Every finding on record at New Castle Health and Rehabilitation Center

Based on document review, interviews, and facility policy review, the facility failed to ensure that one of four residents (Residents (R) 133) reviewed for tube feeding was assessed and monitored for nutritional and fluid needs and to intervene when resident (R133) aspirated tube feeding through the nose and mouth multiple times and gained a significant amount of weight. This failure resulted in harm to R133 when he went into cardiac arrest once while aspirating and was hospitalized three times after aspiration of tube feeding. The facility's Administrator and Regional [NAME] President of Operations were informed on 12/12/25 at 6:00 PM that Immediate Jeopardy existed at F693 Tube Feeding Management related to the failure to ensure that tube feedings were assessed, monitored, and interventions implemented when one of four residents reviewed for tube feeding aspirated tube feeding formula through his nose and mouth. The Immediate Jeopardy began on 05/13/25 when R133 e. experienced a change in condition and was sent to the emergency room and admitted to the hospital. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 12/13/25 at 11:05 AM. Upon identification of immediate jeopardy related to tube feeding assessment, monitoring, and aspiration risk, the facility transferred the affected resident to the hospital and immediately assessed all tube-fed residents for tolerance, weights, and aspiration signs, with the Registered Dietitian and clinical leadership reviewing their status and convening an unscheduled QAPI meeting. The facility provided same-day education to the dietitian and nursing staff on the enteral feeding policy with 100% completion, and implemented a structured audit and monitoring process of MARs and progress notes over several weeks to ensure ongoing compliance and early identification of tube feeding intolerance. The survey team validated implementation of the removal plan through interviews and review of training records. Immediate Jeopardy was removed on 12/13/25 at 12:15 PM. After removal of the Immediate Jeopardy, the deficiency remained at a ''G'' scope and severity for isolated harm.Findings include:Review of R133s Face Sheet located under the Resident tab in the electronic medical record (EMR) revealed the resident was admitted on [DATE] with a diagnosis of feeding tube (gastrostomy status).Review of R133's Care Plan located under the RAI tab in the EMR revealed administer feeding and hydration via feeding tube as ordered, elevate had of bed 30-45 degrees during feeding and for one hour after, flush tube with 30mls of water before and after medication administration and feeding, maintain the head of the bed elevated at all times when feeding is connected, start date 05/19/2024.Review of R133s Progress Notes located under the Resident tab in the electronic medical record (EMR) dated 02/17/25 at 1:39 PM revealed Dietary Progress Notes: Stable weights overweight by standard tube feeding [TF]. Order remained Nurtren 1.5 at 70 milliliters [ml] per hour [hr./ hrs.] for 18 hours for calories of 1890 and free water flush [FWF] of 65ml per hr. for 18hrs for 1170 ml water a day.Review of R133s Progress Notes located under the Resident tab in the EMR dated 02/20/25 at 3:21 PM revealed a Nurse Practitioner (NP) note, tube feedings .RD [Registered Dietitian] managing nutrition . Review of R133's Progress Notes located under the Resident tab in the EMR revealed Dietary Progress Note, dated 03/18/25 stating that the monthly weight trends were stable , overweight by standard, weighed 211.8 on 03/12/25 and to continue same tube feed and FWF as ordered. Review of R133's May 2025 Medication Administration Record (MAR) located under the Resident tab in the EMR revealed the order for May tube feedings should provide 1260 ml over 18 hours and FWF of 1170 every 24hrs. Review of the MAR revealed the following amounts of TF and FWF documented as provided by staff:05/06 TF of 3080 mls and FWF of 2860 mls. 05/07 TF of 2200 mls and FWF of 2070 mls05/08 TF of 3080 mls and FWF of 2860 mls05/09 TF of 3080 mls and FWF of 2860 mls05/10 TF of 3310 mls and FWF of 1879 mls These amounts were in excess of the order for a total of 1260 mls of tube feeding and 1170 ml of FWF in 24 hours.Review of R133s Progress Notes located under the Resident tab of the EMR dated 05/11/25 at 3:54 PM revealed, Patient sent out to hospital at about 0945. At 0936 patient was found unresponsive patient is full code CPR [Cardiopulmonary Resuscitation] initiated after checking pulse, low oxygen level noted with all abnormal vital signs. Patient's feeding was seen oozing out of the patient's mouth. HOB [Head of Bed] elevated, and head turned to side patient was suctioned, increase noted in O2 [oxygen] levels from 60% to 98%. Paramedics resumed compressions transported to hospital with paramedics.Review of R133's Progress Notes located under the Resident tab in the EMR dated 05/21/25 at 11:30 PM revealed R133 was readmitted to facility with the same tube feeding and water flushes rate as before he was found with tube feed formula oozing out of the patient's mouth. Review of R133's Progress Notes located under the Resident tab in the EMR dated 05/23/25 at 10:46 AM, revealed Medical Director (MD) note, Treated for aspiration pneumonia and completed antibiotics.Review of R133's Order History located under the Resident tab in the EMR dated 06/09/25 revealed orders for free water flush changed from 65 mL per hour to 180 mL per shift. 180ml per three shifts equaled 540ml of FWF a day instead of the previous amount of 1170ml a day.Review of R133's Progress Notes located under the Resident tab in the EMR dated 07/11/25 at 12:54 PM, Dietary Progress Notes revealed weights stable, current weight on 06/10/25 is 214.8 .continues to tolerate TF as ordered. Review of R133's August 2025 MAR located under the RAI tab in the EMR revealed, TF 70mL per hr. over 18 hours and free water 180 mL per shift with a total of 540 with 60mL free water before meals and 30mL between meds. This order provided 1260ml of tube feeding formula a day and 540 ml of FWF and additional 60 ml before tube feeding and 30 ml between medications. Review of the August 2025 MAR revealed the following amounts of TF and FWF documented as provided by staff:08/01: TF1680 ml and FWF 1840 mls08/02 TF 1680ml and FWF 1840ml08/03 TF 540mls and FWF 720 ml08/04 TF 450 mls and FWF 630 ml08/05 TF 920mls and FWF 1080 mls08/06 TF 920 mls and FWF 1080 mls08/07 TF1680 mls and FWF 1840 mlsReview of R133's Progress Notes located under the Resident tab in the EMR dated 08/07/25 at 8:57 PM, revealed, call to resident's room and was told resident has aspirated. Upon assessment resident was observed with labored breathing HOB up, 84% room air nonrebreather mask applied at 15L-noted with crackles to bilateral (b/l) lungs. Milky secretions pooling from both nares and mouth. Suction performed twice. Order obtained to send resident out 911. Review of R133s Progress Notes located under the Resident tab in the EMR dated 08/13/25 at 11:36 AM, revealed History Hospital note: R133 came from nursing facility with shortness of breath with concern of overfeeding and aspiration admitted for septic shock pneumonia and urinary tract infection (UTI).Review of R133s Progress Notes located under the Resident tab in the EMR dated 08/14/25 at 11:09 AM, revealed, dietary note: weights net gain of 22.6% over the past seven months. This abrupt change is being evaluated for accuracy, Nurse Practitioners [NP]/MD notified weekly weight. No nutritional interventions needed at this time.Review of R133s Progress Notes located under the Resident tab in the EMR dated 09/18/25 at 10:40 AM, revealed, Dietary Progress Notes: Most recent weight on 09.05.25 is 230lbs. Weight changes and nutrition status were reviewed on site visit. MD aware. Resident remains NPO and continues on prescribed tube feeding: Nutren/Isosource 1.5 at 70ml/hr. 18 hours with concurrent waster flushes providing 2132ml total fluid a day. Review of October 2025 MAR located under the Resident tab in the EMR revealed an order for TF at 70cc/hr. over 18 hours and 180mL of water every shift for a total of 540mL a day with 60mL of free water before meds and 30mL between meds.Review of R133's Progress Notes located under the Resident tab in the EMR dated 10/14/25 at 3:47 PM, revealed, Resident has coarse crackles in the beginning of the shift and Nutren feed was seen coming out of the mouth. dyspneic [difficulty breathing]. Titrated to four liters (L) on the concentrator with HOB to 90 degrees. Suction was done on the resident through the shift as needed during shift and pulse ox went from 88 to 96. Suctioning was provided using yankeur with a total amount of 35 mLs being drawn out. Crackles are still present bilaterally in lung contacted NP and was told to monitor the resident and if any changes to let him know.Review of R133s Progress Notes located under the Resident tab in the EMR dated 10/15/25 at 12:00 AM, revealed resident had course crackles in the beginning of the shift and Nutren feed was seen coming out of the mouth. Crackles still present. Xray ordered and one dose of Lasix [diuretic] ordered. In the afternoon patient noted with swelling on his face. Decision to transfer patient to the hospital.Review of R133's Progress Notes located under the Resident tab in the EMR dated 10/15/25 at 8:03 AM revealed the resident received in bed sleeping. Fluid noted from the mouth and was suctioned. Crackles noted but no respiratory distress noted. Continue to monitor.Review of R133's Progress Notes located under the Resident tab in the EMR dated 10/15/25 revealed nurse assessed resident and observed that resident was aspirating from his mouth, shortness of breath [SOB] and lung crackles. NP was immediately notified and recommended that the resident be sent to the hospital.sent out at 12:50 PM to hospital.During an interview on 12/12/25 at 10:58 AM, the Nurse Practitioner (NP) 1stated he was not aware of a report given from the hospital about potential overfeeding. NP1 revealed that he documented R133 was tolerating the tube feeding after two incidents of aspiration because it depends if the aspiration is based on the tube feeding or if the resident had pneumonia. If not pneumonia, then review the feeding and rates. NP1 revealed that on October 15, 2025, he sent the resident out to the hospital because he was having shortness of breath, increased hypersecretion of saliva not aspiration [despite that three nurses' notes document aspiration of formula feed), and the hospital didn't mention aspiration. NP stated it was high secretions and because of shortness of breath he started medication to lower secretions, oxygen was ordered and the resident was given albuterol treatment and sent out to the hospital because of face swelling.Review of R133's Progress Notes located under the Resident tab in the EMR dated 10/15/25 at 1:54 PM revealed this writer received a call from med student at hospital regarding reason for send out. Updated to change in condition starting yesterday evening, nursing and NP interventions made in house and resident continued, decline despite interventions. No admission diagnosis as yet noted resident still being evaluated.Review of R133s Progress Notes located under the Resident tab in the EMR dated 10/17/25 at 11:51 AM revealed the resident was admitted for sepsis.During a concurrent interview on 12/11/25 at 5:18 PM, the Regional Registered Dietician (RDD) and Registered Dietician (RD) stated that the residual amount of tube feeding in the stomach was mostly zero, but there were times when he had 10, 12 15 or 30 mls. They confirmed in April 2025 the resident tolerated the tube feeding well with no history of vomiting, oozing, or regurgitating tube feeding. The RD revealed he first saw resident in June 2025 as he was the new dietician, and the resident's weight was intact; flushes were good and tolerated feeding well with no complications.They revealed R133 was discussed in IDT meetings because he was a tube feed resident. Regional RD voiced she would provide me with R133's assessments tomorrow but they were not provided before exitDuring a concurrent interview on 12/12/25 at 9:50 AM the RDD and facility RD stated water flush was decreased on 06/09/25 from 65 mL per hr. over 18 hours to 180 mL per shift. The RD confirmed they were not notified in May of R133's aspiration on tube feeding. The RD stated he was not aware of a note on 08/13/25 from the hospital about overfeeding. The RD confirmed he was aware of the weight note on 08/14/25 and aware of risk of overfeeding but did not see documentation of tube feeding oozing out of mouth/ nares. The RD revealed from his assessments while the resident was in the facility he was tolerating his tube feeding. The RD confirmed that an assessment of tube feeding and water flush rate should be conducted after aspiration incidents.During an interview on 12/12/25 at 12:28 PM, the Director of Nursing (DON), Medical Director, NP1, RDD, and Dietician. Resident has chronic encephalopathy and aspirates off and on. Dietician usually, we work with them, and dietary changes the orders and they keep track of tube feeding, aspiration and labs. We have been monitoring the TF closely. The MD was asked about the resident having TF coming out of his nose and should have he been assessed after this and MD said, people vomit when they are sick. Review of the facility's policy titled, Dietary Enteral Nutrition Care Policy with a revision date of 03/28/25 noted Policy: The use of an enteral nutrition tube has a major impact on a resident and his or her quality of life. Procedure.Upon initiation of enteral feeding, the registered dietician nutritionist (RDN) or designee will perform an assessment that will include a calculation of the individual's energy, protein, fluid requirements, and potential medication interactions. If there is an existing nutrition order, a comparison will be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RDN or designee will monitor weight, skin color, labs, physical symptoms, tolerance to feeding, and oral food/ fluid intakes as applicable, periodically, and as needed.The nursing staff will communicate any concerns to the MD, RDN or designee regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels.Review of facility's policy titled, Dietician, FT with no date noted, Position Summary: The primary purpose of your job is to plan and deliver nutritional care to residents in accordance with the physicians' orders and with current federal, state, and local standards, guidelines and regulations that govern the community. Essential Functions: Determine resident nutritional status by evaluating medical records, observation of resident eating habits, feeding abilities, nutritional needs, and diet compliance to develop individualized nutrition care plans, and adjust as needed. Consult with medical staff evaluate effects of nutritional intervention on individual residents and the need for further intervention or plan revision.

Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure consistent implementation of interventions to prevent falls for one (Resident (R ) 67) out of 11 residents reviewed for accidents out of total sample of 35 residents. The facility's failure to ensure consistent interventions were implemented to prevent falls for R67 resulted in harm when R67 experienced a fall with major injury (a hip fracture). This failure increased the risk of other residents falling with major injury. and resulted in the potential for this and other residents to experience additional falls with injury. Findings include:Review of the resident's admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R67 was admitted to the facility on [DATE]. The resident's diagnoses included history of Traumatic Brain Injury (TBI) and Dementia with Agitation. Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition. The assessment indicated the resident had a history of falls since his prior MDS assessment, that the resident experienced two or more falls with no or minor injury since his prior assessment, and that the resident had not experienced any falls with major injury prior to the assessment. The assessment indicated R67 was dependent upon staff to transfer in and out of his bed and indicated the resident did not use a wheelchair during the assessment reference period. Review of R67's Fall Risk Assessment, dated 10/11/25 and found in the EMR under the Observations tab, revealed a fall risk score of 19, which indicated the resident was at high risk for falls. Review of R67's Falls/Risks for Falls Risk Care Plan, dated 12/10/25 and found in the EMR under the Care Plan tab, revealed the resident had experienced multiple falls since his admission to the facility on [DATE], and a fall with a major injury (hip fracture) on 11/26/25. The care plan indicated the resident was a high risk for experiencing falls and indicated the following interventions to prevent further falls including: . close supervision when wheelchair is being serviced, . frequent monitoring when resident is in bed . get resident out of bed to his Broda chair, get out of bed and to common area when awake at night . Review of R67's post fall therapy screening documentation, found in the EMR under the Notes tab, revealed the following recommendations: On 10/13/25 recommend continue with Broda chair in reclined position, (Keep resident) in supervised area; on 10/14/25 Resident (R67) requires assistance for transfer and supervision for safety related to high fall risk due to dementia related behaviors; on 10/22/25 (R67) remains high fall risk requiring redirection with verbal and tactile cues assist of (one staff member) for transfers for safety; and on 10/24/25 Continue with Broda chair and continue with (staff) monitoring and nursing safety interventions. Review of R67's Medication and Treatment Administration Records (MARs and TARs), dated 10/01/25 through 12/12/25 and found in the EMR under the Reports tab, revealed no documentation to indicate R67 was being monitored by staff to prevent falls. Further review revealed monitoring was not listed as a fall intervention. Review of R67's Certified Nurse Aide (CNA) Documentation, dated 10/01/25 through 12/12/25 and provided directly to the survey team, revealed no documentation to indicate R67 was being monitored to prevent falls. Further review of the CNA documentation revealed monitoring was not listed as a fall intervention. Review of the facility's Incident/Accident Reports, provided directly to the survey team, revealed unwitnessed/unsupervised falls experienced by R67 on the following dates: a. On 08/06/25 at 6:00 AM R67 was found on the floor next to the nurse's station after a fall from his Broda chair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. b.On 08/07/25 at 7:41 PM R67 was found lying on his right side on the floor in the hallway. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. c.On 08/13/25 at 4:19 AM R67 was found on the floor next to his wheelchair near the nurse's station after a nurse heard a loud thump. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. d.On 08/18/25 at 10:00 PM R67 was found on the floor by a staff member after slipping out of his wheelchair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. e.On 09/08/25 at 2:45 PM R67 was found by a housekeeper on the floor in the middle of the hall. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. f.On 10/12/25 at 5:36 PM R67 was found on the floor in front of the nurse's station after falling out of his chair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. g.On 10/14/25 at 2:15 PM, R67 was found on the floor in the hallway lying on his right side next to his wheelchair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. h.On 10/21/25 at 10:30 PM, R67 was found on the floor in the hallway next to his wheelchair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. i.On 10/23/25 at 8:30 PM, R67 was found lying on the floor next to his wheelchair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. j.On 11/07/25 at 5:15 PM, R67 was found lying on the floor in the hallway and next to his wheelchair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. k.On 11/28/25 at 10:35 PM, R67 was found on his bottom on the floor in his room. The fall was unwitnessed. The resident complained of pain after the fall and was sent to the local Emergency Department for evaluation and treatment. R67 was found to have a left hip fracture as a result of the fall. The resident was sent back to the facility on [DATE] after his hospitalization related to the fracture. Surgical intervention was not provided for the resident due to his frail health status and the resident was placed on comfort interventions related to the fall, such as pain control medications, prescribed positioning while in bed and in his Broda chair, and increased monitoring to prevent further falls. l.On 12/07/25/ at 6:30 PM, R67 was found laying on his right side on the floor next to his Broda chair. The fall was unwitnessed and the resident was not able to tell staff how the fall occurred. The resident did not have any injuries related to the fall. R67 was observed in the facility hallway on12/10/25 at 8:58 AM. The resident was seated in his Broda chair and was well positioned in the chair. There was no staff observed to be monitoring the resident at the time of the observation R67 was observed in the facility common area on 12/11/25 at 11:01 AM. The resident was restless and agitated and was observed attempting to get up from his chair multiple times during the observation. Staff was monitoring the resident at the time of the observation and repeatedly assisted the resident to sit back down in his chair to prevent him from falling. R67 was observed unattended in a staff office in his Broda chair on 12/11/25 at 11:45 AM. The resident was stuck in the office and not able to back out of the room independently. The resident was agitated and attempting to back out of the office. There was no staff observed to be monitoring the resident at the time of the observation. The surveyor requested assistance from staff to remove the resident from the office. R67 was observed on 12/12/25 at 10:00 AM in the facility hallway seated in his Broda chair and propelling himself throughout the hallway. R67 was not agitated but was active and occasionally attempting to stand up from his Broda chair. There was no staff observed monitoring the resident at the time of the observation. R67 was observed on 12/12/25 at 2:15 PM wheeling himself about the facility hallway in his Broda chair. R67 was not observed to be monitored by staff at the time of the observation. During an interview with Certified Nurse Aide(CNA5) and CNA6 on 12/12/25 at 2:41 PM, both staff members stated they were familiar with R67. CNA5 stated R67 was at high risk for falls because he constantly wanted to stand up from his chair when he was in his Broda chair and stated R67 was supposed to be monitored and was supposed to be within sight of staff at all times while he was up in his Broda chair due to his impulsivity to prevent falls. During an interview with CNA7 on 12/12/25 at 2:57 PM, she confirmed she was familiar with R67 and stated R67 was to be kept at in direct view of staff at all times due to his fall