Every finding on record at Milford Center

Based on interview and record review, it was determined that for one (R7) out of two residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include:Review of R7's clinical record revealed:2/3/26 - R7 was admitted to the facility.2/6/26 11:31 AM - A BIM's assessment was completed for R7 with a score of 15 indicating R7 was cognitively intact.2/6/26 11:34 AM - An admission Social Services Assessment was completed and documented that R7 did not have an Advanced Directive (AD) in place and opportunity to complete AD was marked No. 3/2/26 10:26 AM - During an interview, R7 stated that he did not have an AD and the facility did not offer to assist with formulating one. 3/3/26 9:16 AM - During an interview, E7 (SW) stated that the expectation was to complete the assessment with the resident and if they do not have an AD to offer to assist enacting one. E7 confirmed based on the assessment for R7 that the right to formulate an AD was not offered.3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on interview and record review, it was determined that for one (R8) out of five residents sampled for medication review, the facility failed to ensure that the resident was free from unnecessary meds. Findings include: Review of R8's clinical record revealed:7/12/23 - R8 was admitted to the facility.10/8/24 - A physician's order for R8 documented Trazodone 50 mg give 0.5 tablet by mouth at bedtime for insomnia. 1/10/25 - A physician's order for R8 documented Seroquel 12.5 mg give by mouth at bedtime for schizoaffective disorder.11/13/25 9:07 AM - A provider's progress note documented for R8 to initiate GDR of Seroquel. 11/13/25 8:00 PM - A physician's order for R8 documented Trazadone 50 mg give one tablet by mouth at bedtime for insomnia. 11/13/25 7:48 PM - An IDT progress note documented that R8, had no change in behaviors, no increase or change in medications in the last 30 days, and pharmacy recommendation to GDR: noted will attempt when resident [R8] is clinically stable. [R8] is currently on Seroquel and Trazodone 50 mg.3/4/26 11:43 AM - During an interview, E8 (CNA) stated that if a resident had insomnia, staff are expected to monitor them and maintain safety while the resident is awake and stated that CNA's do not document sleep patterns, including times, or frequency of awakenings.3/4/26 12:04 PM - During an interview, E9 (LPN) stated that staff are expected to monitor residents with insomnia and document any non-pharmacological interventions in the progress notes. E9 also stated that nurses should document how often a resident is awake during the night and duration of time the resident remains awake. 3/6/26 9:13 AM - During an interview, E14 (NP) stated that staff should monitor and document residents' sleep patterns and interventions, specifically residents taking medications to assist with sleep. E14 also stated that if residents have a change in patterns that the provider should be notified to address those changes. E14 confirmed that R8 was on a GDR of Seroquel and stated that typically when one medication is decreased, another medication may be increased to offset the decrease. E14 stated the reason was to decrease polypharmacy and overuse of psychotropic medications; however, in this case, E14 stated she was not sure the reason for the increase in the Trazodone. According to E14, R8 was stable on the combination of medication and did not have increased behaviors or concerns. The facility failed to monitor and document effectiveness of medications used for sleep and failed to document the rationale for increase of Trazodone for R8. 3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on observation, interview, and record review, it was determined that for one resident (R42) out of 37 residents in the investigative sample, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's dental, vision, and hearing status. Findings include:Review of R42's clinical record revealed:8/21/25 - A facility Clinical admission Assessment included a dental assessment section with options to document dental status such as having natural teeth, dentures, or no natural teeth (edentulous). The assessment also included components to evaluate oral/dental status such as cavities, broken teeth, oral abnormalities, gum condition, and mouth pain. A review of the assessment revealed the oral/dental examination was documented as not assessed/no information.8/28/25 - The admission MDS assessment documented in Section B (Hearing, Speech, and Vision) that R42's hearing and vision were adequate. The assessment documented a BIMS score of 15, indicating the resident was cognitively intact. Section L (Oral/Dental Status) was coded as none of the above.11/28/25 - A quarterly MDS documented that R42 had adequate hearing, no hearing aid, adequate vision, and no corrective lenses. 2/26/26 - A quarterly MDS documented that R42 had adequate hearing, no hearing aid, adequate vision, and no corrective lenses. 3/2/26 8:59 AM - During observation and interview, R42 was asked if he had any dental concerns. R42 stated, I have told them I need to go to the dentist, and I don't have any teeth. During the interview, R42 frequently stated huh and was observed holding his hand to his left ear when questions were asked. Questions had to be repeated, and the interviewer had to raise their voice for R42 to hear and respond.3/9/26 12:02 PM - During an interview, E17 (MDS Coordinator) confirmed that R42 had been coded on the MDS as having no issues with hearing or vision. E17 reviewed the Physical Therapy (PT) and Occupational Therapy (OT) evaluations, which documented hearing loss. E17 stated the MDS assessments would need to be updated to reflect accurate information.3/9/26 12:10 PM - During an interview, E16 (Physical Therapist) stated the initial evaluation documented hearing loss in the left ear during the admission assessment. E16 stated this information is not routinely reported to nursing unless the deficit affects therapy participation.3/9/26 3:00 PM - The findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on interview and record review, it was determined that for one (R8) out of 37 residents in the investigative sample, the facility failed to develop a comprehensive care plan with measurable goals and person centered interventions. Findings include:Review of R8's clinical record revealed:7/12/23 - R8 was admitted to the facility. 4/10/25 - A care plan documented that R8 experiences sleep pattern disturbances as evidenced by insomnia with the following interventions: increase daytime activity, maintain bedtime preferred by resident, and provide an environment that is conducive to the resident's ability to get adequate sleep and maintain preferred sleep/wake schedule. The goal documented R8 will maintain a pattern of sleep sufficient to promote health and well-being throughout the review period. 3/4/26 12:04 PM - During an interview, E9 (LPN) stated that the expectation is for nurse's to document in progress notes any non-pharmacological interventions used to assist resident's who have insomnia and those interventions should be documented in the care plan. E9 also stated that care plans should have measurable goals and interventions should be person centered. 3/6/26 11:12 AM - During an interview, E2 (Director of Nursing) confirmed that the care plan was initiated but lacked person centered interventions related to R8's insomnia. 3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on record review and interview, it was determined that for one (R42) out of twenty-seven residents in the investigative sample, the facility failed to ensure services were provided in accordance with professional standards of quality by allowing a Licensed Practical Nurse (LPN) to complete admission assessments that are required to be completed by a Registered Nurse (RN) under the Delaware Board of Nursing scope of practice. Findings include:Delaware Board of Nursing RN, LPN, and NA/UAP Duties (2024) documented: admission assessments - RN. Once a care plan is established, the LPN may perform ongoing assessments.Review of R42's clinical record revealed:8/21/25 - R42 was admitted to the facility.8/21/25 12:00 PM - E11 (LPN) completed the Clinical admission Assessment, Braden Scale Assessment, and Lift Evaluation.The admission assessments for R42 were completed by an LPN rather than a RN, as required under the Delaware Board of Nursing scope of practice.3/9/26 11:20 AM - During an interview, E12 (RN) stated that the expectation was for a Registered Nurse to complete all admission assessments for new residents. E12 confirmed that E11, whose job title is Licensed Practical Nurse, completed the aforementioned assessments.3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on record review and interview, it was determined that for one (R42) out of one sampled resident reviewed for hearing/vision, it was determined that the facility failed to ensure that R42 received proper treatment and assistive device to maintain hearing and vision abilities. Findings include: Review of R42's clinical record revealed:8/21/25 - R42 was admitted to the facility.8/21/25 12:00 PM - A Clinical admission assessment documented that R42 was not using hearing aids to complete the assessment. Hearing ability and vision ability were not assessed, and the assessment documented no corrective lenses in use. 8/22/25 - A physical therapy evaluation documented that R42 had vision impairment and left ear hearing impairment. 8/22/25 - An occupation therapy evaluation documented that R42 had adequate vision with eye condition of cataracts and had minimal difficulty hearing. 8/28/25 - An admission MDS documented that R42 had adequate hearing, no hearing aid, adequate vision, and no corrective lenses. The MDS also documented R42 was a BIMs of 15 indicating cognitively intact.11/4/25 - A progress note documented that Director of Social Services met with [R42] to discuss ancillary services (podiatry, dental, vision and hearing). [R42] declined podiatry however wished to be referred to dental, hearing and vision. [Social Services] will notify clinical team.11/6/25 - A care plan for R42 documented that resident or responsible party accepts ancillary services (vision/hearing/dental/podiatry) as part of the ongoing care with the following interventions: encourage resident to verbalize concerns related to ancillary care, educate resident on benefits of ancillary services, and offer opportunities to revisit decision at care conference. 11/28/25 - A quarterly MDS documented that R42 had adequate hearing, no hearing aid, adequate vision, and no corrective lenses. 2/26/26 - A quarterly MDS documented that R42 had adequate hearing, no hearing aid, adequate vision, and no corrective lenses. 3/2/26 9:01 AM - During an interview and observation, R42 was unable to hear and asked interviewer to speak up during the interview or repeat what was said. 3/5/26 12:45 PM - During an interview, R42 stated that staff were aware he did not have glasses and that he did not have teeth. R42 stated, They talked about it at the meeting. They know about my glasses hearing and my teeth. R42 further stated he was using readers/ glasses but reported they were not helping him see clearly. During the interview, R42 frequently stated huh and was observed holding his hand to his left ear when questions were asked. Questions had to be repeated, and the interviewer had to raise their voice in order for R42 to respond. 3/9/26 10:30 AM - During an interview and observation, R42 stated he was willing to go to appointments if they would acquire hearing aids and glasses he would go to the appointments. During this interview, an observation of R42 holding the phone close to his face and the volume turned up so R42 could hear the video he was watching. 3/9/26 10:35 AM - During an interview, E18 (CNA) stated that if a resident had a change in vision or hearing staff should report it to the nurse so it can be evaluated. 3/9/26 10:40 AM - During an interview, E10 (LPN) stated that if a resident had a change in vision or hearing the nurse would add them to the provider to be seen list to have them evaluated for the change. E10 confirmed that nurses do not typically assess vision and hearing on the quarterly assessments and once the provider sees the resident nursing will monitor until they are referred to the appropriate specialist.3/9/26 11:20 AM - During an interview, E12 (RN) stated that the IDT team will discuss any residents that need services related to vision and hearing and once determined services are required the SW (social worker) will then call and set up appointments. 3/9/26 11:34 AM - During an interview, E7 (SW) stated the expectation is for the SW to make the appointments for outside services once the IDT determines its needed for the resident. E7 stated he was not sure if R42 was receiving services but would find out. 3/9/26 12:10 PM - During an interview, E16 (Physical Therapist) confirmed that R42 had a hearing deficit in the left ear and that it was identified on his initial PT/OT screening. E16 further stated that PT does not notify nursing of the deficit unless it affects the resident receiving therapy services. The facility failed to identify R42's vision and hearing deficit, routinely assess and evaluate, and refer for necessary services related to vision and hearing. 3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R64) out of two residents reviewed for pressure injury, the facility failed to follow a physician's order for dressing change. Findings include:A review of R64's clinical record revealed:2/19/26 - R64 was admitted to the facility with diagnoses including displaced fracture of the left femur, acute kidney failure, and diabetes.2/26/26 - An initial MDS assessment documented R64 was cognitively intact and had one unstageable pressure injury present on admission.2/27/26 - A physician's order documented to apply skin prep to the right heel blister, then apply a foam dressing twice daily.February 2026 - A review of R64's Treatment Administration Record (TAR) revealed the right heel treatment order had been entered as an ancillary order and did not appear on the TAR. As a result, there was no designated area for nursing staff to document completion of the ordered treatment.3/5/26 10:30 AM - During wound rounds, observation of R64's right heel revealed the foam dressing was dated 3/2/26, indicating the dressing had not been changed twice daily as ordered.3/5/26 10:30 AM - During an interview, E4 (LPN) confirmed the foam dressing was dated 3/2/26, indicating the dressing had not been changed twice daily. E4 immediately changed the dressing.3/5/26 10:45 AM - During an interview, E5 (RN) confirmed the treatment order had been incorrectly entered as an ancillary order rather than on the TAR, resulting in no designated location for nursing staff to document completion of the dressing changes.3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Leader) during the exit conference.

Based on interview and record review it was determined that for two (R6 and R72) out of five residents reviewed for unnecessary medications, the facility failed to ensure a clinical rationale was documented for not completing a gradual dose reduction (GDR) of an anti-psychotic medication and failed to respond to a Medication Regimen Review (MRR) pharmacy recommendation promptly. Findings include: A policy titled Medication Monitoring: Medication Regimen Review and Reporting last updated 1/2024 documented . 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. 1.Review of R6's clinical record revealed:3/1/24 - R6 was admitted to the facility.7/18/25 - A physician's order for R6 documented Abilify (antipsychotic) 15 mg by mouth daily for the treatment of schizophrenia. 1/2/26 - A Medication Regimen Review (MRR) documented R6's Abilify to consider a trial dose reduction to 10 mg daily. The provider documented that a GDR (gradual dose reduction) is not indicated due to: dose reduction attempt at this time would risk decompensation of patient and See physician's progress note for rationale. 2/9/26 - A physician's progress note documented Gradual dose reduction of patient's antipsychotic medication was not recommended or ordered during this visit. The providers progress note lacked documentation of a clinical rationale explaining why a GDR was not attempted.3/3/26 3:30 PM - During an interview, E2 (DON) and E5 (Clinical Lead) confirmed the providers progress note lacked a rationale explaining why a GDR was not attempted. 2. Review of R72's clinical record revealed:5/2/22 - R72 was admitted to the facility.5/31/25 - A physician's order for R72 documented Depakote Sprinkles 125 mg give two capsules by mouth two times a day for increased agitation. 12/2/25 - A Medication Regimen Review (MRR) documented for provider to evaluate and consider dose reduction on the following psychotropic medications: duloxetine (antidepressant), Depakote (anticonvulsant) and Seroquel (antipsychotic). The provider (E15, MD) documented that R72 was stable clinically and to attempt GDR (Gradual Dose Reduction) on Depakote. E15 signed the document on 1/7/26. The provider signed the GDR form 36 days after the pharmacy recommendation was completed.1/2/26 - A physician's order for R72 documented Depakote Sprinkles 125 mg give one capsule by mouth two times a day for agitation.The provider changed the order 41 days after the pharmacy recommendation was completed. 3/6/26 11:12 AM - During an interview, E2 (DON) stated the expectation is for MRR recommendations to be addressed as soon as possible and within 30 days. E2 stated the process was the pharmacy sends the recommendations by email to her, then they are printed, and then the provider reviews them. E2 stated that E15 was not prompt in completing recommendations and that recommendations were not always resolved within the expected 30-day timeframe. E2 confirmed that R72's medication was not reduced until 41 days after the pharmacy recommendation. 3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on observation, interview, and record review, it was determined that for two residents (R24 and R42) out of two residents reviewed for dental services, the facility failed to assist residents in obtaining routine dental services. Findings include:1. Review of R24's clinical record revealed:11/15/25 - The admission MDS assessment documented a BIMS score of 15 and in Section L0200 (Oral/Dental Status) coded D, indicating broken teeth or cavities.A care plan created in November 2025 documented a focus area stating: Resident/Responsible Party accepts ancillary services (vision/hearing/dental) as part of ongoing care. Interventions included encouraging the resident to verbalize concerns related to ancillary care, educating the resident on the benefits of ancillary services, and the nurse initiating a response to address areas of concern.3/2/26 12:01 PM - During observation and interview, R24 was observed to be missing multiple teeth, including the middle top three teeth, and had only one tooth remaining on the bottom. R24 stated that a tooth fell out on Friday while eating a cheeseburger and reported that he sometimes has pain. R24 stated that he told E10 (LPN) on Friday when the tooth fell out.3/4/26 2:30 PM - During an interview, E10 (LPN) stated that when residents are assessed for dental needs or request dental services, they are placed on the dental list in a dental binder. E10 showed the surveyor a dental binder that contained a list of residents to be seen by the dental provider and residents scheduled for dental services. R24 was not listed on either list. E10 stated he did not recall R24 reporting that a tooth had fallen out or mentioning any concerns.3/6/26 - A review of the unit dental book revealed that R24 was added to the list for an appointment after surveyor inquiry.2. Review of R42's clinical record revealed:8/21/25 - A facility Clinical admission Assessment revealed a dental assessment section with options to document dental status including: has own teeth, has dentures, or has no natural teeth (edentulous). The assessment also included components to evaluate oral/dental status including cavities, broken teeth, oral abnormalities, gum condition, and mouth pain. Review of the assessment revealed the oral/dental examination was documented as not assessed/no information.8/28/25 - The admission MDS assessment documented a BIMS score of 15, indicating the resident was cognitively intact. Section L0200 (Oral/Dental Status) was coded as none of the above.11/4/25 2:32 PM - A progress note by E13 (Former Social Services Director) documented: Met with [R42] to discuss ancillary services (podiatry, dental, vision, and hearing). [R42] declined podiatry; however, wished to be referred to dental, hearing, and vision. [Social Services] will notify the clinical team.There was no evidence in the clinical record that a referral for dental services was initiated.A care plan last revised 2/25/26 revealed a focus area titled Resident/Responsible Party accepts ancillary services (vision/hearing/dental) as part of their ongoing care, initiated 11/6/25. Interventions included encouraging the resident to verbalize concerns related to ancillary services, educating the resident on the benefits of ancillary services, and offering opportunities to revisit decisions at care conferences. The care plan did not include resident-specific interventions addressing the resident's edentulous status, monitoring of oral health, or referral for dental services.3/2/26 8:59 AM - During observation and interview, R42 was asked if he had any dental concerns. Observation revealed R42 was missing both upper and lower teeth. R42 stated, I have told them I need to go to the dentist, and I don't have any teeth.3/4/26 - During an interview, E10 (Licensed Practical Nurse) stated that the process for a resident to be seen by the dentist is for the resident to notify staff of a problem or request to see a dentist, after which the resident is placed on the list in the dental book. Review of the dental book revealed that R42 was not listed for dental services.3/9/26 - During an interview, E2 (DON) confirmed that R42 was not listed for dental services and had not been referred for dental evaluation despite the resident requesting dental services.As a result, the facility failed to ensure residents received assistance in obtaining routine dental services to maintain oral health and comfort.3/9/26 3:00 PM - Findings were reviewed with E2 (DON) and E5 (Clinical Lead) during the exit conference.

