and signed by the Administrator on [DATE], revealed the facility received a call from the receiving facility that Resident #7 had arrived with medications that had another resident's name (Resident #4). Review of a statement by LPN #1 revealed, The family kept rushing me stating she needed to leave so I asked (nurse's name) to get the meds from the room. (Nurse's Name) brought me a bundle of medications from the med room and I turned and handed to the family. A written statement from LPN #2, revealed that she pulled the wrapped sleeve of medications from the medication room and gave to LPN #1 for Resident #7 on the day of discharge to the other facility Record review of the receiving facility's Nurse's notes, dated [DATE] at 1:34 PM, revealed Resident #7 arrived at the facility and would verbally respond but at the end of the assessment, she was asleep, easily aroused, and would fall back to sleep and snoring at times. Resident #7's blood pressure (BP) was ,[DATE]. At 2:10 PM the resident was in Trendelenburg position and BP ,[DATE]. Nurses's notes on [DATE] at 3:42 noted the resident's BP ,[DATE] and the physician was contacted and gave an order to give one (1) liter of Normal Saline; 500 cubic centimeters (cc's) bolus then 100 cc's an hour to be given in the infusion lab. At 4:30 PM the Nurse's Note documented Resident #7's BP ,[DATE]. The nurse's notes revealed on [DATE] at 10:30 PM, the Resident was sent back to the room with a blood pressure of ,[DATE] and verbally responsive. Review of a report from the local hospital, dated [DATE], revealed Resident #7 had a [DIAGNOSES REDACTED].#7 was noted to have a BP of ,[DATE] and IV fluids were infused, 500 cc bags, two (2) bags total, and the resident was sent back to the facility with a BP of ,[DATE]. Interview with the receiving facility's Director of Nursing (DON) on [DATE] at 8:40 AM, revealed Resident #7 arrived at the facility on [DATE] between 11:30 AM and 12:00 Noon and was slow to respond. The DON stated the resident's BP was ,[DATE] and when re-checked was ,[DATE]. The DON stated that the Physician was notified and the resident was sent out and received IV fluids at the local hospital's infusion lab. The DON stated that staff reported to her that the bundle of medications that were sent with the resident did not belong to her, they belonged to someone else and there were medications missing from the bundle. The DON confirmed the medications had Resident #4's name on the packages, which included [MEDICATION NAME], Carvedilol, [MEDICATION NAME] and [MEDICATION NAME], which were missing for the 9:00 AM dose for [DATE]. The DON stated she called the resident's daughter, who reported the resident had taken nine (9) or 10 medications that were for the 9:00 AM time and a Narco (pain medication). The DON stated the name on the medications in the bundle was (Resident #4's name), and the doses for 9:00 AM were missing for [DATE]. The DON stated that her Administrator called the discharging facility's Administrator to let her know the wrong medications were sent with Resident #7. During an interview on [DATE] at 2:30 PM, the discharging facility's DON revealed she was made aware of the mistake of Resident #7's medication on discharge when the RN supervisor called her on [DATE] about 6:15 PM. She was told that the facility had sent the wrong medication with Resident #7 to the receiving facility, that the medication sent belonged to (Resident #4's name). The DON said she was not told the condition of Resident #7. The DON said when a resident is discharged the Nurse fills out a form containing a list of the medications and the quantity. The DON revealed they do not count each medication. She stated the medications are in sealed packages. When asked how the medication was checked and reconciled if it was not counted, the DON replied, I don't know. The DON said the discharge summary was usually filled out the day before a planned discharge and two (2) different people usually filled out the discharge summary. The DON stated, We gave the wrong medication to the wrong person. She said she didn't know the patient ended up with emergency treatment until told by the Surveyor. During an interview on [DATE] at 4:15 PM, the facility Administrator acknowledged the facility gave the wrong medications to Resident #7 upon discharge to another facility, that the nurse got a stack of Resident #4's medications from the medication room and handed them to the discharging nurse, who gave them to the family of Resident #7 to take to the receiving facility. She revealed the two (2) residents had the same first names and were on the same floor but opposite ends. The Administrator stated the facility realized they had made the mistake of giving Resident #7 the wrong medication on discharge when the daughter called. The facility admitted Resident #7 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's Minimal Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.