risk when he was up in his Broda chair. She stated staff usually tried to keep the resident at the nurses station when he was up in his wheelchair. She stated, He [R67] has to stay in line of site. It is a team effort. He [R67] will get up in a heartbeat. CNA7 stated R67's fall/safety monitoring was expected to be documented in his record in CNA documentation. During an interview with the Director of Nursing (DON), the Administrator, the Regional [NAME] President (VP) of Operations and the Regional Nurse on 12/12/25 at 4:43 PM, all confirmed R67 was expected to remain in line of site of staff at all times when up in his Broda chair. The stated he was to be supervised in this manner due to his high fall risk. The Regional VP of Operations confirmed R67 should have been directly monitored by staff when each of the unwitnessed falls occurred from R67's Broda chair and stated R67 needed to be placed formally on 1:1 supervision by staff when up in his chair to prevent falls. Review of the facility's Fall Prevention and Management Policy dated last revised/reviewed on 07/07/25 indicated, Residents will be assessed for fall risk(s) on admission, quarterly, and as needed. If risks are identified, preventative measures will be put in place and care planned. All falls will be reviewed and investigated.

Based on observations, interviews, and policy review, the facility failed to ensure food was discarded and/or stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 109 residents that receive food from the kitchen.Findings include:During initial observations of the kitchen on 12/09/25 beginning at 9:47 AM, the following was observed:In the dry storage, there were two 19.5-ounce plastic squeeze bottles of chocolate syrup with an expiration date of 5/16/25.In the walk-in refrigerator, there were three 19.5-ounce bottles of chocolate syrup, three 19.5-ounce bottles of vanilla syrup that were opened. The opened bottles of chocolate and vanilla syrup displayed an expiration date of 5/16/25. The Dietary Manager (DM) confirmed that the bottles of chocolate and vanilla syrup were past the expiration date displayed on the bottles. During an interview on 12/09/25 at 11:10AM the DM confirmed that the flavored syrups were past the manufactures use by date and should not be available for use. The DM also stated that those food items were [served during] activities and should have been looked at by the dietary staff. The dietary staff was ultimately responsible for ensuring food items were not expired. During an interview on 12/10/25 at 10:17AM, the Administrator stated that the facility had no policy that directly addressed the manufacture use by date or the expiration displayed on a food item. Review of the facility's policy titled, Equipment Cleaning and Sanitation Policy, dated 08/25/20, revealed The food and nutrition services staff will maintain a clean and sanitary environment in food service areas. The policy did not address food storage policies and procedures.

Based on observation, interview, and record review, the facility failed to 1. have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the 105 facility residents, who were either over the age of 65 and/or were autoimmune compromised, to be infected by Legionella and 2. ensure one Licensed Practical Nurse (LPN)4 performed hand hygiene between wound treatments for one (Resident (R) 10) . This has the potential for cross-contamination of pathogens from one wound which can then be transferred to another.Findings include:1.A review was conducted of a facility document titled Premise Plumbing System undated revealed a diagram of the facility's water system. There was no documentation on the diagram that indicated high-risk areas in which water pathogens might develop. During an interview on 12/12/25 at 8:56 AM, the Maintenance Director stated he had not seen a water flow diagram of the facility's water system before and confirmed the diagram did not identify the high-risks areas for pathogen development. Review of website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 04/07/21 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella bacterium.Legionellosis: any illness (disease) caused by the exposure to Legionella. Legionnaires' disease (LD) and Pontiac fever (PF) are the two known types of legionellosis.Potentially fatal, multisystem respiratory illness, accompanied by pneumonia.Symptoms.high fever, chills, muscle pain, headache, dry cough, diarrhea, vomiting, confusion, and delirium common.Immune suppressed.transplant patients, cancer, cardiac, diabetes, steroid/drug therapy.Sick/in poor health. Elderly/infirm.Heavy smokers, lung/COPD diseases.Describe the building water systems using flow diagrams & a written description: Include details such as where the building connects to the (municipal) water supply, how water is distributed and used (processed), where hot tubs, water heaters, cooling towers, etc. are located. 2. Review of the admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE] with a history of stroke. Review of R10's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/15/25 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of zero out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated the resident had a stage four pressure ulcer, and unstageable pressure ulcer, and a venous stasis ulcer at the time of the assessment and indicated the resident was receiving hospice services. Review of R10's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders tab, revealed orders for wound care to be provided for the resident, including: Cleanse abscess to left ischium, pat dry, apply calcium alginate, cover with dry dressing daily; Cleanse area to left lateral foot with normal saline, pat dry, apply calcium alginate, cover with clean dry dressing daily; Cleanse left groin with normal saline, pat dry, apply collagen and cover with clean dry dressing daily; Cleanse left trochanter with normal saline, apply collagen and cover with clean dry dressing daily; Cleanse right lateral foot with normal saline, pat dry, apply calcium alginate, cover with dry dressing daily; and Cleanse sacrum with normal saline, pat dry, apply calcium alginate and cover with clean dry dressing daily. Review of R10's skin and wound care plans, most recently dated 11/18/25 and found in the EMR under the Care Plan Tab, revealed R10 had multiple chronic wounds and indicated orders were to be followed related to the provision of wound care. During an observation on 12/11/25 at 2:52 PM, Licensed Practical Nurse (LPN)4 and the Assistant Director of Nursing (ADON) were observed completing R10's wound care LPN4 removed all of the resident's dressings and then donned a pair of gloves and wore the same pair of gloves while going from wound to wound to clean each of the wounds with normal saline. LPN4 changed her gloves and sanitized her hands and then applied the ordered treatment to each of the resident's wounds while wearing the same pair of gloves. R10 was repositioned while LPN4 wore the gloves she used to apply treatment to all of the resident's wounds. LPN4 then removed the gloves and sanitized her hands before leaving R10's room. During an interview with LPN4 and the ADON on 12/11/25 at 3:19 PM, LPN4 stated she thought she only needed to change her gloves and sanitize her hands between dealing with dirty processes and clean processes. She stated she was not aware she should change her gloves and sanitize her hands when moving from one wound to the next to avoid cross contamination of wounds. The ADON stated she was not sure what the facility's process related to infection control during the provision of wound care was. During an interview with the Director of Nursing (DON) on 12/11/25 at 4:00 PM, she stated her expectation was infection control processes were to be maintained during the provision of wound care to prevent cross contamination of wounds. She confirmed LPN4 should have removed her gloves and sanitized her hands when proceeding from wound to wound while providing treatment to R10. Review of the facility's Clean Dressing Change Policy dated last revised/reviewed on 02/10/25 indicated, Where sterile technique is not ordered or indicated, wounds will be dressed using clean technique which avoids direct contamination of material and supplies.