Based on record review, interviews and review of other facility documentation as indicated, it was determined that for one (R1) out of three sampled residents the facility failed to ensure that grievances received by the facility included prompt efforts to resolve problems. In addition, the facility failed to ensure that a written decision was issued to the complainant. Findings include:Review of the facility's policy titled, OPS204 Grievance/Concern revised 10/15/24 indicated: Policy: . All patients and/or their representatives may voice grievances/concerns and recommendations for changes. Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient or patient representative . The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process. receiving and tracking grievances through to their conclusion . Purpose: To assure prompt receipt and resolution of patient or representative grievance/ concern . Process: 10. If the grievance/concern is unable to be resolved satisfactorily, refer the patient/representative to the Market President for assistance. Review of R1's clinical record revealed the following:10/28/29 - R1 was admitted to the facility with diagnoses including but not limited to congestive heart failure, atrial fibrillation, diabetes, chronic kidney disease, post right below knee amputation and a gangrene wound on the left toe. 11/11/25 9:16 AM - A nurse progress note documented that R1 was sent to the ER (Emergency Room) for treatment and evaluation due to change in respiratory status. R1 was found unresponsive with a fasting blood sugar of 30 mg /dl (milligram/deciliter).11/12/25 - A facility Grievance Form by E1 (NHA, Grievance Officer) documented that FM1 (Family Member) Expressed that [R1] with recent 911 to hospital will not be coming back due to care issues. Grievance investigation revealed . after review, moved to reportable . [R1] did not return . Resolution of Grievance - No. 11/12/25 - A written statement by E1 documented:On 11/12/25, [FM1] stopped me as I entered my office. She was carrying some personal items. She was upset that:- That staff had inquired about her husband who refused to identify himself and wanted personal items from the room.- On the night prior to R1 going out, [R1] had his cellphone on an open (R1 was engaged in a telephone call) and was calling out to someone asking for clinical help. The person (a female) stated that she was not his nurse but was doing something in the room.- Stated that R1 felt that the direction of staff and on - call physician was that if R1 went out to ER they would be sent back given the current vitals and treatment.- Staff had called and provided her with updates but when she called back to check it was hard to find staff to pick up the phone (during med - pass).- The ER staff reported that [facility] staff was 'rude' during the process of sending [R1] out. [E1, NHA] stated that though not present during the send out we would review the clinical changes with our [P21, MD]. [E1] then took [FM1] to room with E8 [LPN/Wound Nurse], [E4, ADON], [E5. RN UM], and [E6, Quality Care Coordinator] where they were finishing up care plans. [E1] interrupted and asked if they would perform a clinical review of what happened, and the impromptu partial IDT (Interdisciplinary Team) meet to go over what could be reviewed at that time. [E1] told [FM1] that as we get closer to understanding the acute episode we can discuss further and that the impromptu meeting would show our commitment to process review, [FM1] left satisfied. The following day, despite the IDT stating [FM1] left (sic) [E1] left a VM (voice message) and then moved the grievance to reportable. 11/13/25 - A facility incident report submitted to the state agency documented, . [E7, DBO, Director of Business Office] had a conversation with [FM1] . in regard to [R1] not returning to the facility . expressed concerns about the care her father received while admitted to the facility . 12/2/25 9:30 AM - During a telephone interview, FM1 stated that she went to the facility and talked to the management last month (November 2025). FM1 stated that she had discussed her concerns regarding [R1's] care to the nursing team who in turn told her that an investigation will be done. FM1 further stated that, I have not heard back from them. 12/2/25 11:00 AM - A follow up review of R1's grievance form revealed a lack of a written decision issued to [FM1, complainant].12/2/25 11:10 AM - In an interview, E1 stated that the Grievance filed by FM1 was not resolved because, [R1] did not return to the facility, and I left a voice message for [FM1] but she did not return the call so I talked to [E3, Clinical Lead] about it and we decided to move it as a state reportable incident.12/2/25 2:00 PM - When asked regarding FM1's unresolved grievance, E3 stated that she met with the Market President and discussed the grievance concerns, investigations concluded and the grievance was closed. It was escalated to a reportable event. E3 further stated that, [E1] reached out to [FM1] via phone, left a voice mail in regards to the results of the investigation, but to my knowledge, [FM1] did not return [E1's] phone call. [FM1] was provided [E5's, RN UM] personal cell phone number for any future questions or concerns. [FM1] never called [E3] at any point. The facility failed to ensure that a written decision was issued to the FM1, the complainant.12/3/25 4:05 PM - Findings were reviewed with E1, E2 (DON), E3 (Clinical Lead) and E15 (Regulatory Nurse) during the Exit Conference.

Based on interview and record review, it was determined that for one (R1) out of three residents sampled for care plan review, the facility failed to revise the person - centered care plan interventions to address R1's refusal to obtain his daily weights. Findings include:Cross Refer F842Review of R1's clinical records revealed:10/28/25 - R1 was admitted to the facility with diagnoses including CHF (congestive heart failure).10/29/25 - R1 had a physician's order to notify provider if R1 gains more than two lbs. (pounds) in one day, or five lbs. in a week related to CHF. 10/28/25 (revised 11/4/25) - A care plan was developed for R1's risk for decreased ability to perform ADLs (Activities of Daily Living) . resistive to daily morning weights for CHF. 11/3/25 - R1's admission MDS (Minimum Data Set) assessment revealed that R1 had an intact cognition with a BIM score of 15. R1 required substantial to maximal assistance of one staff person with bed mobility including lying to sitting on side of the bed. R1 also required moderate assistance of one staff person with sit to stand or chair -to - chair transfer, using the wheelchair for mobility. 12/2/25 - Review of R1's October and November 2025 TARs (Treatment Administration Record) revealed a lack of evidence that R1's daily weights were obtained on October 28, 29 and 31, 2025 and from November 2 through 11, 2025. 12/2/25 - A review of R1's Weight Summary from 10/28/25 through 11/11/25 revealed that R1's weights were only obtained two times on 10/30/25 (255 lbs. with use of wheelchair) and 11/1/25 (258.2 lbs. with use of mechanical lift). 12/2//25 - Review R1's nurse progress notes from 10/29/25 through 11/11/25 revealed the following documentation: 10/29/25 7:15 AM - [R1] refused the weight this morning stated (sic) 'I don't trust the lift'.11/2/25 6:40 AM - [R1] told this writer, 'The 7-3 shift took the weight yesterday and it was 258, I should go with that number, (sic) educated [R1] it's a daily weight but he refused.11/3/25 6:57 AM - [R1] refused the weight this morning, stated 'I don't feel the weight this morning' (sic) educated [R1] but still refused.11/6/25 6:58 AM - [R1] refused the weight this morning (sic) stated 'I don't feel it'. 11/8/25 6:17 AM - In the morning stated, 'I don't trust the Hoyer lift or the chair' (sic) educated [R1] they are all accurate but still he refused.12/3/25 8:00 AM - During an interview, E9 (LPN) stated that she was the night nurse and E9 confirmed that R1 had always refused to get his weights taken using the Hoyer lift machine. E9 further stated, [R1] was thinking that the Hoyer lift machine's weighing scale calibration was not accurate. I told the day shift nurse about his weight refusals. Although the facility identified R1's refusals to obtain his weight, the facility failed to ensure that R1's person centered care plan interventions were included to address his refusals to obtain his weight. In addition, the facility failed to address the issue of R1 refusing to get weighed using the Hoyer lift weighing scale. 12/3/25 4:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Clinical Lead) and E15 (Regulatory Nurse) during the Exit Conference.

Based on record review and interview, it was determined that the facility failed to maintain a complete and accurate record for one (R1) of three sampled residents. Findings include:Cross Refer F657Review of R1's clinical record revealed:12/2/25 - Review of R1's October and November 2025 TARs (Treatment Administration Record) revealed a lack of evidence that R1's daily weights were obtained and completed on October 28, 29 and 31, 2025 and from November 2 through 11, 2025. 12/3/25 10:00 AM - During an interview, E3 (Clinical Lead) confirmed the incomplete documentation. 12/3/25 4:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Clinical Lead) and E15 (Regulatory Nurse) during the Exit Conference.

Based on observation, interview, and record review, it was determined that for five (R4, R12, R38, R66 and R87) out of six residents reviewed for respiratory care, the facility failed to ensure residents' respiratory equipment (Bi-PAP mask and IVAPS mask) were stored in a protective plastic bag, the oxygen tubing was labeled and the filter on the oxygen concentrator was cleaned. Findings include:1. A review of R4's clinical record revealed: 12/16/22 – R4 was admitted to the facility. 7/8/24 – A physician's order for R4 documented to use IVAPS (Intelligent Volume-Assured Pressure Support) every night shift for bedtime and as needed for when napping. 8/1/25 – A quarterly MDS assessment documented that R4 received oxygen therapy and used a non-invasive mechanical ventilator. 8/8/25 – A care plan documented R4 as a risk for respiratory complications related to chronic respiratory failure with an intervention to use the IVAP at bedtime. 9/15/25 9:50 AM – An observation revealed that R4's IVAPS mask was sitting on top of the bedside table with no protective bag available. 9/15/25 10:28 AM – During an interview, E6 (LPN) confirmed that R4's IVAPS mask should be stored in a protective bag. E6 mentioned that it is usually in a bag and promptly retrieved a protective bag to place R4's IVAPS mask inside. 2. A review of R12's clinical record revealed: 2/12/25 – R12 was admitted to the facility. 2/28/25 – A physician's order for R12 documented to use Bi-PAP at bedtime and as needed. 7/9/25 – A quarterly MDS assessment documented that R12 received oxygen therapy and used a non-invasive mechanical ventilator. 7/19/25 – A care plan documented R12 as a risk for respiratory complications related to COPD and acute and chronic respiratory failure, with interventions including using a Bi-PAP at bedtime and as needed. 9/9/25 – A physician's order for R12 documented to clean the external filter on the oxygen concentrator every Tuesday on the night shift and as needed. 9/15/25 9:24 AM - An observation revealed that R4's Bi-PAP mask was sitting on top of the bedside table with no protective bag available. The external filter on the oxygen concentrator was completely full of dark gray dust. 9/15/25 9:36 AM - During an interview, E13 (LPN) confirmed that R12's Bi-PAP mask should be stored in a protective bag. E13 stated that the external filter needed to be cleaned and immediately cleaned the filter and replaced it. 3. Review of R38's clinical record revealed: 7/23/25 - R38 was admitted to the facility with diagnoses including but not limited to obstructive sleep apnea and congestive heart failure. 9/15/25 9:11 AM - An observation revealed R38's BiPap mask and tubing sitting on the nightstand and not enclosed in protective bagging. 9/15/25 12:20 PM - During an observation E10 (RCA) confirmed R38's BiPap equipment was not in protective bagging. E10 stated, I'll take care of that now. 9/23/25 2:45 PM – Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference. 4. Review of R66's clinical record revealed: 1/7/21 - R66 was admitted to the facility. 9/22/24 - A physician's order for R66 documented oxygen via nasal cannula at 3L/min continuous every shift. 9/22/24 11:12 AM - A physician's order for R66 documented clean external filter on oxygen concentrator every Tuesday dayshift, RT (respiratory therapy) to complete. 9/15/25 1:30 PM - An observation of R66's oxygen concentrator filter noted with dusty thick gray particles. 9/16/25 9:16 AM - An observation of R66's oxygen concentrator filter noted with dusty thick gray particles. 9/16/25 1:16 PM - During an interview, R66 stated the nurse cleaned the filter this morning and they don't normally do that. 9/16/25 1:40 PM - During an interview, E16 (LPN) confirmed the oxygen concentrator was covered in thick gray particles when it was cleaned this morning. E16 confirmed that it was signed off on the MAR on 9/9/25 but E16 stated it did not appear it was cleaned. 9/23/25 2:45 PM – Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference. 5. Review of R87's clinical record revealed: 9/2/25 - R87 was admitted to the facility with diagnoses that included but not limited to, pneumonia and respiratory failure. 9/2/25 - A physician's order for R87 documented change oxygen tubing weekly every night shift, every Tuesday. label each component with date and initials. 9/15/25 11:07 AM - An observation of R87's oxygen tubing revealed no label. 9/15/25 11:10 AM - During an interview, E177 (RN) confirmed there was no label on the oxygen tubing. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on observation and interview, it was determined that the facility failed to ensure food and beverages were stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:9/15/25 8:29 AM - The corners of numerous ceiling tiles in the dry food stoage room had a variety of different sized black and gray circular areas, which appeared to be mold. 9/15/25 9:17 AM - The clear plastic tubing that connected the kitchen juice machine to the beverage dispenser contained several areas of a blackish gray substance that appeared to be mold. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on interview and record review, it was determined that for one (R87) out of thirty (30) residents reviewed in the investigative sample, the facility failed to develop a care plan to address the administration of oxygen via nasal cannula and the use of an incentive spirometer. Findings include:A review of R87's clinical record revealed: 8/29/25 - R87 was admitted to the facility with diagnoses that included but not limited to, pneumonia and respiratory failure. 9/2/25 - A physician's order for R87 documented oxygen at 6L/min via nasal cannula continuously. 9/3/25 - A physician's order for R87 documented incentive spirometer - encourage patient to use as often as tolerated. 9/15/25 11:07 AM - An observation of R87's bedside table revealed an incentive spirometer. R87 stated that he is using the spirometer. 9/16/25 - 2:03 PM - A review of R87's care plan lacked evidence of a care plan addressing he administration of oxygen via nasal cannula and the use of an incentive spirometer. 9/16/25 2:25 PM - During an interview E2 ( quality manager) confirmed there wasn't a care plan developed for oxygen administration via nasal cannula or the use of an incentive spirometer. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R69) out of seven residents reviewed for ADLs, the facility failed to provide nail care for a dependent resident. Findings include:Review of R69's clinical record revealed:6/30/21 - R69 was admitted to the facility.6/11/25 - A care plan documented that R69 required assistance and was dependent for all ADLs.6/16/25 - An annual MDS assessment for R69 documented that the resident was severely cognitively impaired and required substantially maximal assistance for personal hygiene.9/15/25 9:15 AM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R69's fingernails were long and needed to be trimmed. 9/16/25 9:30 AM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R60's fingernails were long and needed to be trimmed. 9/17/25 1:03 PM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R60's fingernails were long and needed to be trimmed. 9/17/25 1:02 PM - During an interview, E5 (CNA) stated that she will trim and clean the resident's nails are trimmed and cleaned on the days the resident receives her baths. 9/17/25 1:04 PM - During an interview, E6 (LPN) confirmed that the right hand and left hand had long fingernails with dark debris under the nails. 9/17/25 1:10 PM- During an interview, E2 (Quality Manager) confirmed that R69's right and left hands had long fingernails with dark debris underneath each fingernail. E2 stated she would take care of it.9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on observation, interview and record review it was determined that for one (R69) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure that R69 received the treatment/services to prevent further decline in ROM. The facility lacked evidence that the palm device was applied to the left palm. Findings include:Review of R69's clinical record revealed:6/30/25 - R69 was admitted to the facility.5/7/25 10:15 AM - A physician's order documented that R69 was to have a left palm guard applied in the morning with AM care and removed with PM care. There was no stop date to this order.6/11/25 - A care plan documented that R69 required assistance and was dependent for all ADLs. In addition, R69 had a care plan with a goal to maintain skin integrity and prevent contractures with interventions that include applying a palm guard at 10:00 AM to the left hand for up to 6 hours daily as tolerated after morning care.6/16/25 - An annual MDS assessment for R69 documented that the resident was severely cognitively impaired and required substantially maximal assistance. with all ADL's. 9/15/25 - On the following times, an observation of R69 was made without the left hand palm guard: 9:05 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM. 2:00 PM, and 3:00 PM.9/16/25 - On the following times, an observation of R69 was made without the left hand palm guard: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, and 2:00 PM.9/17/25 9:00 AM - An interview with E7 (CNA), confirmed she has never applied and has not seen the palm guard on the resident's left hand. 9/17/25 9:12 AM - An interview with E5 (CNA), confirmed she has never applied and has not seen the palm guard on the resident's left hand. 9/17/25 - On the following times, an observation of R69 was made without the left-hand palm guard: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, and 2:00 PM.9/17/25 - 10:10 AM - During an interview, E2 (Quality Manager) confirming that R69 did not have a left palm guard. E2 stated that she would be addressed immediately. 9/18/25 9:16 AM - During an interview, E8 (Director of Rehab) confirming R69's order for left palm protector was a standard order with no stop date. E8 revealed the left hand palm guard order entered on 5/5/25 was stopped on 6/6/25 by mistake.9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 and E3 (DON) during the exit conference.