Based on record review, interviews, and review of facility policy, the facility failed to ensure risk vs benefits was explained to the resident or representative prior to the use of psychotropic medications for four (Residents (R )67, R20, R39, and R4) out of five residents reviewed for unnecessary medication out of a total sample of 35 residents. This facility's failure created the potential for residents to receive medications that were not necessary or desired related to their psychiatric/mental health care. Findings include:1.R67 was admitted to the facility on [DATE], according to the resident's admission Record, dated 12/12/25 and found in the Electronic Medical Record (EMR) under the Profile Tab. The resident's diagnoses included history of Traumatic Brain Injury (TBI) and Dementia with Agitation. Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/25 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition. The assessment indicated the resident had short and long-term memory deficits. The assessment indicated the resident was receiving antidepressant, antianxiety and antipsychotic medications. Review of R67's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders Tab, revealed orders, all with an initial order date of 12/01/25 for the resident to receive Trazodone (an antidepressant medication) 50 milligrams (MG) three times daily for restlessness and agitation, Risperdal (an antipsychotic medication) 0.5 mg once daily for major depression, Risperdal 1 mg every night at bedtime for dementia with agitation, and Buspirone (an anti-anxiety medication) 30 mg twice daily for anxiety. Review of R67's Medication and Treatment Administration Records (MARs/TARS), dated 12/01/25 through 12/12/25 and found in the EMR under the Orders Tab, revealed the resident was receiving his psychotropic medications per physician's orders. Review of R67's record revealed no documentation that the risk vs. benefits were discussed prior to the administration of any of the resident's psychotropic medications. 2. Review of R20's quarterly MDS located under the RAI tab with an ARD of 11/25/25 revealed a BIMS score of three out of 15 indicating severe cognitive impairment and a diagnosis of emotional lability and Dementia. Review of R20's Orders located in the EMR revealed a physician's order, originally dated 07/27/25, for Trazodone (an antidepressant medication) tablet 50 mg twice a day at 9:00 AM and 9:00 PM with medication monitoring for the antidepressant. Review of R20's EMR revealed no documentation that the risk vs benefits were discussed with the resident or representative prior to starting Trazadone. 3. Review of R39's EMR Face Sheet revealed the resident was admitted on [DATE] with a diagnosis of depression. Review of R39's admission MDS located under the RAI tab of the EMR with an ARD of 11/24/25 revealed a BIMS score of 15 out of 15, indicating cognitively intact. Review of R39's Orders located in the EMR revealed a physician's order for sertraline (antidepressant) tablet 25 mg oral give once a day, start date 11/18/25. Review of R39's EMR revealed no documentation that the risk vs benefits were discussed with the resident or representative prior to starting the Sertraline. 4.Review of R4's EMR located under the MDS tab revealed the admission MDS with an ARD of 5/01/24 revealed an admission date of 04/24/24; a BIMS of seven out of 15 indicating a severe cognitive impairment; diagnosis of arthritis, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, anxiety disorder, psychotic disorder, Senile degeneration of brain, not elsewhere classified; medications received antipsychotic, antianxiety, anticoagulant, antiplatelet; documented GDR as clinically contraindicated dated 05/02/24. Review of R4's EMR located under the Care Plan tab revealed a plan of care for the use of psychotropic medication; indicating that R4 was at risk for adverse reactions related to the use of psychotropic medications received for the diagnosis of dementia with psychosis, anxiety, and a seizure disorder. Review of R4's EMR located under the Orders tab revealed a physician order dated 10/31/24 for the antipsychotic risperidone 0.5 milligrams (mg). Give two tablets by mouth for dementia with severe agitation twice a day. A review of R4's EMR revealed no documentation that the risk vs. benefits were reviewed with the resident's responsible party prior to starting the psychotropic medication. During an interview with the Administrator, Director of Nursing (DON), and the Regional [NAME] President of Operations on 12/12/25 at 1:52 PM, they confirmed risk vs benefits had not been discussed for the administration of psychotropic medication for R67. The DON stated her expectation was for the risk and benefits to be discussed for each psychotropic medication being administered to any resident residing in the facility in order to ensure residents and/or their representatives were aware of the risks and benefits related to the medication. Review of the facility's undated Nursing Home Resident Rights Document indicated, The Resident has the right to be fully informed of the type of care provided, and risks and benefits of proposed treatments.