Based on interview and record review it was determined that for one (R20) out of one resident reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bladder continence. Findings include:Review of R20's clinical record revealed: 3/21/21 - R20 was admitted to the facility. 8/18/22 - A care plan documented that R20 was incontinent of urine and was unable to cognitively or physically participate in retraining with the following interventions: assist with perineal care as needed, monitor for signs and symptoms of infection, and provide privacy and comfort. 1/10/25 - A post voiding diary follow up assessment documented that R20 was assessed for urinary and fecal incontinence and the outcome determined R20 was a candidate for prompted voiding. The assessment lacked documentation regarding a toileting plan or update for the care plan. 5/15/25 - A quarterly MDS documented R20 had a BIMS score of 15 indicating the resident was cognitively intact. The MDS documented that R20 required supervision or minimal assistance for toileting and was occasionally incontinent of urine. Additionally, the MDS documented R20 was not on a toileting program. May 2025 - The CNA documentation record revealed that R20 was incontinent of urine 9 times out of 111 opportunities. June 2025 - The CNA documentation record revealed that R20 was incontinent of urine 27 times out of 117 opportunities. July 2025 - The CNA documentation record revealed that R20 was incontinent of urine 29 times out of 113 opportunities. August 2025 - The CNA documentation record revealed that R20 was incontinent of urine 44 times out of 112 opportunities. 8/14/25 - A quarterly MDS documented that R20 had a BIMS score of 12 indicating the resident was moderately impaired. The MDS documented that R20 required supervision or minimal assistance for toileting and was frequently incontinent of urine. Additionally, the MDS documented R20 was not on a toileting program. September 2025 - The CNA documentation record revealed that R20 was incontinent of urine 20 times out of 59 opportunities. The CNA documentation and task list lacked evidence of frequency of toileting and any approaches individualized to R20. The CNA documentation combined urinary continence and bowel continence and provides an unclear determination of continence status. 9/15/25 11:02 AM - During an interview, R20 stated she was able to take herself to the bathroom and was continent. 9/22/25 10:06 AM - During an interview, E14 CNA stated that R20 was an assist of one with toileting and stated R20 can verbalize the need for toileting. E14 stated that R20 was not on a toileting program currently. E14 also stated R20 had an increase in incontinence and required staff assistance for toileting hygiene. 9/22/25 10:11 AM - During an interview, E15 (LPN) stated that R20 was able to toilet herself but required assistance from staff for hygiene care. E15 stated that R20 is not on a toileting program currently and staff takes R20 to the toilet every two hours. E15 did confirm that R20 was having increased incontinent episodes and stated R20's behaviors made it difficult for staff to complete toileting hygiene. The facility failed to develop an infividulized toileting program to improve or maintain bladder continence. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R10) out of three residents sampled for dental services, the facility failed to assist R10 in obtaining routine dental services. Findings include:Review of R10's clinical record revealed:7/23/23 - R10 was admitted to the facility.6/27/25 - An annual MDS documented that R10 had no broken or loosely fitting dentures, no natural teeth or tooth fragments, no abnormal mouth tissue, and no obvious broken teeth.9/15/25 9:57 AM - An observation of R10 revealed loosely fitting dentures. 9/15/25 10:13 AM - An interview with FM1 (Guardian) revealed that R10 had not seen a dentist. 9/17/25 11:11 AM - An interview with E12 (Scheduler) confirmed that a dentist comes to the facility and residents also can go to outside dental providers. E12 stated, residents will request to see the dentist and will get added to the list. 9/17/25 11:44 AM - An interview with E10 (Regulatory Compliance Advisor) confirmed that R10 had not been seen by the dentist.9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on record review and interview, it was determined that for one (R2) out of thirty sampled residents, the facility failed to ensure the clinical record contained accurate documentation. Findings include:Review of R2's clinical record revealed:11/28/23 - R2 was admitted to the facility.9/10/25 - A review of a facility investigation documented that R2 was involved in a resident to resident altercation with R53. 9/10/25 11:06 AM- A physician's order documented that R2 was to be sent to ER for treatment and evaluation. 9/10/25 - A review of the CNA documentation record revealed that R2 was not available for all ADL tasks on the 7:00 AM to 3:00 PM shift. 9/22/25 10:20 AM - An interview with E7 (CNA) confirmed that R2 was in the facility on the date of 9/10/25 at approximately 12:15 PM and the documentation of not available was inaccurate.9/23/25 9:00 AM - An interview with E10 (Regulatory Compliance Advisor) confirmed that R2 was sent to the ER at 12:15 PM and confirmed the documentation should reflect receiving care prior to R2 leaving the facility. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on observation, interview, and record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents and supervision the facility failed to provide adequate supervision and assistive devices to prevent elopement. This put R1 in immediate jeopardy and at risk of a serious adverse outcome. R1 was able to elope from the facility on 6/13/25 through an unsecured sliding door in the conference room. R1 wandered across a busy roadway approximately 0.6 miles away from the facility and was found asleep on the grass. R1 was missing for 1 hour and 23 minutes. An immediate jeopardy (IJ) was identified starting on 6/13/25. Due to the facility ' s corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 6/17/25. Findings include: A policy titled Elopement of Patient last reviewed by the facility on 6/12/25 documented Patients/Residents (hereinafter patient) will be evaluated for elopement risk upon admission, readmission, quarterly, and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility ' s knowledge and supervision, if necessary Review of R1 ' s clinical record revealed: 1/2/20 - R1 was admitted to the facility with diagnoses including but not limited to paranoid schizophrenia, sick sinus syndrome, cardiac pacemaker and anxiety. 3/17/20 - Review of R1 ' s care plan documented [R1] attempts to leave the building without an escort [R1] will have 3 or less episodes weekly of attempt (sic) to leave the building without an escort Additionally, [R1 ' s] elopement care plan was revised on 4/16/25 and on the date that [R1] eloped from the facility 6/13/25 12/3/24 3:00 PM - A physicians order documented the Wander Guard/Wander Elopement Device due to poor safety awareness every shift check placement of the device and in supplemental documentation document the location 3/19/25 - A quarterly MDS revealed R1 ' s cognition was moderately impaired. 4/21/25 - Review of R1 ' s facility elopement risk assessment documented Wandering behavior, a pattern or goal - directed: Yes The facility investigation documented the following timeline for R1 ' s elopement on 6/13/25: 6/12/25 11:53 PM - E3 (LPN) checked R1 ' s wander guard. 6/13/25 3:00 AM - E4 (CNA) provided water and a snack to R1. 4:00 AM - R1 was at the nurses' station and E3 provided orange juice and a snack to the resident. R1 then self-propelled back to his room. 5:40 AM - R1 was noticed to be missing and additionally: -R1 ' s wheelchair was in front of the conference room door the sliding door in the conference room was open -R1 was not seen and the elopement protocol was initiated -A whole house room to room check determined all residents were accounted for -R1 was the only resident missing -When the search for R1 was started a face sheet of R1 was printed to provide to all staff and that R1 had a wander guard order. -R1 was searched for outside of the facility by staff as well 6:00 AM - E2 (DON) was notified by staff. 6:10 AM - DON called E1 (NHA) to notify. 6:15 AM - Police were notified. The facility continued to search for R1. 6:57 AM - E5 (CNA) driving to work saw someone resembling a resident sleeping on the grass at a home on Old Shawnee Road and [NAME] Boulevard. 7:00 AM - E5 arrived at work and was notified R1 was missing. 7:03 AM - E5 and E6 (RCA) drove back to the location where R1 was lying in the grass. R1 was asked to enter the car to travel back to the facility. R1 returned to the facility with both staff. 7:30 AM - A head to toe assessment was performed on R1 and the on-call NP was notified. Neurological checks were initiated for the next 24 hours. In addition, R1 was placed on 1:1 supervision until all the sliding doors in the conference room were secured. 7:36 AM - Staff attempted to contact emergency contact #1 left message. 8:08 AM - Staff attempted to contact emergency contact #2 left message. 8:18 AM - Staff contacted emergency contact # 3 and notified him of the elopement. A root cause analysis of the elopement revealed a contractor exited through a door but failed to relock. As a result, the door will not be used for entry or exit. The maintenance department repaired the sliding glass door in the room to open just six inches to prevent use as an exit. The contractor will receive re-education upon his return to the facility. 6/13/25 10:45 AM - The following was completed: -Elopement drills were done to validate compliance with the facility policy and procedures and education provided. -Maintenance audited all doors and windows in facility. -Residents with wander guard devices were audited for function and placement. Conference room sliding doors are checked daily and signed and dated by designated staff. -A lock and signage has been placed on the conference room door to keep door closed at all times. -Upon review the only three staff that have a key to unlock the conference room door are E1, E2 and E7 (Wound Nurse). 6/26/25 - Staff interviews with E8 (LPN), E9 (CNA), and E10 (CNA) confirmed staff education and elopement drills had been completed. Based on the review of the facility's thorough investigation, documented response, completion of in-service training and elopement drills, audits and staff interview the immediate jeopardy was determined to be past non-compliance as of 6/17/25. 6/26/25 2:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on interview and record review, it was determined that for one (R89) out of two residents reviewed for falls, the facility failed to assess for and implement interventions to reduce R89's risk for falling. R89 sustained twelve falls which included two falls resulting in head trauma that required transfer to an acute care hospital. Findings include: A facility policy titled Falls Management effective 9/15/01 (last revised 3/15/24) included: Patient will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. 1. All patients will be assessed for risk of falls upon admission, with reassessments (e.g. quarterly, post-fall) performed to determine ongoing need for fall prevention precautions. 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized interventions strategies as patient condition changes. Cross refer to F690 Review of R89's clinical record revealed: 2/12/24 - R89 was admitted to the facility with dementia. 2/12/24 5:14 PM - An admission fall risk assessment documented a fall risk score of three indicating that R89 was at low risk for falls, required supervision for ambulation, that R89 had sustained one to two falls in the past three months prior to admission, and lacked evidence of a documented ambulation/elimination status. 2/12/24 5:16 PM - A clinical admission assessment documented that R89 was continent of urine. 2/19/24 - An admission MDS assessment documented that R89 was cognitively intact with a BIMS of 13, required verbal cues or touching/steadying assistance by one staff member for toileting supervision/touching assistance for ambulation, was occasionally incontinent of urine and a trialed toileting program was not attempted. Review of R89's fall and incontinence care plans lacked evidence of an individualized toileting program to reduce R89's risk for falling. 3/3/24 7:48 PM - An incident report documented that R89 was found sitting on floor next to her bed. 3/5/24 4:30 AM - An incident report documented that nursing responded to the patient's call bell. Upon entry to the room the patient was observed sitting on the floor beside her bed. She stated she had been attempting to go to the restroom when she fell . There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 3/11/24 Approx. (approximately) 2:15 AM - An incident report documented that the nurse was called to assess the patient s/p (after) falling in her room. Upon entry to the room the patient was observed sitting on the floor beside her bed. 4/9/24 1:00 AM - An incident report documented that R89 was observed sitting on the floor next to her bed. When staff responded, resident stated that she was trying to get to the bathroom. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 5/7/24 8:30 PM - An incident report documented that R89 was lying on the floor in her bathroom. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 5/11/24 3:30 AM - An incident report documented that the nurse heard R89 yelling from her room, Help, I am on the floor! Upon entering resident's room, R89 was noted sitting on her buttocks on the floor beside her bed. 5/12/24 - R89's fall risk score was 19 which indicated that R89 was at high risk for falling. 5/23/24 - R89's fall risk assessment score was 21 which indicated that R89 was a high risk for falling. 5/24/24 - R89's bowel and bladder assessment included that R89 had urinary incontinence and to implement pelvic floor rehabilitation. This intervention was not individualized related to R89 having severely impaired cognition. In addition, there was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 5/25/24 - A 5-day MDS assessment documented R89 was cognitively impaired with a BIMS of 6, that ambulation was not attempted due to a medical condition or safety concerns and required substantial/maximal assistance with toileting. 6/13/24 10:01 AM - An incident report documented that R89 was observed lying face down on the floor in the bathroom in her room. It was documented that R89 stated, I was getting off the toilet and couldn't stand anymore. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 6/21/24 8:37 PM - An incident report documented that R89 was found in her room next to the bed. 6/27/24 6:30 PM - An incident report documented R89 was observed scooting on the floor in the doorway of her room. 7/5/24 7:40 PM - An incident report documented that R89 reported falling from her bed after attempting to get up. 7/17/24 6:50 PM - An incident report documented that the nurse was notified that R89 had a fall in her room. Upon entry into the room R89 was observed sitting on the floor in the bathroom in front of the toilet. R89 stated that she had attempted to toilet herself but had missed and fallen. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 7/18/24 10:55 PM - An incident report documented that the nurse heard a noise and then yelling. R89 was observed laying on the floor between the bed and wheelchair. R89's head was on the base of the bedside table. Once R89 was assisted to a seated position, a large amount of blood was on the floor. It was observed that R89 had a large laceration to the back of her head and was sent 911 to the hospital. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 7/19/2024 3:55 PM - A wound progress noted documented that R89 had a laceration to back of her head noted with 2 staples in it. This was as a result of the 7/18/24 fall. 8/14/24 - A quarterly MDS assessment documented that R89 was not assessed for cognition, was frequently incontinent, and was partial/moderate assistance for ambulation and toileting. 8/17/24 6:35 PM - An incident report submitted to the state agency documented that R89 sustained a fall with a forehead laceration with bleeding that was not controlled. R89 required a transfer to the hospital. There was no evidence the facility conducted a urinary continence assessment that included voiding patterns. 11/19/24 9:23 AM - During an interview, E1 (NHA) and E2 (DON) confirmed that the facility was only conducting assessments for voiding patterns on admission and not on residents with repeated falls including when a residents had repeated falls attempting to go to the bathroom. E2 also confirmed that a generic toileting plan is not beneficial to reduce risk for falls if the resident was not assessed for voiding patterns. 11/19/24 9:50 AM - During an interview, E1 (NHA) confirmed that R89 was not assessed for patterns of incontinence and that R89 was not on an individualized toileting program to attempt to reduce R89's risk for falling. 11/25/24 1:00 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, record review and interview, it was determined that for three (R89, 411, and 412) out of three residents reviewed for hydration, the facility failed to ensure that R411 and R412 were offered sufficient fluid intake to maintain proper hydration and health. R411 was emergently sent to hospital and was diagnosed with a BUN of 32, and acute kidney Injury. R412 received an order for IV (intravenous) hydration for a sodium level of 156, the facility failed to insert the IV and R412 sodium level rose to 161. R412 was emergently sent to the hospital 36 hours later with facial droop and lethargy. For R89, the facility failed to follow a physician's order and evaluate R89's weight when R89 had a significant weight loss. Findings include: A facility document titled, Nutrition and Hydration Care and Services, dated 1/1/04 and reviewed 2/1/23 included, Staff will provide nutritional and hydration care and service to each patient consistent with each patient's comprehensive assessment Monitor intake and output Diagnoses of dehydration with clinical findings At risk for dehydration R411's clinical records revealed: 6/5/24 - R411 was admitted to the facility with diagnoses including acute kidney injury, acute osteomyelitis [infection of the bone] to the right hip bone and anal/rectal cancer. 6/5/24 - R411's physician's orders included cefepime [antibiotic] 2 gram/IVBP [intravenous piggyback] 100 ml every 12 hours and vancomycin [antibiotic to treat a bacterial infection] 1gram/200 IVBP every 24 hours, .Patient will need vanco trough level [lowest concentration of vancomycin in the blood] 2 times weekly .and weekly CBC . [complete blood count] .colostomy [a surgical opening in the intestinal wall or colon to allow stool to drain into a bag] care every shift. 6/6/24 - R411's care plan documented, Resident exhibits or is at risk for dehydration as evidence by infection and vomiting, diarrhea . The interventions included, Encourage resident to consume all fluids .monitor lab work as ordered and report as indicated. 6/6/24 - R411's admission nutritional assessment documented a fluid goal of 1700 ml/24 hours. 6/10/24 - R411's clinical records documented a vancomycin peak [highest contraction of vancomycin level in the blood] of 9.8, a trough level of 9.8. Vancomycin therapeutic trough level is between 5.0 to 10.0, and the peak level is between 20.0 to 40.0. 6/11/24 - R411's admission MDS documented a BIMS score of 15, indicating a cognitively intact status. R411's MDS lacked documentation of the presence of a colostomy on the left lower abdomen. 6/12/24 3:44 PM - A nursing progress in R411's clinical records documented, Resident has new orders per [E15] NP and Infectious Disease request: Increase Vancomycin .daily until 7/14/2024. 6/13/24 - R411's clinical records documented a vancomycin peak of 12.3, trough of 12.3 and BUN [a blood test to measure kidney function] of 17, (normal range is between 7-17), and a creatine [a blood test to measure kidney function] level of 1.00 [normal range for women is between 0.6 to 1.1]. 6/17/24 - R411's clinical records documented a vancomycin peak of 12.5, a trough of 12.5, and a BUN level of 19. 6/24/24 - R411's clinical records documented a vancomycin peak of 24.2, trough of 24.2 and BUN of 19. 6/27/24 - R411's clinical records documented a BUN 18, creatine 1.40. The Cefepime was decreased to 1 gram every 12 hours and vancomycin at 1 gram every 24 hours. A review of R411's daily documented fluid intake from 6/7/24 through 6/30/24 revealed: 6/6/24 - 690 ml, 6/7/24 - 1,040 ml, 6/8/24 - 1,020 ml, 6/9/24 - 1,620 ml, 6/10/24 - 950 ml, 6/11/24 - 1,620 ml, 6/12/24 - 500 ml, 6/13/24 - 840 ml, 6/14/23 - 720 ml, 6/15/24 - 1,450 ml, 6/16/24 - 1,450 ml, 6/17/25 - 1,150 ml, 6/18/24 - 1,190 ml, 6/19/24 - 980 ml, 6/20/24 - 1,040 ml, 6/21/24 - 810 ml, 622/24 - 730 ml, 6/23/24 - 1,240 ml, 6/24/24 - 1,100 ml, 6/25/24 - 1,190 ml, 6/26/24 - 1,260 ml, 6/27/24 - 1,260 ml, 6/28/24 - 340 ml, 6/29/24 - 960 ml, 6/30/24 - 580 ml R411's did not meet the fluid goals of 1700 ml for 24 out of 24 days. 7/1/24 - R411's clinical records documented a vancomycin peak of 23.1, peak of 23.1, BUN of 32 (above the normal level) and creatine level of 2.60 (above the normal level). 7/1/24 9:17 AM - R411's clinical records documented, Pt [patient] not feeling well this am, BM from colostomy all over bathroom with a very strong odor. Pt lethargic, not answering questions with full responses. Daughter in law came in to visit, also concerned with pt change in mental status. BP [blood pressure] 96/56 .sent to the ER [emergency room ] for evaluation. 7/1/24 9:51 AM - R411's clinical records documented (progress note from the NP, Pt seen today for follow up. Pt was found resting in bed, in mild distress. Pt daughter at bedside. Pt stated I don't feel well. Something is wrong. Pt c/o [complaint of] chills, diarrhea, weakness, sob [shortness of breath], BP 96/56 .noted lethargy, sob and appeared ill. Pt was sent to ER for further evaluation. 7/1/24 1:37 PM - R411's clinical records documented, Called Sussex ER for pt update. Per ER nurse-Pt still being evaluated, may be admitted due to abnormal labs . 7/1/24 6:06 PM - R411's emergency hospital records documented, Patient was found to have acute kidney injury her creatinine peaked at 4.3, now trending down to 2.5, patient was seen by nephrology .now improved to 2.5, s/p [status post] IV fluids. Labs show an acute kidney injury .Patient will require admission to medicine service for acute kidney injury likely from volume loss from C. difficile as well . final diagnoses - Acute kidney failure, dehydration. 11/21/24 10:00 AM - A review of R411's fluid intake records from 6/7/24 through 6/30/24 lacked evidence that R411 reached the fluid goals of 1700 ml/24 hours for 24 out of 24 opportunities. During an interview E15 (dietitian) provided the Surveyor with a facility document titled, Week at a glance, menu. The menu documented the fluids served with each meal. 11/22/24 8:45 AM - During an interview, E21 (CNA) stated, We give them {residents] what's on the tray, and they ask if they want anything more. 11/22/24 1:30 PM - The surveyor asked E13 (MD) during a telephone interview if the residents labs are reviewed by the facility's providers along with the infectious providers, E13 stated, Yes, they are reviewed and signed by the providers in the building as well. 11/25/24 10:00 AM - During a telephone interview C1 (MA) stated, We follow the levels for the antibiotics. The patient is in the building, and they must make sure she is drinking enough. The facility failed to monitor and ensure that R411 received sufficient fluid intake despite the diagnoses of acute kidney injury, the use of nephrotoxic (risk of damaging the kidneys) medications (which placed R411 at higher risk for diarrhea) and the presence of a colostomy. 2. R412's clinical records revealed: 7/20/22 - R412 was admitted to the facility with diagnoses including dementia, hypertension, chronic kidney disease and diabetic mellitus. 7/22/22 - R412's nutritional care plan documented, . Presents with nutritional risk r/t (related to) DM (diabetes mellitus) . CKD (chronic kidney disease). 4/19/24 - R412's quarterly MDS assessment documented a BIMS score of 2, indicating severe cognitive impairment. The MDS assessment also documented that R412 was independent with eating and needed substantial or total help from staff with all other activities of daily living. 6/26/24 9:33 AM - R412's nutritional assessment documented a fluid goal of 2,100 ml per day. 7/1/24 2:48 PM - R412's clinical records documented, .Vomit x 1 episode . 7/3/24 8:47 AM - R412's clinical records documented, Patient to increase fluids today. R412's clinical records lacked evidence of documentation of increased fluids given. 7/4/24 1:27 PM - R412's clinical records titled Interact [a document for a change in condition] documented, .15.7-pound weight loss since 4/16/23 . R412's clinical records lacked evidence of interventions for the weight loss. 7/6/24 4:37 AM - R412's clinical records documented, Nutrition note: no meals offered this shift, resident id d [did] consume a 240mL of extra fluids . 7/6/24 11:46 AM - R412's clinical records documented, Hypernatremia . [high sodium level in the blood] .Plan Give 1/2 NSS [normal saline] at 75cc/hr [hour] x1 liter. Repeat BMP [Basic Metabolic Panel] on Monday. 7/6/24 12:21 PM - R412's clinical records documented a sodium level of 156, and a BUN of 34. 7/7/24 11:49 AM - R412's clinical records documented, .Resident noted with a poor appetite for lunch. Consumed less than 25% of his lunch requiring assistance with feeding by nursing staff . 7/7/24 12:00 AM - R412's clinical records documented, .Attempts to restart iv were unsuccessful. Therefore, a phone call will b [be] made to [Name of IV Company}. R412's clinical records lacked evidence that the IV was started. 7/7/24 3:09 PM - R412's clinical records documented, .Resident has new orders to administer IV fluids sodium chloride 0.45% @ 75ml/hr [hour] X 1 liter for hypernatremia, However, previous shift unable to obtain IV access for fluid hydration. [Name of IV Company] notified by this writer confirmation # 319625. Spoke with [Name of IV Company staff's name]. Who states she doesn't have a ETA as of yet? Also states the technician has been dispatched. Oncoming nurse made aware of all the above mentioned and to follow up. R412's clinical records lacked evidence that the IV company came out to start the IV access. 7/7/24 4:15 PM: E8 (NP) documented in R412's clinical records, Seen today for IV access. Nurse attempted 2 times but unsuccessful to place PIV, Patient ordered for IVF for Hypernatremia of 156 Plan: Attempt to place PIV again, Call the IV team again and get an ETA. The clinical records lacked evidence of fluids given to R412. 7/8/24 10:35 AM - R412's clinical records documented lab results, Sodium- 161 BUN 34.0. 7/8/24 11:37 AM - E8 (NP) documented in R412's clinical records, .Sent to hospital for critical sodium level and to rule out stroke seen today for increased sodium level and right mouth drooping. Nursing reports patient had a sodium level of156 on Saturday, nursing called on-call and patient was started on sodium chloride 0.45% at 75 mL/h IV for the hypernatremia. Nursing staff unable to get IV line started and had to order from outside company to come in and place a midline. Company schedule to come out Monday morning. Sodium rechecked on 7/8/2024 and was at 161 and chloride at 126. Patient found resting in bed and unable to answer questions, patient mumbling. Patient's right lip drooping. No line placed in patient yet for IV solution. Vitals are stable. Patient's sister present and updated that patient will be sent to the hospital to address the hypernatremia and rule out stroke Lab from 7/8/2024-sodium 161 and critical. Sent to the hospital due to no IV access and sodium needing to be addressed. Patient unable to make out words, this is new for patient . 7/8/24 1:43 PM - A facility document reported to the Division documented, During clinical rounds this morning it was noted that an IV order from 7/6/24 was attempted multiple times by nursing staff unsuccessfully. The contracted IV placement specialists had not yet arrived in the facility to place the ordered midline. Investigation initiated and ongoing. 7/9/24 12:30 PM - R412's hospital records documented, Hypernatremia with sodium as high as 158-160, this is improving with D5 water. 7/10/24 2:04 PM - R412 was readmitted to the facility. R412's hospital discharge summary documented, AKI (acute kidney injury) on CKD, Resolved. 7/11/24 - R412 readmission nutrition assessment documented, Readmit s/p [status post] hosp [hospitalization ] for hypernatremia .facial droop which corrected per hospital records s/p IV hydration. The assessment also documented, Is there a nutritional problem? And the answer was, No. R412's readmission care plan and nutritional assessment lacked evidence of interventions for hydration despite the recent hospitalization for increased sodium level. 7/15/24 12:40 PM - E8 (NP) documented in R412's clinical records, readmitted .was sent to emergency for evaluation secondary to elevated sodium levels and right facial droop. Facial droop improved . may have been secondary to hypernatremia Creatinine at baseline was 1.4-1.5 currently at 1.5-2.1. Patient stable and discharged back to facility for care. 7/24/24 - A facility document to the Division titled, 5 day follow up, included, While a delay in treatment occurred, there was no negative outcome for the resident the IV contracting company will be contacted for discussion related to providing timely services and notification to facility. In addition, education was completed with facility licensed nursing staff to include concerns with ability to carry out physicians' orders to follow facility protocol of notifying Director of Nursing or Assistant Director of nursing for further direction and follow up. In addition, medical providers were notified that other types of supplemental hydration can be administered in place of peripheral to include by not limited to Hypodermoclysis [a method to give fluids under the skin for patients who need hydration] therapy. The kits have been ordered to have on hand. Licensed nursing staff have also been educated on this process and procedure. 11/20/24 10:00 PM - During an interview E7 (Dietitian) stated, The residents' weights are reviewed to formulate what their fluids goals are, and that is added to their meal tickets. 11/22/24 10:30 PM - During a telephone interview the Surveyor asked E3 (NP) at what time would the plan of care have to be changed for the resident with a sodium level 156 and the IV hydration could not be started. E3 stated, That would depend on what the nurses tell me, and how long it would take for [Name of IV Company] to come to the building. I don't think it should be longer than 8 hours if the patient is not drinking though. 11/22/24 11:00 AM - During an interview E5 (LPN) stated, The patient would have to go out for treatment really soon if they can't start the IV and he is not drinking. 11/22/24 11:15 AM - During an interview E6 (LPN) stated, The patient would probably have to go out in about 4 hours if they can't get the IV started. 11/22/24 2:30 PM - During a telephone interview, the Surveyor asked E13 (MD) about the timeliness in care and treatment for a patient with a diagnoses of chronic kidney disease and a documented sodium level of 156 on 7/6/24 and a sodium level of 161 on 7/8/24. E13 stated, That depends on if the resident was drinking fluids and if he looked sick. The facility sent him out when he started having symptoms. E13 further stated that R412 did not suffer from any adverse effects from the delay in treatment despite documented of lethargy and facial droop. 11/22/24 2:45 PM - A review of R412's clinical records from 6/20/24 through 7/20/24 lacked evidence that he was monitored for adequate fluid intake. The facility failed to ensure that R411 was offered sufficient fluid intake to maintain proper hydration and health. And that R412 received care and treatment in a timely manner for increasing sodium levels. 40163 3. Review of R89's clinical record included: 2/12/24 - R89 was admitted to the facility. 2/12/24 - R89 weighed 15.2 pounds on admission. 7/1/24 - A nutrition note documented that R89 had a weight loss of 13.2 pounds (9.1%) in three months. 8/14/24 - A quarterly MDS assessment documented that R89 was a set up assistance for eating and not on a physician prescribed weight loss regimen. 10/1/24 - A physician order included: Weigh every day shift every Thursday for four weeks. 11/7/24 - Review of R89's EHR revealed that there were only initials and a check mark and no weight recorded. The facility lacked evidence of R89s weekly weight being obtained. 11/11/24 10:53 AM - A nutrition progress note documented that R89 has had a significant unplanned, undesired weight loss of 12.6%. R89 had a 19 pound weight loss in six months. Although the facility implemented nutritional interventions, the facility failed to evaluate R89's 11/7/24 weight per physician order. 11/14/24 12:14 PM - During an interview, E28 (LPN) confirmed that the facility lacked evidence that R89's 11/7/24 weekly weight was obtained and that R89 had experienced a significant weight loss. 11/25/24 1:00 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for medications, the facility failed to ensure that R1 was ordered and received necessary insulin for a diagnosis of insulin dependent diabetes upon her admission to the facility from 2/14/24 to 2/19/24. The facility's failure placed R1 in a severe adverse outcome, hyperglycemia, and diabetic ketoacidosis. Due to this significant medication error R1 became unresponsive and was emergently transferred to a hospital and received emergent treatment for hyperglycemia, diabetic ketoacidosis, and acute kidney injury resulting in harm to the resident. Based on interviews and review of the facility documentation and other sources, an Immediate Jeopardy (IJ) was called on 2/23/24 at 1:14 PM. The IJ was abated on 2/23/24 at 3:50 PM. Findings include: A facility nursing policy dated 12/8/14, and revised 6/1/21, titled, 24 Hour Chart Check, documented .The licensed nurse completing the 24 Hours Chart Check identifies and corrects improper orders in the medical record .the purpose is to validate the correctness of orders, proper transcription, and to prevent improper treatment or omission of treatment, medication, ancillary orders, or documentation . R1's records revealed: 2/14/24 9:11 PM - R1 was admitted to the facility with diagnoses including but not limited to insulin dependent diabetes mellitus with hyperglycemia. R1's hospital physician's discharge orders included, insulin lispro (insulin lispro 100 units/ml injectable solution) via continuous insulin pump per current pump settings. 2/15/24 - R1's baseline care plan documented, Non-insulin dependent diabetic. 2/15/24 - E5's (NP) progress notes documentation included, .Patient (R1) to continue on insulin .I reviewed external hospital notes/discharge summary . 2/15/24 - The MAR lacked evidence of an order or an administration of insulin. 2/16/24 - E5's (NP) progress notes documentation included, .Patient (R1) to continue insulin . 2/16/24 - The MAR lacked evidence of an order or an administration of insulin. 2/19/24 6:40 AM - R1's clinical records documented that R1 was observed with medical status changes including respiratory distress. R1's blood sugar was, was greater than 500, and the glucometer read HI. Normal blood sugar ranged between 70-120 (World Health Organization). 2/19/23 7:35 AM - R1's electronic emergency room records documented blood sugars of 580 and 980. 2/22/24 12:10 PM - A review of R1's MAR from 2/14/24 through 2/19/24 lacked evidence that the facility administered any insulin. 2/22/24 1:30 PM - During a telephone interview, E5 (NP) stated, I saw that the resident (R1) had an episode of low blood on 2/15/23 at 6:00 AM, and I wanted to wait to see if she needed insulin. E5 confirmed that she did not order blood sugar checks to monitor R1's blood sugar status for further evaluation. E5 also confirmed that her documentation in R1's medical records included resident (R1) continues on insulin. 2/22/24 2:00 PM - During a telephone interview, E4 (RN) stated, The hospital nurse told me that the resident (R1) was diabetic when she called report. A review of R1's medical records lacked evidence that the doctor was notified of the admission orders. E4 (RN) stated, I don't remember which doctor I spoke to. I did not know I had to write that information down. 2/23/24 10:25 AM - During a telephone interview with E6 (Consultant Pharmacist) stated, I reviewed R1's records on 2/15/24, but I missed the order for the insulin. E6 confirmed that R1's order for insulin dated 2/14/24 was missed from the hospital records. The facility failed to order and administer R1 with necessary insulin to treat her diabetes per her hospital discharge orders dated 2/14/24. R1 was sent to the hospital and was diagnosed with hyperglycemia, diabetic ketoacidosis, and acute kidney injury. 2/23/24 1:14 PM - Based on interviews and review of the facility documentation and other sources, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), E3 (RRM). 2/23/24 3:50 PM - E1 (NHA) submitted an acceptable abatement plan with documentation that all current residents with diagnosis of diabetes were audited to ensure that insulin orders, blood sugar checks, labs needed, diabetes care plan and hypoglycemic protocols were in place. All current licensed nursing staff and personnel involved in the admission process including providers, and consultant pharmacist, were and will be provided with re-education on 24 hours chart checks, admission process with intense focus on reviewing the hospital records thoroughly for focus on diabetes medications, and residents admitted with insulin pumps, transcription of orders with focus on reviewing diagnosis and orders with physician and documenting the name of the provider who approved the orders. The facility's Immediate Jeopardy was abated at this time. 2/23/24 3:55 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM).