Based on record review, interviews, and review of facility policy, the facility failed to ensure timely reporting of allegations of potential abuse/neglect for four (Residents (R ) R67, R126, R134, and R39) out of seven residents reviewed for abuse out of a total sample of 35 residents. The facility's failure to ensure timely reporting of the allegation of abuse created the potential for these and other residents to experience ongoing effects related to abuse.Findings include:1.Review of the resident's admission Record, dated 12/12/25 and found in the Electronic Medical Record (EMR) under the Profile tab revealed R67 was admitted to the facility on [DATE] with diagnoses that included history of Traumatic Brain Injury (TBI) and Dementia with Agitation. Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition. The assessment indicated the resident had short and long-term memory deficits. Review of R67's Progress Notes, dated 09/03/25 and found in the EMR under the Notes tab, revealed This nurse was notified by CNA (Certified Nursing Assistant) staff that the resident [R67] attempted to enter the room of two [unnamed] female residents. One [unnamed] resident reported that he [R67] tried to get into bed with her and stated she would call 911 if the behavior recurs. Upon assessment, no injuries were noted, and both residents were assessed to be WNL [within normal limits]. DON [Director of Nursing] was notified. A room change was recommended to prevent further incidents. Review of the facility's Incident and Accident Report Log, dated 06/09/25 through 12/09/25 and provided directly to the survey team, revealed no entry on the log related to the 09/03/25 incident of potential abuse of the two unidentified females by R67. Nothing could be found in facility or R67's records to indicate the 09/03/25 incident of potential abuse of the unidentified female residents by R67 had ever been reported by staff to the Administrator or DON or by Administration to the appropriate Agencies (including the State Agency (SA). During an interview with the Administrator and DON on 12/10/25 at 12:49 PM, they confirmed incidents of potential resident to resident abuse were expected to be entered into the Incident and Accident Log and confirmed the 09/03/25 incident of potential resident to resident abuse should have been reported to Administration by staff immediately after it occurred and should have been reported by administration to the SA within two hours of staff becoming aware of the incident. The DON denied being notified as documented in the 09/03/25 nurse's note. 2. A review of R134's EMR titled Resident Face Sheet, located on the resident's dashboard, indicated the facility admitted the resident on 09/05/25. A review of R134's EMR titled admission MDS with an ARD of 09/11/25 indicated the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident had no behaviors directed towards others. The assessment indicated R134 was ambulatory. A review of R134's EMR titled nursing Progress Notes located under the Resident tab dated 09/27/25 revealed R134 attempted to propel his wheelchair around R126. R126 then refused. R134 grabbed R126's wheelchair handles and pulled R126 back. This action caused R126 to fall to the ground. 3. A review of R126's EMR titled Resident Face Sheet, located on the resident's dashboard, indicated the facility admitted the resident on 08/29/25. A review of R126's EMR titled admission MDS with an ARD of 11 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated the resident had no behaviors directed towards others. The assessment indicated R126 used a front wheeled walker. A review of R126's EMR titled nursing Progress Notes located under the Resident tab dated 09/27/25 revealed R134 attempted to propel himself around R126 and when R126 refused to move R134 grabbed the wheelchair handles to R126's wheelchair and pulled back. R126 fell and sustained a skin tear on his right elbow during the incident. Nursing immediately assessed R126 for injuries and pain. Nursing administered the resident Tylenol. A review of a document provided by the facility titled Incident Online Submission Form indicated the facility reported the resident-to-resident, which involved R134 and R126 to the State Survey Agency (SSA) on 09/29/25. The facility reported incident (FRI) revealed on 09/27/25 that R134 attempted to propel himself around R126. R126 did not move and R134 then grabbed R126's wheelchair handles and pulled R126 back. R126 fell to the ground. Nursing assessed R126 and the resident sustained a skin tear on his right elbow. An investigation ensued. Staff and other residents' statements were included. R134 denied that he had deliberately caused R126 to fall out of his wheelchair and hurt R126. During an interview on 12/11/25 at 10:17 PM, the Administrator stated Registered Nurse (RN)4 failed to report the resident-to-resident which involved R134 and R126 immediately to her. The Administrator stated staff were to notify her immediately of any resident-to-resident alleged abuse. 4. Review of R39's admission MDS located under the RAI tab of the EMR with an ARD of 11/24/25 revealed a BIMS revealed the resident had a score of 15 out of 15 which indicated the resident was cognitively intact. Review of R39's Facility Reported Incident (FRI) dated 12/01/25 revealed, Description of Incident:[R39] who is a short-term care resident at the facility has a past medical history of sepsis, muscle weakness, other abnormalities of gait and mobility, other specified chronic obstructive pulmonary disease (COPD), chronic pain syndrome, depression, hyperlipidemia, pain in left knee, vitamin deficiency, diabetes mellitus. R39 is alert and oriented, able to make her needs known, requires assistance with activities of daily living (ADL), and uses wheelchair for locomotion. [R39]'s BIMs of 15. On 11/30/25 at approximately 1:00 PM Certified Nurse Assistant (CNA) began assessing the residents' brief. Resident stated to CNA, 'I'm not wet. If I am, I will let you know.' The CNA continued to checking the brief, at which point the resident struck the CNA on the arm and stated, 'Stop, you're being too rough and you're hurting me.' The CNA responded, 'Please don't put your hands on me.' Resident continue to report knee pain despite scheduled and as needed (PRN) pain medication. Bedside table, call bell, and personal belongings placed within reach for safety and comfort. A head-to-toe assessment was completed; no obvious signs of injury were noted. RP [Responsible Party] and NP [Nurse Practitioner] were made aware. Date of violation: 11/30/25 Time of violation: 7-3On November 30, 2025, writer entered the resident's room to apply icy hot. CNA was present in the room. While the writer was applying the topical medication, the CNA began assessing the resident's brief. Resident stated to the CNA, 'I'm not wet. If I am, I will let you know.' The CNA continued checking the brief, and told writer to look at the resident brief, because its soil and needs to be changed. At which time the resident struck the CNA on the arm and stated, 'Stop, you're being too rough and you're hurting me.' The CNA responded, 'Please don't put your hands on me, thank you,' and then exited the room. Writer apologized to the resident and informed her that staff would return in approximately 30 minutes to allow time for her pain medication to take effect. Resident agreed, then stated, 'I'm going to call my kids so they can get me out of here. That CNA is rough, has an attitude, and she doesn't realize she'll get old one day.' Writer apologized again and informed the resident that the social worker would be available Monday morning and that a message would be forwarded for follow-up. The Administrator was notified on 12/01/25 which was a delay in notification. Review of the facility's Delaware Resident Abuse Policy dated last revised/reviewed on 09/28/22 indicated, This Facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone; and Facility staff must immediately report all such altercations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately initiate an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy; and Timing: All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable State Agency. lf the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the DOH (Department of Health) immediately, but not later than 2 hours after the allegation is made.