Based on record review, interview and review of other facility documentation as indicated, it was determined that for three (R37, R89 and R105) out of 25 initial pool residents reviewed for Advance Directives in relation to code status, the facility failed to ensure that code status' were accurate and congruent in all facility documents. For R37, his electronic medical records (EMR) failed to match the Resident Healthcare Instructions Checklist filed in the advance directive tab of the paper chart located in the Memory Care nursing station. For two residents (R89 and R105), their EMRs failed to match the staff generated shift report that R89's staff nurse in the Memory Care unit and R105's staff nurse in the East unit use as a reference in determining the code status. Furthermore, interviews with multiple staff revealed inconsistencies regarding where to find the back up information on each resident's code status in the event of an EMR system failure. The discrepancy put R37, R89 and R105 at immediate jeopardy (IJ) of a serious adverse outcome by not having a confirmed, accurate code status in the event of a medical emergency. The inaccuracies could result in CPR being administered to a resident requesting to not be resuscitated (DNR) or CPR not being performed on a resident requesting that all life sustaining measures be performed (Full Code). The IJ was identified on [DATE] at 4:00 PM and was abated on [DATE] at 3:42 PM. Findings include: The facility policy on Code Status Orders, dated [DATE], indicated that Code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Patient identification mechanisms and information about each patient's code status (Full code vs. Do Not Resuscitate (DNR)) will be easily accessible to the clinical staff for all patients .To ensure that the patient's desired resuscitation wishes are documented in the medical record. 1. Review of R37's clinical records revealed the following: [DATE] - R37 had an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 4:05 PM - Review of R37's code status was displayed in the EMR as DNR. [DATE] at 9:40 AM - During an interview, E35 (LPN) stated that the facility provides a copy of the signed advance directive with the code status to the receiving provider. E35 further stated that the documents were usually scanned into the EMR and added, .if we can't find a scanned signed copy of the code status in the (EMR), we look at the chart and print copies from the documents filed in the advance directive tab. [DATE] at 9:42 AM - Review of R37's paper chart revealed an undated Resident Healthcare Instructions Checklist filed in the advance directive tab that documented Attempt CPR. [DATE] at 9:43 AM - When asked about the discrepancy of R37's code status from the EMR physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R37's code status was recorded in two different documents that did not match. 2. Review of R89's clinical records revealed the following: [DATE] - R89 had an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 3:45 PM - Review of R89's electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] at 9:40 AM - During an interview, E35 (LPN) stated that in the event that a resident becomes unresponsive, she will first determine the code status by checking the shift report sheet. E35 stated, It has the residents' updated code status. The night nurse in the Memory Unit checks and updates the resident's code status for any status changes in the staff generated shift report. [DATE] at 2:00 PM - Review of the Memory Care Unit's shift report sheet documented R89's code status as a Full Code. R89's code status was recorded in two different documents that did not match. 3. Review of R105's clinical records revealed the following: [DATE] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 2:45 PM - Review of R105's EMR documented the residents code status as DNR. During an interview on [DATE] at 2:52 PM, E32 (RN) stated the resident's code status was located at the front of chart and in the computer. I can also see it on the MAR, in front of the chart and on the assignment sheet too. During an interview on [DATE] at 2:54 PM, E45 (LPN) stated residents' code statuses were located In the computer, its right there on the dashboard [EMR] and then in the beginning of the chart. E45 stated she would not look at the resident assignment sheets because they may not be up to date. [DATE] 2:55 PM- Review of the East unit's resident assignment sheets for nurses documented R105 as having a code status of full code. [DATE] 3:33 PM- Review of the undated resident healthcare instructions checklist documented R105 as a DNR code status, reviewed with E43 (MD). The checklist was filed in the advance directives tab in the chart. During an interview on [DATE] at 3:36 PM, E6 (RN UM) was asked the locations of resident code status information. E6 answered Under their name and picture in the EMR, physicians orders and front of paper chart. E6 then explained under emergent conditions, E6 would look it up depending on where I was in the building, whatever was closest. E6 confirmed R105's code status as a DNR using the EMR. When asked where else staff could locate resident code status and information, E6 stated, The healthcare instruction checklist and staff can use the assignment sheets. E6 was shown the discrepancy between R105's EMR that documented the resident as a DNR and the resident assignment sheet which documented the resident as a full code. R6 stated, That has not been updated . the nurses are supposed to update them, I would have to ask them how often they update them. There is one that can be generated from the software. I don't work the cart, but this (the resident assignment sheet) is what nurses use. E6 then reported she would update the resident assignment list to reflect R105's ordered code status as well as review the rest of the residents on the assignment sheet. [DATE] 4:00 PM - E3 (RNC) and E1 (NHA) were made aware of the above findings. [DATE] at 3:20 PM - In an interview, E36 (LPN) stated that when a resident becomes unresponsive, she would check the resident's profile and code staus order in the EMR. E36 also stated that the code status is documented in the nurse shift report (referring to the staff generated shift report). In the event that the EMR is not available, E36 stated that she would go to the chart and check the advance directive tab for the signed copy of the residents code status. [DATE] at 4:00 PM - E1 (NHA) and E3 (RNC) were notified by the survey team that during the initial pool record review, it was identified that three residents (R37, R89 and R105) did not have consistent advance directives related to code status in their medical records and that nursing staff were unable to consistently state where the accurate code status could be found. [DATE] at 5:58 PM - In an interview, E1 reported that an abatement plan had been initiated and that facility - wide education related to resident emergency code status, location of code status, and protocol for determining code status was being implemented. [DATE] at 7:36 PM - E1 confirmed that an audit was completed of all residents to ensure accurate code status'. [DATE] at 10:24 AM - E1 provided the survey team with an action plan for continued training. [DATE] at 3:42 PM - E1 provided the survey team with updated policies and evidence of licensed staff education. The survey team through interview and record review confirmed: -advanced directives/code status for all residents were accurate and congruent in all facility documents. -facility nursing staff were able to articulate how to find the code status for all residents. -staff education was conducted and was ongoing for staff prior to working. Abatement of the IJ was called at 3:42 PM on [DATE]. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on [DATE], beginning at 3:15 PM.

Based on observation, clinical record review, interviews, review of the facility's policies and procedures, and review of other facility documentation as indicated, it was determined that the facility failed to ensure that emergency equipment was available for potential accidental dislodgement for two (R7 and R67) out of two active residents in the facility reviewed for [CONDITION(S)] ([CONDITION(S)]) related care. The lack of available emergency equipment, in addition to the lack of competent trained staff in [CONDITION(S)] care posed an immediate jeopardy (IJ) situation to the residents with tracheostomies. The IJ was identified on 6/8/22 at 6:05 PM and was abated on 6/9/22 at 1:55 PM. Additionally the facility failed to ensure [CONDITION(S)] supplies were available for ordered treatments for R67. Lastly, during a random [CONDITION(S)] care observation of R7, the facility failed to ensure auscultation of R7's breath sounds at the conclusion of [CONDITION(S)] care. Findings include: EMERGENCY EQUIPMENT (SUPPLIES): Review of the facility's policy and procedure titled [CONDITION(S)] Emergency Bedside Supplies, with a revision date of 6/1/21, stated the following emergency supplies will be kept at the resident's bedside and nursing is responsible for maintaining the supplies. Supplies include a spare [CONDITION(S)] tube with obturator (device that closes or blocks up an opening) of the same manufacturer brand and size currently used or one size smaller if the same size is not available, syringe for cuff inflation/deflation, manual resuscitation (Ambu) bag with any necessary connectors to fit the resident's [CONDITION(S)] tube. 1. Review of R7's clinical record revealed the following: 8/6/21- R7 was admitted to the facility with a [CONDITION(S)]. 8/6/21 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #6 [MEDICATION(S)] size and as needed. 6/8/22 beginning at 2:29 PM - A joint observation with E5 (RN UM) was done of the emergency supplies that must be at the bedside. All supplies were observed with the exception of a replacement Shiley #6 [MEDICATION(S)] cuffless [CONDITION(S)] tube. Upon confirmation of the lack of replacement [CONDITION(S)] tube at the bedside, E5 left R7's room and returned to the room at 2:42 PM, approximately 13 minutes later with a replacement [CONDITION(S)] tube with the obturator. 6/8/22 2:39 PM - During an interview with the assigned LPN (E39), the Surveyor asked if the emergency supplies at the bedside was previously checked during the day shift and E39 stated it was not done. E39 was able to locate all of the emergency supplies and confirmed the replacement [CONDITION(S)] tube and obturator were not at the bedside. E39 proceeded to leave the room and stated she will locate E5 (RN UM). 6/8/22 3:45 PM - An interview with E12 (NPE) revealed for a resident with a [CONDITION(S)], emergency supplies that must be at the bedside for potential accidental decannulation of a [CONDITION(S)] tube included a spare [CONDITION(S)] tube with obturator or one size smaller and a syringe. 2. Review of R67's clinical record revealed the following: 7/5/18 - R67 was admitted to the facility with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. 8/4/21- A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R67's care plan for [CONDITION(S)], last updated 5/9/22, had a goal that the resident would have no complications developed by the [CONDITION(S)] for 90 days. Some of the interventions included in the care plan included to keep the Ambu bag and extra [CONDITION(S)] tube in the resident's room. 6/8/22 2:45 PM - During screening of R67 for the initial pool, E32 (RN) was asked to show the Surveyor the emergency supplies for R67. On R67's wall near the bedside was a bag with a replacement [CONDITION(S)] tube, however, there was no Ambu bag present. From 2:45 PM to 2:48 PM, E32 searched R67's room for an Ambu bag and after three minutes, located it on the far side of R67's room in a cardboard box. E32 then stated, There was new equipment delivered, someone must have moved it by accident. b. 2/15/22 - An order was implemented for R67's [CONDITION(S)] tube to be changed monthly and as needed. R67's care plan for [CONDITION(S)], last updated 5/9/22, had a goal that the resident would have no complications developed by the [CONDITION(S)] for 90 days. Some of the interventions included in the care plan were as follows: [CONDITION(S)] tube changed every 30 days. R67's care plan for alteration in respiratory status related to [CONDITION(S)], last updated 5/9/22, included the intervention that the [CONDITION(S)] tube be changed per physician order. 2/9/22 11:11 AM - A note in R67's clinical record documented, eMAR progress note: change [CONDITION(S)] tube monthly .every 1 month(s) starting on the 1st for 28 day(s). [CONDITION(S)] tube size not available at this time. Ancillary [staff] made aware to reorder. NP made aware. Will reschedule for 2/11/2022, pending delivery. [R67's] (mother) made aware as well. No respiratory distress observed. 2/11/22 2:53 PM - A note in R67's clinical record documented, Residents [CONDITION(S)] tube changed today as per physicians orders per monthly. 5/1/22 5:26 PM - A note in R67's clinical record documented, No inner cannula (smaller tube for insertion into the [CONDITION(S)] tube) available to change. [CONDITION(S)] care provided. 5/15/22 2:36 PM - A note in R67's clinical record documented, [CONDITION(S)] care including inner cannula and drain sponge every day and evening shift inner cannula has been cleansed none available to replace. Drain sponge changed. 5/16/22 2:57 PM - A note in R67's clinical record documented, No inner cannula available to exchange. 5/18/22 8:57 PM - A note in R67's clinical record documented, No inner cannula available to exchange. 5/19/22 12:59 PM - A note in R67's clinical record written by E49 (RT) documented, Talked with patients RN about [CONDITION(S)] inner cannula supply issue. No current [CONDITION(S)] inner cannula's available, but we do have [other sized] inner cannula's that fit and will not cause a patient safety concern. Discussed usage with RN and I will speak with materials manager regarding current solution. Review of the May 2022 TAR revealed the changing of R67's inner cannula was incorrectly documented as completed on 5/1/22. 6/1/22 12:06 PM - A note in R67's clinical record documented [CONDITION(S)] care including inner cannula was changed by respiratory therapist. 6/13/22 at 11:35 AM - During an observation of [CONDITION(S)] care with E32 (RN), E32 was asked if the facility always has [CONDITION(S)] supplies for R67, E32 replied, No, but before Surveyor's came the respiratory therapist changed the order so we would have the supplies. During an interview on 6/14/22 at 9:52 AM, E6 (RN UM) confirmed that R67's [CONDITION(S)] supplies were not always available. During an interview on 6/14/22 at 10:11 AM with E51 (supply staff), it was confirmed that at times R67's [CONDITION(S)] supplies were unavailable. E51 stated it was due to Back order because of COVID. During an interview on 6/14/22 at 10:55 AM, E2 (DON) reported that when R67's supplies are unavailable she Will drive to our other center. Then we will call our provider and they will give us an order to change the date. E2 attributed the facility's lack of supplies for R67's [CONDITION(S)] care to back orders and one product was discontinued, we couldn't order it. 6/16/22 11:08 AM - An interview with E50 (Supervisor) for respiratory contract service it was reported that From time to time there have not been inner cannula's. COMPETENT TRAINED STAFF: 3. 6/8/22 3:45 PM - An interview with E12 (Nurse Practice Educator - NPE) revealed that all licensed nurses at the time of orientation training and validation completed [CONDITION(S)] care and documented on the facility's Clinical Competency Validation for [CONDITION(S)] Care documentation. E12 confirmed that this document did not include the steps to take during a [CONDITION(S)] dislodgement. E12 stated the last training and competency validation for [CONDITION(S)] dislodgement was conducted by a previous Contracted Respiratory Therapist and E12 would provide this information to the Surveyor as soon as possible. 