Based on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of abuse for three (Residents (R) 134, R126, and R67) of seven residents reviewed for abuse out of 35 sampled residents. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from Abuse. Findings include:1. A review of R134's electronic medical record (EMR) titled Resident Face Sheet, located on the resident's dashboard, indicated the facility admitted the resident on 09/05/25. 2. A review of R126's EMR titled Resident Face Sheet, located on the resident's dashboard, indicated the facility admitted the resident on 08/29/25. A review of a document provided by the facility titled Incident Online Submission Form was completed. The facility reported the incident involving R134 and R126 to the State Survey Agency (SSA) on 09/29/25, as documented in the 'Incident Online Submission Form'. The facility reported incident (FRI) revealed on 09/27/25 that R134 attempted to propel himself around R126. R126 did not move and R134 then grabbed R126's wheelchair handles and pulled R126 back. R126 fell to the ground. Nursing assessed R126 and the resident sustained a skin tear on his right elbow. An investigation ensued. The facility's investigation included staff and resident interviews. R134 denied that he had deliberately caused R126 to fall out of his wheelchair and hurt R126. Staff were asked if they have ever witnessed R134 redirecting other residents who use wheelchairs, instead of asking staff if they had witnessed R134 attempting to hurt other residents. During an interview on 12/11/25 at 5:07 PM, the Administrator confirmed the resident-to-resident incident which involved R134 and R126 was incomplete since she did not ask staff about abuse. 3.Review of the resident's admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R67 was admitted to the facility on [DATE], according to the. The resident's diagnoses included history of Traumatic Brain Injury (TBI) and Dementia with Agitation. R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition. The assessment indicated the resident had short and long-term memory deficits. Review of R67's Progress Notes, dated 09/03/25 and found in the EMR under the Notes tab, revealed This nurse was notified by CNA [Certified Nursing Assistant] staff that the resident [R67] attempted to enter the room of two [unnamed] female residents. One [unnamed] resident reported that he [R67] tried to get into bed with her and stated she would call 911 if the behavior recurs. Upon assessment, no injuries were noted, and both residents were assessed to be WNL [within normal limits]. DON [Director of Nursing] was notified. A room change was recommended to prevent further incidents. Review of the facility's Incident and Accident Report Log, dated 06/09/25 through 12/09/25 and provided directly to the survey team, revealed no documentation on the log related to the 09/03/25 incident of potential abuse of the two unidentified females by R67. Review of facility records and R67's records revealed no documentation to indicate an investigation had been initiated/completed related to the 09/03/25 incident of potential abuse of the unidentified female residents by R67. During an interview with the Administrator and DON on 12/10/25 at 1:49 PM, they confirmed an investigation of potential abuse was expected to be initiated and completed related any incident of potential abuse/neglect, including the 09/03/25 incident of potential resident to resident abuse of the two unidentified female residents by R67. Review of a facility policy titled Abuse, Neglect and Exploitation dated 09/28/22 indicated . Investigation protocol. The person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses. witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident.If there are no direct witnesses, then the interviews may be expanded. For example, to cover employees on the unit, or, as appropriate, the shift. For injuries of unknown source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well.

Based on record review, observations, interviews, and review of facility policy, the facility failed to ensure a splint was applied routinely for one (Resident (R ) R2) out of five residents reviewed for position and mobility out of a total sample of 35 residents. The facility's failure to ensure R2's splint was routinely applied created the potential for this and other residents to experience an unnecessary decline in Range of Motion (ROM). Findings include:Review of the resident's admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]., according to the. The resident's diagnoses included Anoxic Brain Damage and Persistent Vegetative State. Review of R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and inability to communicate. The assessment indicated a brace/splint was not being applied for the resident. Review of R2's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders tab, revealed no orders for the resident's use of a splint/brace. Review of R2's Splint/Brace Care Plan, dated 10/01/25 and found in the EMR under the Care Plan tab, revealed R2 required the use of a splint/brace related to a contracture of her right hand. The care plan indicated the resident's splint/brace was to be applied every day and removed at night. Review of R2's record revealed no documentation to indicate her splint/brace was being applied per her plan of care. Observations of R2 lying in her bed in a vegetative state and unable to move her body were conducted on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM and 11:59 AM. The resident's splint/brace was not applied to her right hand during any of the observations. The brace was observed lying on the bedside table next to the resident's bed. During an observation along with Certified Nursing Assistant (CNA2) on 12/11/25 at 10:31 AM, CNA2 confirmed the care planned splint/brace was not applied to R2's right hand at the time of the observation and confirmed R2's brace/splint was supposed to be applied during the day every day. During an interview with the Director of Nursing (DON) on 12/11/25 at 10:55 AM, she stated her expectation was R2's splint was to be applied according to her plan of care in order to prevent further decline in the resident's ROM. Review of the facility's Splint Issuance Policy dated last revised/reviewed on 03/24/25 indicated, Splints shall be issued or fabricated with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance; and Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan.