6/8/22 4:45 PM - During an interview with E12 in the presence of E1 (NHA), E12 provided evidence of inservice and competency validation conducted for [CONDITION(S)] dislodgement on 6/3/21. Review of the list revealed that three (3) RNs (E5, E31 and E32) out of 15 current RNs completed training and competency validation. E12 confirmed the facility was unable to provide evidence for the remaining 12 RNs. 6/8/22 6:05 PM - During an interview with E1 and E12 (NPE), the parties were advised that the lack of emergency equipment and lack of competent trained staff for dislodgement of a [CONDITION(S)] was an Immediate Jeopardy. Findings were confirmed with E1 and E12. E1 stated that the facility began the training and competency validation process within the past hour. 6/8/22 6:30 PM - The facility had evidence of training for a total of (7) RNs, including retraining of the three (3) previously trained RNs (E5, E31 and E32). 6/8/22 7:36 PM - The facility's abatement plan included: - Proper emergency [CONDITION(S)] supplies have been placed at both [CONDITION(S)] patients bedside as of approximately 3:15 PM on 6/8/22. - Out of 15 RN's on staff, 7 (seven) have already been educated on decannulation and emergency [CONDITION(S)] care. The remaining RNs will be educated on the topic prior to the start of their next scheduled shift. Any newly hired RN's or agency RN's will be educated upon starting employment at the center. - Orders were placed to ensure emergency [CONDITION(S)] supplies (i.e. Ambu bag and replacement [CONDITION(S)] supplies) are checked by nursing and tracked on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - The facility will develop a policy and procedure for emergency decannulation by 6/9/22. 6/9/22 10:00 AM - Interviews were conducted with current nursing staff to determine they received training as outlined in the written plan. 6/9/22 10:00 AM - The facility provided a copy of the policy and procedure for emergency decannulation. 6/9/22 1:55 PM - The facility provided evidence that all current RNs completed their training and the IJ was abated. Review of the facility's policy and procedure titled [CONDITION(S)] Care, with a revision date of 7/15/21, stated upon completion of [CONDITION(S)] care, .33. Evaluate patient's respiratory rate, heart rate, breath sound, pulse oximetry, and cough effort. 4. 6/13/22 beginning at 11:00 AM - During a random [CONDITION(S)] care observation, E21 (RN) performed routine [CONDITION(S)] care, including suctioning of R7. E21 evaluated R7's respiratory rate, heart rate, pulse oximetry, and cough effort, however, failed to evaluate R7's breath sounds post [CONDITION(S)] care. 6/13/22 1:45 PM - An interview with E12 (NPE) confirmed that R7's breath sounds should have been auscultated after routine [CONDITION(S)] care. 6/22/22 beginning at 3:15 PM - The above findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on interview, review of the clinical record, review of the facility's guideline and review of professional clinical resources as indicated, it was determined that for one (F87) out of five (5) sampled residents for pressure ulcer (PU) reviews, the facility failed to ensure that the resident received the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers (PU's) from developing. R87 was admitted to the facility with no PU, was assessed as being at risk for the development of PU's, yet the facility failed to develop and implement preventative measures, including an individualized turning and repositioning (T&R) program that resulted in R87 acquiring an avoidable unstageable PU of the sacrum on 6/1/22. Findings include: According to the National Pressure Ulcer Advisory Panel (April 2016), the stages of pressure injuries/ulcers (categorization system used to describe the severity of PUs) included: Stage III (3) - skin develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Undermining may occur. Stage IV (4) - ulcer has become so deep that there is damage to the muscle and bone and sometimes to tendons and joints. Unstageable - Tissue loss in which actual depth of the ulcer is unable to be determined due to the presence of slough (yellow, tan, gray, green or brown dead tissue) and/or eschar (dead tissue that is tan, brown or black and tissue damage is more severe than slough in the wound bed). Review of the facility's undated guidelines revealed the following: Pressure Ulcer Prevention Guidelines. Basic Prevention Interventions for all patients at risk. Perform daily observation of the skin . Apply moisturizer daily. Apply moisture barrier to high risk areas such as heels, elbows, etc . Encourage frequent repositioning/weight shifting . Utilize pressure redistributing surface . Risk Factor Impaired/Decreased mobility/function. Example of Intervention . Individualized positioning and repositioning schedule . refer to rehabilitation for seating/positioning/interventions to increase mobility and function . turning and repositioning plans are implemented regardless of bed surface . Guidelines: Turning and Repositioning . Provide turning and repositioning to individuals at risk for pressure ulcers; specifically, those who have impaired mobility and/or impaired sensation. Turning and repositioning plans are implemented regardless of bed surface. Schedules are based on individual needs, risks, tissue tolerance . Cross-refer F697 Review of R87's clinical records revealed the following: 5/17/22 3:24 PM - A Nursing Documentation Note (Progress Note) documented that R87 was admitted for pain management and therapy. The Admission Nursing Skin Assessment documented the presence of three (3) small scabs on top of the right foot, however, R87 was not admitted with a PU. R87 was documented as having pain during T&R with a pain rating of 10 and at rest, a 7 (Pain Scale of zero (0) to 10 with 0 being no pain and 10 being the worst pain imaginable). 5/17/22 - The care plan stated that R87 required assistance with ADLs and interventions included one staff person to provide extensive assistance with bed mobility. 5/17/22 - The Braden Scale (completed by facility Nurse's) was completed with a score of 15 or that R87 was at mild risk for the development of PU's. There was lack of evidence that the facility developed and initiated an individualized T&R program when R87 was assessed as being at risk for the development of a PU. 5/17/22 through 5/24/22 - CNA Documentation Survey Report stated R87 required total assistance of staff on two (2) out of 17 shifts documented, required extensive assistance of staff for 13 out of 17 shifts and limited assitance of staff for two (2) out of 17 shifts. 5/24/22 - A weekly skin check documented no new skin injury/wounds. 5/24/22 - The 5 day Admission MDS Assessment documented that R87 required extensive assistance of two plus staff for bed mobility and transfers, required extensive assistance of one person for toileting, was frequently incontinent of urine and bowel, had no PU's, and R87 was not on a T&R program. 5/24/22 - R87's Braden score was 16 or at mild risk for the development of PU's. 5/30/22 (initial date and revised on 6/8/22) - A care plan stated that R87 was at risk for skin breakdown related to assistance needed with bed mobility and urinary incontinence. Resident has an actual unstageable pressure ulcer (identified on 6/1/22) that included the following interventions: - Pat (do not rub) skin when drying. - Provide preventative skin care (i.e. lotions, barrier creams as ordered). - Assist resident in turning and repositioning every 2 hours (intervention was created on 6/1/22). - Observe skin condition daily with ADL care and report abnormalities. - Offload/float heels while in bed with use of pillows (created on 6/1/22). - Obtain RD consult (created on 6/1/22). - Pressure redistribution surface to bed per guideline. 5/17/22 through 5/31/22 - CNA documentation stated that the following interventions were completed for the prevention of skin breakdown: - Preventative skin care - float heels with use of pillows in bed: For 13 out of 42 shifts, there was lack of evidence that this intervention was implemented. - Preventative skin care - lotion/cream apply barrier cream to buttocks with incontinence care: For 13 out of 42 shifts, there was lack of evidence that this intervention was implemented. There was no evidence that an individualized T&R plan was developed and implemented although R87 was assessed for being at risk for the development of PU's. 5/31/22 - R87's Braden score was 15 or at mild risk for the development of PU's. 6/1/22 1:58 PM - A Wound Assessment by E24 (RN WCN) documented a sacral unstageable PU measuring 1.5 cm L x 3 cm W x 0.1 cm D with 20% granulation, 60% slough, and 20% necrotic. The wound was reported by the CNA who was providing personal care to R87. The NP was notified, care plan updated and orders updated. E24 instructed R87 on the importance of repositioning every two (2) hours to assist with wound healing and to prevent further skin breakdown and R87 verbalized understanding. 6/2/22 - CNA documentation stated that a new intervention to assist R87 to T&R and check skin every 2 hours was initiated, however, there was lack of evidence that this intervention was completed. 6/2/22 2:00 AM - A Nursing Progress Note stated, .sacral wound dressing in place .Resident refused to stay on side even after education. C/O (complaint of) anxiety not relieved by non pharmacological measures . 6/2/22 8:00 AM - A Nursing Progress Note stated, .treatment completed to sacrum (sic) wound. turned and repositioned every 2 hours side to side . 6/3/22 -6/5/22 - CNA documentation revealed that R87 was assisted to T&R and skin was checked every 2 hours as ordered. 6/8/22 12:40 PM - An interview with E24 (RN WCN) revealed that she performed weekly wound rounds and reported any updates to E2 (DON) and the Medical Practitioner. E24 stated that R87's new skin impairment was identified by the CNA providing care to R87 on 6/1/22, however, E24 did not recall the name of the CNA. 6/10/22 3:30 PM - An interview with E24 in the presence of E3 (RNC) was conducted. E24 stated that she recalled initially when R87 was admitted to the facility, R87 was able to T&R independently, however, R87 had difficulty due to pain in the lower part of her body. E3 related that according to the MDS (dated 5/24/22), R87 required assistance of staff with bed mobility. The Surveyor identified there was lack of developing and implementing an individualized T&R program for R87 and E3 related to the Surveyor to follow-up with E2 (DON). 6/13/22 2:30 PM - An interview with the assigned CNA (E25) revealed that R87 was T&R every 2 hours with skin checks during the shift and stated that R87 has not refused to be T&R every 2 hours. 6/14/22 2:45 PM - An interview with the assigned CNA (E42) revealed that R87 was T&R every 2 hours with skin checks during the shift and stated that R87 has not refused to be T&R every 2 hours. 6/14/22 1:50 PM - An interview with E2 (DON) in the presence of E1 (NHA) was conducted. E2 confirmed prior to the identification of the sacral PU on 6/1/22, R87 scored as being at mild risk for the development of a PU on the Braden Scale and R87 required assistance of staff for bed mobility as R87 was unable to perform this without staff assistance. At the conclusion of the interview, the Surveyor requested evidence of whether the facility developed and implemented an individualized T&R program. After the interview, E2 stated that T&R was documented in the resident's clinical record and the Surveyor informed E2 that the Surveyor had reviewed R87's clinical records, including Nursing progress notes and there was lack of evidence of an individualized T&R plan. 6/22/22 beginning at 3:15 PM - The above findings were reviewed during the Exit Conference with E1 and E2.

Based on record review and interview it was determined that for one (R2) out of three residents reviewed for accidents, the facility failed to ensure that the appropriate assistive device and supervision were used during transfers. R2 was transferred twice (bed to wheelchair and wheelchair to bed) without a mechanical lift (a machine used to move a resident if the resident cannot safely transfer from surface to surface) and two person assist. This resulted in harm when R2 experienced pain and was found to have a broken leg. Findings include: A facility policy entitled Safe Resident Handling (effective 10/1/2005 with a revision date of 5/12/16) included: All residents will be assessed on admission .by a licensed nurse for assistance with transfer activities. Review of R2's clinical record included: 2/12/2021 9:15 AM - A Physical Therapy note from the hospital (prior to admission to the facility) documented that the resident was not safe for staff to transfer, and if rehab was not available, R2 would be sent home with a mechanical lift. 2/12/2021 11:54 AM - A Nursing Procedure: Social Worker's note from (a hospital) documented: Loss of caregivers may limit ability for patient to remain in family care as patient is noted as bed bound x (times) approximately 4 years (per recent case management notes). Daughter reports that with active therapy patient was making progress toward stand pivot transfer to wheelchair but had not achieved status. 2/12/2021 1:50 PM - R2 was admitted to the facility with a urinary tract infection, COVID-19, and a history of a stroke with right-sided weakness. R2's admission progress note documented that R2 did not have pain at that time. There was no evidence of a lift/transfer assessment being completed at the time of admission. 2/13/2021 7:50 AM - A nursing progress note included: Resident oob (out of bed) to wheelchair stand pivot transfer. Once pt (patient) in bed and staff exiting her room she started calling staff back and states, my right knee hurts bad 10/10 (on a 0-10 scale, 10 is the worst possible pain), pt (patient) cries out with gentle palpation (touch). 2/13/2021 4:46 PM - A progress note documented, 1530 (3:30 PM) X-ray right knee shows fracture (broken bone). E6 (Medical Doctor) here and aware. Doctor [MEDICATION NAME] resident and order received to send to (hospital) via 911 for eval (evaluation). 2/15/2021 1:45 PM (approximately 2 days after R2 was sent from the facility to the hospital) - A late entry progress note for 2/13/2021 at 8:39 AM documented: Lift assessment attempted however after initial stand and pivot to wheelchair and back to bed, resident c/o (complained of) pain after returned to bed. Assessment could not be completed at this time. 2/22/2021 4:15 PM - During a telephone interview with E4 (CNA), E4 confirmed that R2 was transferred twice without the supervision of a licensed nurse and that R2 could not fully bear weight. E4 stated that it was a short distanced quick transfer and that R2 did not have to bear much weight because the transfer was 1, 2, 3 boom. 2/23/2021 11:37 AM - During a telephone interview with E5 (LPN), E5 stated if therapy had not evaluated the resident for transfer status, that she would review the hospital paperwork to determine transfer status while the resident was an inpatient at the hospital. E5 confirmed that an admission lift/transfer assessment was not completed, and stated that she asked E4 (CNA) to wait for her, but E4 did not wait for E5's supervision during R2's two transfers. E5 reported that she wanted to complete the lift/transfer assessment, but was unable to related to E4 having transferred R2 alone and the resident at that point was in too much pain. E4 transferred R2 twice without a mechanical lift and adequate supervision resulting in pain and a broken leg. Additionally, a lift/transfer assessment was not completed before attempting a resident transfer. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) on 2/24/2021, at the exit conference, beginning at 11:30 AM.

Based on observations, interviews and review of CDC (Centers for Disease Control) COVID-19 guidelines and facility policies it was determined that the facility failed to follow COVID-19 precautions to isolate and cohort six (R1, R4, R6, R8, R10, and R12) out of six residents on the long term care section and three (R14, R17 and R18) out of three residents on the rehabilitation section by placing asymptomatic and presumptive positive COVID-19 residents in shared rooms. On the locked dementia unit, an asymptomatic resident (R21) was a roommate with a COVID-19 positive resident (R20). Additionally, the facility failed to follow proper infection control practice when staff stated that they used the same personal protective equipment (PPE) when providing care to COVID positive/presumptive residents and three asymptomatic residents (R21, R22 and R23) in the locked dementia unit. These failures put the residents at risk for contracting COVID-19. An immediate jeopardy (IJ) was called on 4/17/2020 at 7:10 PM and was abated on 4/17/2020 at 10:59 PM. Findings include: 3/27/2020 - The facility's COVID-19 policy included: In addition to Standard Precautions, Contact and Droplet Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Control (CDC) guidance. Follow local public health and state regulations when applicable. This policy refers to a document called Special Circumstance COVID-19 Outbreak Intervention Tiers for confirmed patients or employees with COVID-19 which included to: Ensure patient has been placed in a private room with the door closed .Care for these patients with dedicated healthcare personnel (cohort staff) to minimize the risk of transmission and exposure to other patients and other health care workers, as much as able. 4/2/2020 - The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) issued COVID-19 Long-Term Care Facility Guidance that included: Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status .When possible, facilities should exercise consistent assignment, or have separate staffing teams for COVID-19-positive and COVID-19-negative patients. 4/15/2020 - The Governor of Delaware's Eleventh Modification State of Emergency Declaration included: All nursing facilities, assisted living facilities, rest residential facilities, and intermediate care facilities for persons with intellectual disabilities shall immediately implement, to the best of their ability, the following personnel practices: Establish a cohort of staff who are assigned to care for residents with known or suspected COVID-19. Designate a room, unit, or floor of the facility as a separate observation area where newly admitted and readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19. Designate a room, unit, or floor of the facility to care for residents with known or suspected COVID-19. Documentation review and observation revealed: 4/17/2020 2:20 PM - Review of the current facility line listing and resident census revealed there were ten residents (R2, R3, R5, R7, R9, R11, R13, R15, R16, and R19) that the facility identified as presumptive positive for COVID-19 that were in the same rooms as asymptomatic residents. There was also one COVID-19 positive resident (R20) in the same room as an asymptomatic resident (R21). 4/17/2020 2:30 PM - The following nine asymptomatic residents (R1, R4, R6, R8, R10, R12, R14, R17, and R18) were not identified on the line listing as having COVID-19 or presumptive COVID-19. These residents were observed to have roommates that were identified by the facility to be presumptive positive for COVID-19. 4/17/2020 2:30 PM to 4:10 PM - During staff interviews on the locked dementia unit, several staff (E9 (CNA), E10 (CNA), E10 (Activity Aide), E7 (LPN) and E8 (RN)) stated they were told by the facility's supervisors and administrators to consider all of the residents on this unit as COVID-19 positive, so staff all stated that they wore the same gown and mask for their entire eight hour shift while providing care to all residents on the unit. 4/17/2020 2:45 PM - E12 (locked dementia unit manager) confirmed that R21, R22 and R23 were the only aymptomatic residents on the locked dementia unit and that R20 tested COVID-19 positive and R20 and R21 are roommates. 4/17/2020 6:42 PM - During an interview with E5 (Corporate Nurse), it was confirmed that nine asymptomatic residents (R1, R4, R6, R8, R10, R12, R14, R17, and R18) were sharing a room with one or two of the 10 facility identified presumptive positive COVID-19 residents (R2, R3, R5, R7, R9, R11, R13, R15, R16, and R19) and that one COVID-19 positive resident (R20) was in the same room as an asymptomatic resident (R21). While the facility maintains an infection prevention and control program they failed to adhere to and implement standard and transmission based precautions to prevent the spread of infection there by jeopardizing the safety and well fare of residents. The facility failed to isolate the ten residents (R2, R3, R5, R7, R9, R11, R13, R15, R16, and R19) that were identified as presumptive positive for COVID-19 and one resident (R20) positive for COVID-19. Additionally, the facility failed to follow proper infection control practice when staff stated they used the same PPE on COVID-19 positive/presumptive residents and asymptomatic residents and failed to provide dedicated health care personnel for COVID-19 positive and presumptive positive residents. These failures put twelve residents (R1, R4, R6, R8, R10, R12, R14, R17, R18, R21, R22, and R23) who were asymptomatic for COVID-19 at risk for contracting COVID-19. 4/17/2020 7:10 PM - E1 (NHA) was notified by the surveyor that an IJ was identified when the facility failed to properly isolate and cohort positive and presumptive COVID-19 residents. The facility had one positive resident (R20) positive resident in the same room with an asymptomatic resident (R21). The facility cohorted 10 (R2, R3, R5, R7, R9, R11, R13, R15, R16, and R19) presumptive COVID positive residents with nine (R1, R4, R6, R8, R10, R12, R14, R17, and R18) asymptomatic residents. Additionally, the facility failed to follow proper infection control practice when staff stated they used the same PPE on COVID-19 positive / presumptive residents and three (R21, R22 and R23) asymptomatic residents on the locked dementia unit. These failures put residents at risk for contracting COVID-19. 4/17/2020 10:45 PM - E1 (NHA) provided the abatement plan for the IJ. 4/17/2020 10:59 PM - The IJ was abated after the following was completed: the facility corrected the improper isolation and the improper infection control techniques to prevent the spread of infection in the facility by moving asymptomatic residents to rooms without COVID-19 positive / presumptive residents and developed an appropriate plan to cohort staffing and provide staff education. 4/22/2020 3:10 PM - Findings were reviewed with E1 (NHA), E2 (Assistant Director of Nursing) and E4 (Corporate Nurse) during an exit teleconference.

Based on observation, record review and interview, it was determined for three (R18, R7 and R5) out of four residents investigated for falls, the facility failed to: - Provide adequate supervision; - Conduct thorough fall investigations, including obtaining witness statements to identify hazards and identify interventions to reduce hazards; - Ensure the correct mechanical lift was used during a transfer; and - Ensure the licensed nurse immediately conducted a post fall assessment. For R18, who had severe cognitive impairment, poor safety awareness, and resided in the locked Dementia unit, the facility failed to provide adequate supervision. R18 sustained 9 falls between (MONTH) (YEAR) - (MONTH) (YEAR). R18 sustained harm when he/she broke his/her wrist from a fall on 8/27/18 and had a broken spine from a fall on 11/8/18. For R7, who had moderate cognitive impairment, impulsive behavior, poor safety awareness, and resided in the locked Dementia unit, the facility failed to provide adequate supervision. R7 sustained 19 falls between July, (YEAR) - February, 2019. R7 sustained harm when he/she received a 7 cm laceration on the left ear on 9/20/18, requiring treatment in the emergency department. For R7 and R18, the facility failed to conduct thorough fall investigations with root cause analyses and they lacked witness statements. For R5, the facility failed to utilize the correct mechanical lift and failed to ensure the licensed nurse assessed the resident before transfer from the floor post fall. Findings include: Review of the facility's Guidelines for Managing a Fall (dated 2011) revealed that staff was to remain calm and stay with the patient. Call for help, and request that someone collect any tools you may need to assess the patient's condition. Call for the licensed nurse to assess the patient. Review of the facility's Fall Response Protocol (revised 5/2013 and used for patient falls) revealed that staff were to evaluate and monitor the patient, then document and investigate the circumstances. Immediate interventions included to perform an assessment for injuries and performing a neurological assessment for all unwitnessed falls and witnessed falls with head injury. Lastly, complete the fall investigation and update the care plan to reflect new interventions. Review of the facility policy entitled Falls Management (revised 3/15/16) revealed, Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. The Purpose: To reduce risk for falls and minimize the actual occurrence of falls; to address injury and provide care for a fall. Practice Standards within the policy included, Communicate patient's fall risk status to caregivers . Develop individualized plan of care. Review and revise care plan regularly. If patient falls update care plan to reflect new interventions. 1. Review of R18's record revealed: 4/7/18 - R18 was admitted to the facility to the secured Dementia unit with multiple [DIAGNOSES REDACTED]. 4/7/18 - A care plan, developed for being at risk for falls related to dementia and [MEDICAL CONDITION] and included a goal that stated, Resident will have no falls with injury for 90 days. Interventions included: Place call light within reach while in bed or close proximity to the bed; Maintain a clutter-free environment in the resident's room and consistent furniture arrangement; When resident is in bed, place all necessary personal items within reach; Monitor for and assist with toileting needs; and Bed rails to bed for enabler (to assist with repositioning by giving R18 something to hold onto). 4/7/18 - A care plan was developed for Resident is at risk for complications due to [DIAGNOSES REDACTED]. The interventions included administer medications as ordered and assess for effectiveness and side effects and report abnormalities to physician; and monitor labs and report abnormal labs to physician. Neither care plan included monitoring of R18's gait (posture when walking) and/or mobility (ability to move or be moved freely and easily) or to monitor safety. [MEDICAL CONDITION] can affect gait and mobility. 4/8/18 - A care plan was developed for impaired / decline in cognitive function or impaired thought process related to dementia and [MEDICAL CONDITION]. Interventions included: Create a calm, soothing environment by using dim lighting, reducing noise, limiting number of people, and reducing clutter. 4/12/18 - A fall assessment reflected that R18 had a score of 12, a high fall risk. 4/13/18 - The Admission MDS reflected the following: R18 was assessed with [REDACTED]. R18 was occasionally incontinent of urine without a toileting program in place. R18 was able to transfer, walk in room and in corridor independently. R18's locomotion on the unit was described as being independent using a cane/crutch. R18 did not have any falls in the last six months. 4/17/18 - A care plan, developed for Resident is occasionally incontinent of urine with potential for improved control or management of urinary elimination related to dementia, included a goal that R18 will demonstrate improved urinary elimination control as evidenced by experiencing fewer episodes of incontinence. Interventions included: Complete a voiding diary and evaluate for patterns of incontinence at appropriate intervals; Discuss and plan voiding schedule with resident; and Provide access to the bathroom. There were no revisions made to this care plan during R18's stay at the facility. 7/6/18 - A progress note stated that R18 had a history of [REDACTED]. 7/6/18 - R18's medical [DIAGNOSES REDACTED]. 7/6/18 - A significant change MDS reflected that R18 continued with severe cognitive impairment and was frequently incontinent of urine and always incontinent of bowel without a toileting program in place. R18 required extensive assistance for transfers with one person physical assist and was able to walk in his/her room and the corridor with supervision. Locomotion on the unit required supervision and mobility devices used were listed as walker and wheelchair. Review of change of condition notes and facility event summary reports described R18's falls: 7/24/18 at 11:40 AM - R18 was witnessed sliding off the mattress and landed on his/her buttocks. Staff were not able to prevent the fall. R18's cognitive/behavior factors before the fall revealed that R18 was alert, confused, poor safety awareness. The root cause of the fall was resident slipped out of bed and the corrective action was a low bed and fall mat(s). A recommendation by the Primary Clinician was to monitor R18 for transfers. It was unclear how R18 was going to be monitored for transfers. 7/28/18 at 3:00 AM - R18 had an unwitnessed fall; R18 slid out of bed onto the floor. Later, R18 stated he/she was trying to use the bathroom and was confused after the roommate turned the lights on and off during the night. The root cause of the fall was identified as the light being turned on and off by R18's roommate with the corrective action being to monitor lighting at night. It was unclear if the facility identified that R18 fell while trying to go to the bathroom. No interventions were added to the care plan for toileting or to prevent sliding off of the bed. 7/30/18 - Goals under the care plan for at risk for falls were amended to include resident will have under 1 fall per week and the following interventions were added: bed in lowest position; chair alarm; fall mat(s); Therapy / Rehab - PT treatment 3 times per week; assist resident with bed mobility getting in and out of bed with assistance of one; remind resident to use call light when attempting to ambulate or transfer; and PT evaluation. Given R18's severe cognitive impairment, it was unlikely that R18 had the mental capacity to remember to use the call bell. Review of change of condition notes and facility event summary reports described R18's falls: 8/27/18 at 3:50 PM - R18 lost his/her balance and fell to the floor. Although this fall was witnessed by the spouse of one of the residents, there were no witness statements. R18 was transferred to the hospital for treatment of [REDACTED]. 9/21/18 at 4:20 AM - R18 had a witnessed fall at which time R18 slid onto the floor, stating that he/she was exercising. There was no witness statement or recommendations identified after this fall. 9/28/18 - The intervention to transfer R18 with the assist of 2 people was added to R18's at risk for falls care plan. 10/1/18 - A quarterly MDS reflected that R18 had severe cognitive impairment and was frequently incontinent of bowel and urine; there was a bowel toileting program in place, but no urinary toileting program. R18 required extensive assistance with transfers with two person physical assist and R18 was able to walk in the room with extensive assistance with two person physical assist. Locomotion on the unit was coded as requiring extensive assistance with one person physical assist and R18 used a wheelchair for mobility. 10/1/18 - R18's fall assessment was 17, a high fall risk. 11/8/18 at 8:00 AM - A change of condition note and event summary report reflected an unwitnessed fall at which time R18 fell in the dining room when attempting to get up out of his/her chair to use the bathroom. This resulted in R18's transfer to an acute care facility for surgery for [REDACTED]. The cognitive / behavior factors before the fall were listed as alert, confused, poor safety awareness. The root cause stated, Resident has poor safety awareness, dementia. The facility failed to identify why R18, a resident with dementia and severe cognitive impairment, was in the dining room without adequate staff supervision. The facility failed to ensure that R18 was properly supervised, in spite of his/her increasing debility and numerous notations that R18 was confused and had poor safety awareness. A toileting program was not implemented, despite R18's incontinence issues and the care plans were not revised to reflect a need for supervision. As a result, R18 experienced 9 falls during his/her stay at the facility between April, (YEAR) and November, (YEAR). Two of the falls resulted in harm to the resident with regard to the 8/27/18 broken wrist and the 11/8/18 compression [MEDICAL CONDITION]. Findings were reviewed with E1 (NHA), E2 (DON) and E9 (ADON) on 3/4/19 during the exit conference beginning at 2:45 PM. 2. Review of R7's clinical record revealed: 6/27/17 - R7 was admitted to the facility with multiple [DIAGNOSES REDACTED]. A variety of care plans were developed for R7: - 7/19/17: Being at risk for falls related to cognitive loss, lack of safety awareness and vision impairment. Fall prevention interventions included: When in bed place all necessary personal items within reach; Monitor for and assist with toileting needs; Place call light within reach while in bed and in close proximity to bed; Provide verbal cues for safety and sequencing when needed. Additional interventions added: 2/9/18 - Supervision when out of bed; 5/1/18 - Low bed; Maintain clutter-free environment in room and consistent furniture arrangement; 7/27/18 - Remind to use call light when attempting to ambulate or transfer; 10/15/18 - Continue reminders to call for assistance for transfers; 10/23/18 - R7 looks forward to going back to bed after meals. Put back to bed 30 minutes after meals; 12/19/18 - Perimeter mattress with reminder bumpers; 12/31/18 - Toileting schedule; 1/14/19 - Utilize night light in room/bathroom; 2/11/19 - assess for changes in medical, mental and pain status and report to physician as indicated; and 2/18/19 - Fall mat(s). - 9/8/17: Impaired vision due to [MEDICAL CONDITION] (eye condition leading to [MEDICAL CONDITION]) with an intervention to enhance vision and maximize independence (large print signs on dresser drawers, adequate lighting, keep items in same location per resident request/needs). - 10/11/17: Impaired/decline in cognitive function related to dementia that included the goal that R7 will be able to make simple decisions by responding yes or no. - 7/19/18: Restorative walking program that included the goal to walk R7 100 feet daily. - 7/30/18: Sliding out of bed to the floor and sits on the floor, refuses help to get off the floor, and states is more comfortable on the floor. 1/3/19 - A Quarterly MDS Assessment revealed that R7 had moderate cognitive impairment (BIMS score 8 out of 15; borderline for severe cognitive impairment), was continent of urine, and needed extensive assistance with one staff for bed mobility, which included getting to a seated position. R7 also required extensive assistance with one staff to walk in the hallway and was unsteady and only able to stabilize with staff assistance. 7/26/18 - 2/16/19 - Review of R7's fall investigation documentation provided by the facility, progress notes and Change of Condition Evaluations revealed that R7 experienced 19 falls in approximately seven months: a. Falls 7/26/18 (10:40 AM) - R7 lost his/her balance and staff assisted R7 to the floor in the dining room. The root cause of the fall was identified as poor recall, poor safety awareness, impulsive. Recommendations included to continue to provide a safe environment. 8/5/18 (2:50 PM) - R7 was found on the floor when going to/from bathroom with the root cause identified as poor safety awareness, impulsive. A recommendation was made to continue to provide safe environment. 8/10/18 (1:30 AM) - R7 removed his/her body alarm and was seen in his/her doorway and fell into the hallway. R7 denied the need to use the bathroom and just wanted to get up. The root cause was identified as poor safety awareness. A recommendation was made to continue with plan of care. 8/25/18 (6:45 AM) - R7 removed his/her body alarm and was found on the floor in the bathroom. The root cause was identified as dementia, poor safety awareness, impulsive. A recommendation was made to continue plan of action. This was R7's second fall going to the bathroom. R7 had no toileting program in place. 8/30/18 (10:00 AM) - R7 fell in the dining room while attempting to move toward his/her walker. The root cause was identified as poor safety awareness. A recommendation was made to supervise when out of bed, but did not include keeping R7's walker within reach. 9/14/18 (12:15 PM) - R7's alarm activated and while walking to the bathroom without using the walker, R7 lost his/her balance and hit his/her shoulder on the door frame of the bathroom and fell on to his/her face/stomach. The root cause was identified as dementia, poor safety awareness. Recommendation included to monitor R7, remind him/her use walker or call for assistance. In light of R7's cognitive impairment, it was unclear how well R7 would remember to use his/her walker or remember to call for assistance. 9/20/18 (1:20 PM) - R7 was found on the floor in his/her room with a 7 cm left ear laceration requiring four stitches in the emergency department. The root cause was identified as dementia, poor safety awareness. A recommendation was made to monitor R7 when out of bed. This was the fourth fall documenting that R7 was going to the bathroom without assistance. A toileting plan was not in place. 10/15/18 (7:30 AM) - R7 was found on the floor in his/her room. Documentation reflected that R7 was going to the bathroom. The root cause stated, dementia, safety awareness. A recommendation was made to remind R7 to call for assistance. This was the fifth fall of R7 going to the bathroom; R7 had no toileting plan in place. It was unclear how well R7 would remember to call for assistance given his/her cognitive impairment. 10/19/18 (9:20 AM) - R7 was found sitting on the floor in his/her room. A recommendation stated, continue plan of care. 11/3/18 (5:30 PM) - R7 fell trying to walk in the dining room. R7's feet caught on the wheels of the wheelchair. It was unclear how R7 could fall in the dining room, which was a supervised common area. 12/13/18 (6:45 PM) - R7 fell in another resident's room trying to get into bed. R7 was to be supervised when out of bed, so it's unclear how R7 would be in another resident's room. 12/18/18 (5:55 AM) - R7 was found sitting on the floor of his/her room. It was unclear if R7 was trying to go to the bathroom. A recommendation was made for a perimeter mattress which was implemented after this fall. 12/25/18 (9:00 PM) - R7 was seen falling when trying to walk to the bathroom. A recommendation was made for a toileting program. This was the 6th fall when R7 was going to the bathroom. 1/11/19 (1:55 PM) - R7 was seen reaching for another resident's wheelchair in the dining room and slid out of his/her wheelchair onto his/her knees, then eased self to the floor. A recommendation included to monitor for change of condition. There was no therapy evaluation to determine any measures that may minimize R7 from sliding out of the wheelchair in the future. 1/21/19 (5:30 PM) - R7 was found on the floor when trying to go to the bathroom. A recommendation included to monitor for change of condition. This was the 7th fall when R7 was trying to use the bathroom. There was no individualized toileting plan in place. 2/4/19 (11:30 AM) - R7 was found on the floor next to his/her bed while trying to go to the bathroom. This was R7's 8th fall while trying to go to the bathroom without an individualized toileting plan in place. 2/10/19 (6:15 PM) - R7 was observed falling to the floor when trying to go to the bathroom. This was R7's 9th fall while trying to go to the bathroom without an individualized toileting plan in place. 2/15/19 (1:04 PM) - R7 slid out of bed onto the fall mat and R7 said he/she was about to use the bathroom. A recommendation was made to continue with plan of care. This was R7's 10th fall while trying to go to the bathroom without an individualized toileting plan in place. 2/16/19 (8:45 AM) - R7 yelled for staff and was found on the floor on his/her stomach facing the bathroom. R7 said he/she was trying to go to the bathroom. Recommendation included to continue plan of care, ensure glasses are within reach. This was R7's 11th fall while trying to go to the bathroom without an individualized toileting plan in place. b. Failure to thoroughly investigate falls - 10 falls without statements from staff or witnesses: 8/30/18; 9/20/18; 10/15/18; 11/3/18; 12/13/18; 12/25/18; 1/11/19; 1/21/19; 2/10/19; and 2/15/19. - 5 falls with inaccurate footwear (recorded as barefoot or unknown when staff statement included that R7 wore grippy socks): 9/14/18; 10/19/18; 12/18/18; 2/4/19; and 2/16/19. - 1 fall in another resident room that did not include the room number: 12/13/18. - 3 falls when the facility failed to identify that R7 was on a toileting program: 1/11/19; 1/21/19; and 2/4/19. - 17 falls (before 2/15/19) when the facility failed to identify that R7 was on a restorative nursing program. - 1 fall marked as witnessed when was found on the floor: 8/5/18. R7 fell seven times trying to go to the bathroom (including the 9/20/18 fall resulting in a laceration) before a toileting plan was recommended (after the 12/25/18 fall). R7 experienced five more falls while attempting to go to the toilet after the toileting plan recommendation was implemented. R7's toileting plan was not individualized. 2/12/19 - A Physical Therapy (PT) screen for wheelchair positioning was completed a month after R7 slid from the wheelchair (1/11/19) in the dining room while reaching forward. PT documented that R7 sat midline with neutral pelvic alignment, could self-propel, used a regular cushion and attempted to stand. PT stated that R7 had increased falls due to cognitive and functional decline and recommended enhanced supervision. 2/28/19 (8:35 AM) - During an interview with E5 (UM) when obtaining R7's chart, E5 stated our frequent faller and R7 does not usually get hurt. When asked what strategies are in place to prevent falls, E5 stated, toileting schedule, rounds. The UM added, I am not a CNA, so I can't help. When R7 is trying to get up I ask him to wait and he/she says ok, but when I go to get help, he/she will get up. 2/28/19 - At 8:58 AM, R7 was observed being escorted to the sofa by the nursing station after breakfast. R7 stood up at 9:00 AM and walked, with shuffling feet, not clearing the floor, for approximately 22-23 feet down the hallway toward R7's room before staff noticed. At 9:10 AM, E10 (LPN) ran from the nursing station area to R7 and assisted the resident to walk the rest of the way to his/her room. At 9:25 AM, R7 was laying in bed (low bed) with a fall mat on the floor and the wall light illuminated. R7 was not supervised when out of bed as written in the care plan. 2/28/19 (12:30 PM) - R7 was observed asleep in bed. At 12:56 PM, R7 was attempting to get up from bed. When E5 (UM) asked R7 if he/she was ready to get up, R7 said yes. E5 told the resident let me get someone to help you and E5 left the room. R7 continued to struggle to sit upright in bed, but did not achieve a seated position when E11 (CNA) entered the room at 12:59 PM and assisted R7 up to a standing position using extensive assistance to get R7 up from bed. E11 stated, hold still and get your balance then you need to lift your feet as R7 shuffled with extensive assist of 1 staff to walk to the bathroom. Immediately after using the toilet, R7 was taken to the dining room in a wheelchair for lunch. 3/1/19 (5:32 AM) - During an interview with E12 (night time CNA assigned to R7), when asked what E12's role was in preventing falls for R7, E12 stated R7 wears a clip alarm, I check on (R7) every 2 hours, (R7) will call out (to use the toilet), grippy socks and low bed. 3/1/19 (8:20 AM) - R7 was observed being wheeled to the dining room for breakfast. At 9:00 AM R7 was finishing the meal. After receiving medications at 9:04 AM, R7 finished drinking his/her coffee. After breakfast (9:20 AM) R7 began to self propel in the wheelchair out of the dining room into the hallway and headed toward his/her room. 3/4/19 (9:15 AM) - During an interview, E11 (CNA) clarified that the toileting program is every two hours, but, can be more often with (name of resident). The facility failed to individualize R7's toileting plan based on his/her toileting habits. 3/4/19 (10:13 AM) - E2 (DON) was interviewed to determine what was analyzed when conducting R7's fall investigations. E2 stated that documentation in the electronic record and the RMS Event Summary Report (facility incident report) were used to determine the root cause/conclusion and corrective actions. E2 confirmed the RMS Event Summary Report errors with R7's footwear and whether the resident was on a toileting program and restorative nursing program, stating they were mine. E2 added that it has been hard to manage R7's falls since there have been times when, after taking R7 to the toilet, he/she would get right up. The facility failed to: - supervise R7 which resulted in 19 falls from (MONTH) (YEAR) - (MONTH) 2019. R7 was harmed when he/she received a 7 cm laceration on his/her left ear and requiring 4 stitches at the emergency roiagnom on [DATE]; - conduct thorough investigations to determine the root cause of R7's falls resulting in inappropriate recommendations / interventions to minimize fall risk; and - identify and implement an individualized toileting program for R7; 3. Cross refer F 684, example #2 5/15/17 (latest revision) of the facility Safe Resident Handling/Transfer Equipment Policy: Review of the policy revealed that the Sit to Stand Lift was only to be used on residents who have some weight bearing ability and head/trunk control. Review of R5's medical record revealed: 9/6/18: R5's facility face sheet revealed that he/she was admitted to the facility for rehabilitation. 9/6/18 - A nurses' note stated that a lift-transfer-repositioning evaluation was completed. Because R5 was unable to weight-bear at least 50% on one or both legs, R5 needed a total lift (mechanical lift) to transfer. 9/7/18 - Review of a Physical Therapy (PT) initial evaluation stated that R5's motor control and gross motor coordination was impaired - paralysis of bilateral lower extremities with 0/5 (no) strength. 9/23/18 6:38 PM - E24 (RN) stated in the progress notes that R5's daughter approached him/her at the nurses station, stating that R5 was dropped with the sit to stand lift after lunch, the nurse never came in to assess R5, and the family was upset. The facility's follow-up investigation revealed the following: E24's (RN) statement: On 9/23/18 at 6:34 PM, R5's daughter approached me (E24) stating that R5 told her he/she slipped out of the sit to stand lift at 1:00 PM today and wanted to know why a nurse never came to assess R5. There was no documentation in the medical record and I (E24) did not get that information in report from day shift nurse . R5 stated that two CNAs had him/her in the sit to stand and he/she slipped out of it and landed on his/her bottom on one of the CNAs feet. One of the CNAs left to get a third CNA, and the three CNAs picked him/her up off the floor. E24 asked R5 if they used a hoyer lift. R5 said no - one CNA lifted under each shoulder and picked up the legs and put him/her back in bed. R5 also stated that one of the CNAs said she was not comfortable using the sit to stand and that she would never use one again- that she would only use a hoyer lift. E24 assessed R5 at this time and found no apparent injuries. 9/24/18- The facility provided education to the three CNAs involved in the fall (E14, E17 and E25) that both a fall and lowering a resident in a downward position need to be reported to a nurse immediately, so the resident can be assessed. Findings were reviewed with E1 (NHA), E2 (DON) and E9 (ADON) on 3/4/19 during the exit conference beginning at 2:45 PM.

Based on record review and interview, it was determined that the facility failed to ensure the appropriate treatment and services to restore and /or maintain bladder function were implemented for two (R28 and R32) out of 40 sampled residents. The facility failed to assess and implement appropriate interventions for R28 and R32 to prevent a decline in continence (ability to control urine). The facility failed to implement interventions such as a voiding diary and individualized toileting program to restore and/or maintain bladder function. This resulted in a decline in urinary continence for R28 and R32. Findings include: The facility's policy and procedure for Continence Management documented that the Urinary Incontinence (having decreased or no voluntary control over urination) Assessment and/or Bowel Retraining Assessment and the Three Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. A plan of care is to be developed based on information from assessments and voiding diary and implement revisions to the plan of care as needed. The purpose is to provide appropriate treatment and services to minimize urinary tract infections (increase in bacteria in any part of the urinary system) and restore as much normal elimination function as possible. 1.The following documentation was contained in the clinical record for R28; 1/9/14- Physician History and Physical documented occasional incontinence (less than 7 episodes of incontinence), urinary tract infections, marked atrophy (wasting away of part of the body) and loss of muscle tissue function. 1/10/14- Care plan was initiated and incorrectly documented R28 was incontinent of urine and is unable to mentally or physically participate in a retraining program due to atrophy and loss of muscle tissue function with the goal of R28 having incontinence care needs met by staff. The interventions included assisting with perineal (private area) care. 1/16/14- Nursing Assessment Expanded form documented that R28 was occasionally incontinent of urine, that the toileting method was the bathroom and that no trial of a toileting program had been attempted. 1/16/14- 5 day Minimum Data Set ((MDS) standardized assessment tool used in long term care facilities) assessment documented R28 was independent in decision making, was occasionally incontinent of urine and required the limited assistance of one person for transferring and walking in her room. R28 required extensive assistance of one person for toilet use. 1/23/14- Nursing Assessment documented R28 was occasionally incontinent of urine and no current toileting program or trial was being used to manage the resident's urinary continence. The facility failed to ensure the appropriate treatment and services to restore and/or maintain bladder function were initiated when the resident was admitted to the facility and assessed as being occasionally incontinent. 2/4/14 and 2/9/14- Nursing Assessments documented R28 was always continent of urine and that no toileting program was in use. The 2/4/14 MDS indicated R28 was always continent. 4/11/14- Quarterly MDS assessment documented R28 was independent for decision making, was frequently incontinent of urine ( 7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and required extensive assistance of two persons for transferring and that walking did not occur. R28 continued to require extensive assistance of one person for toilet use. 4/13/14- Nursing Assessment Expanded documented that R28 was occasionally incontinent of urine and currently toileted in the bathroom and no trial of a toileting program was implemented. Review of the CNA flow sheets from 1/9/14 through 4/30/14 revealed the following episodes of urinary incontinence experienced by R28: -12 episodes of incontinence out of 68 opportunities for January or 18% of the time. -9 episodes of incontinence out of 84 opportunities for February or 11% of the time. -34 episodes of incontinence out of 93 opportunities for March or 37% of the time. -40 episodes of incontinence out of 90 opportunities for April or 44% of the time. 5/23/14- Nurse's note documented a toileting schedule had been initiated and that a bedside commode was to be kept in the resident's bathroom and brought to the bedside when needed. Resident prefers not to use the bedpan. After the surveyor brought R28's urinary incontinence concern to the attention of the facility, a Urinary Incontinence Evaluation was completed and a voiding diary was initiated, both on 5/23/14. In addition, the facility initiated a care plan with appropriate interventions. On 5/27/14 at approximately 9:40 AM during an interview with E8, RN Unit Manager it was confirmed that the care plan was incorrectly implemented upon admission and should have been implemented for a resident who was incontinent of urine with a potential for improved control or management of urinary elimination. E8 also confirmed that even with the incorrect care plan in place there should have been a voiding diary initiated as part of the urinary assessment. On 5/28/14 at approximately 10:30 AM during an interview with E2, DON it was confirmed that the facility had recognized that R28 had a decline in health, including her ability to walk and would become anxious and short of breath. E2 also confirmed that the facility had failed to identify the decline in urinary continence and failed to put interventions in place. The facility failed to identify the decline in urinary continence resulting in the failure to complete a Urinary Continence Evaluation, implement a voiding diary and initiate an individualized toileting program to restore and / or maintain bladder function. The above information was confirmed with E2, DON and E3, Corporate Nurse on 5/27/14 at approximately 2:00 PM. 2. The following information was contained in the clinical record for R32: 1/6/14 - Nursing Assessment Expanded documented that R32 was incontinent of urine that was not of new onset, level of urinary incontinence was not rated,a voiding diary was not initiated,a trial toileting program was not implemented. 1/7/14- Admission Minimum Data Set Assessment (MDS) documented in the urinary continence section that R32 was occasionally incontinent. R32 required extensive assistance to the toilet. A voiding diary was not completed following this assessment. 1/10/14- A care plan for bladder incontinence was initiated for R32 with the goal of fewer episodes of incontinence x90 days. Interventions initiated for R32 included incontinent care via staff, toileting program as directed and a toileting schedule of upon awakening, after meals and before bed. There is no evidence that the toileting program was based on an individualized assessment. 3/26/14 -Nursing Assessment Expanded documented that R32 was occasionally incontinent, and that a trial toileting program was in place and was used to manage the residents incontinence. 3/27/14- Quarterly MDS in the urinary continence section assessed R32 as frequently incontinent. A voiding diary was not done by the facility. Review of CNA flow sheets from 1/1/14 through 3/31/14 revealed the following episodes of urinary incontinence experienced by R32: -13 episodes of incontinent out of 93 opportunities for January of 14% of the time. -30 episodes of incontinence out of 84 opportunities for February of 36% or the time. -34 episodes of incontinence out of 93 opportunities for March or 37% of the time. 4/5/14- A progress note was written in response to the evaluation of R32's bladder incontinence care plan, and documented the following in reference to R32: "continues to have incontinent episodes. Incontinence care needs met. Toileted before meals, after meals, bedtime and whenever needed." On 5/28/14 at 9:35AM an interview was conducted with E2, DON, who stated that the facility was "aware that we had an issue" with a potential decline in toileting function. As a result of potential declines in continence, the facility "put processes in place to check for the decline". R32 was missed in this audit. E2 confirmed R32's decline in bladder function, and the facility's failure to implement an effective toileting plan. The facility failed to identify and provide appropriate treatment for [REDACTED]. Findings were reviewed with E1, NHA and E2, DON on 5/28/14 at 11:15 AM.