Based on record review, interviews, and review of facility policy, the facility failed to ensure consistent and comprehensive management of nutritional services for one Resident (R ) R67) out of three residents reviewed for nutrition out of a total sample of 35 resident. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits.Findings include:Review of the resident's admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R67 was admitted to the facility on [DATE] The resident's diagnoses included history of Traumatic Brain Injury (TBI) and Dementia with Agitation. Review of R67's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition. The assessment indicated the resident had short and long-term memory deficits. The assessment indicated the resident had not experienced significant weight loss or gain during the assessment reference period, indicated the resident required set-up assistance from staff to eat his meals and indicated there were no interventions in place to prevent weight loss at the time of the assessment. Review of R67's Nutrition/Hydration Risk Care Plan, dated 12/10/25 and found in the EMR under the Care Plan tab, indicated the resident was at risk for significant weight loss related to his altered mental status and history of being combative with cares/services. Interventions included provide diet per physician's order and weight per physician's order. Review of R67's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders tab, revealed orders, with an initial order date of 12/03/25 for the resident to receive a regular diet and for weights to be obtained weekly. There were no current orders in the order set for the resident to receive any type of supplement or nutritional intervention to prevent weight loss. Review of R67's Vital Signs Report, dated 12/13/25 and found in the EMR under the Orders tab, revealed the following weights (which indicated a significant weight loss of 10.49% in less than 30 days) : 11/11/25: 162 pounds (LBS) 12/03/25: 145 pounds (LBS) The record did not indicate anything to show a re-weight had been obtained for R67 after his significant weight loss was recorded on 12/03/25. Review of R67's Dietary Progress Notes, dated 12/06/25 and found in the EMR under the Notes tab, revealed Resident [R67] recently readmitted from the hospital. He has experienced significant unintentional weight loss, decreasing from 162 LBS to 145 LBS (BMI (Body Mass Index) 19.66) over approximately one month, which is concerning for malnutrition risk. Resident is on a regular diet with staff assistance and encouragement provided as needed, and oral nutritional supplements (Boost 8 oz twice daily) are being used to support caloric and protein intake. Fluid intake remains below estimated needs, and staff continue to encourage fluids throughout the day. Review of R67's Medication and Treatment Administration Records (MARs/TARS), dated 12/01/25 through 12/12/25 and found in the EMR under the Orders tab, revealed the resident had not been receiving any type of nutritional supplement during that time period. During an interview with Licensed Practical Nurse (LPN5) on 12/10/25 at 2:23 PM, she confirmed she was responsible for R67's care on that date and confirmed she could not locate anything in the resident's record to show R67 was receiving the supplements indicated per his nutritional progress notes and could not locate anything to show the resident had been re-weighed after his 12/03/25 weight indicated a significant weight loss. She stated R67 had been receiving a supplement but had recently been hospitalized and the supplement order had not been put back in the EMR upon the resident's return from the hospital on [DATE]. During an interview with LPN 4/Unit Manager on 12/10/25 at 2:27 PM, she confirmed she was in charge of the unit where R67 resided and confirmed she was not able to locate anything to show R67 had been re-weighed after his documented 12/02/25 weight loss nor was she able to locate anything to confirm R67 had been receiving his supplement during the month of December 2025 since his return from the hospital. She confirmed it appeared the order for the resident's supplement had not been re-entered after the resident's return from the hospital on [DATE] During an interview with the Registered Dietician (RD) on 12/11/25 at 10:08 AM, he confirmed R67 was expected to receive his recommended nutritional supplement to help prevent unplanned weight loss and stated a re-weight was expected to be obtained within 24 hours with any documented significant weight loss. He stated he was not aware R67 had not been getting his nutritional supplement since his return from the hospital on [DATE]. During an interview with the DON on 12/11/25 at 10:51 AM, she confirmed her expectation was a re-weight should be obtained as soon as possible (within 24 hours) with any documented significant weight loss and confirmed R67 should have been receiving his recommended dietary supplement (Boost 8 ounces twice daily). Review of the facility's Resident Weight Policy dated last revised/reviewed on 03/23/25 indicated, Weights will be obtained routinely in order to monitor nutritional health over time. The facility's policies related to the maintenance of nutritional health were requested by the survey team on 12/11/25 at 5:30 PM, however the policies were not received prior to survey exit on 12/13/25.

Based on record review, interviews, and review of facility policy, the facility failed to ensure bed rails in use were necessary for one (Resident (R) 2) of 11 residents reviewed for accidents out of a total sample of 35 residents. The facility's failure to ensure the necessity of R2's bed rails created the potential for this and other residents to experience accidents related to the use of unnecessary bedrails. Findings include:Review of the resident's admission Record, dated 12/12/25 and found in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]. The resident's diagnoses included Anoxic Brain Damage and Persistent Vegetative State. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and inability to communicate. The assessment indicated the resident was totally dependent upon staff to complete all of her Activities of Daily Living (ADLs) including movement in bed and transfers in and out of bed. The assessment indicated the resident did not have bed rails in place on her bed. Review of R2's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders tab, revealed no orders for the resident's use of bed rails. Review of R2's comprehensive care plan, most recently dated 09/30/25 and found in the EMR under the Care Plan tab, revealed no care plan to indicate the resident's use of bed rails. R2's record was reviewed comprehensively and no documentation could be found to indicate informed consent had been obtained for the use of bed rails on R2's bed. Observations of R2 lying in her bed in a vegetative state and unable to move her body were conducted on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM. Grab bars (short bed rails) were raised on both sides of the resident's bed during all of the observations. During an observation of R2 conducted along with Licensed Practical Nurse (LPN)5 on 12/10/25 at 1:30 PM, LPN5 confirmed 1/4 grab bars were in the raised position on both sides of R2's bed and confirmed R2 was not able to move at all. She stated R2 was unresponsive and was completely dependent upon staff to complete all of her ADLs. She stated the resident's bilateral grab bars were usually in the raised position. During an interview with the Director of Nursing (DON) on 12/10/25 at 2:13 PM, she confirmed R2 was unresponsive and stated R2 was not able to use her grab bars in any way and the grab bars should not have been installed on the resident's bed. Review of the facility's Bed Rail Policy dated last revised/reviewed on 12/03/25 indicated, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the resident's functional abilities; and If a bed or side rail or bar is used, the facility will: .b. Evaluate the risk versus benefits of using a bed rail and review them with the resident or if applicable, the resident's representative, and c. Obtain informed consent for the installation and use of the bed rails prior to the installation

Based on review of facility policy, record review, observations and interviews, the facility failed to ensure a medication rate of less than five percent when two errors were made out of a total of 25 opportunities, during the administration of (one Resident's (R) 114). The facility's observed medication error rate was eight percent. The facility's failure created the potential for R114 and other residents to experience negative physical and/or psychosocial effects related to the incorrect administration of their medication. A total of 35 residents were reviewed in the sample.Findings include:R114 was admitted to the facility on [DATE], according to the resident's admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab. The resident's diagnoses included Type 2 Diabetes. R114 was observed receiving his medication administered by Licensed Practical Nurse (LPN4) on 12/11/25 at 8:48 AM. LPN4 administered the resident's Basaglar Insulin and Insulin Lispro separately per insulin pen. LPN4 did not prime the insulin pen prior to the administration of the Insulin Basaglar or the Insulin Lispro. Review of R114's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. This indicated the resident was cognitively intact. The assessment indicated the resident received insulin on seven of seven days observed during assessment reference period. Review of R114's Physician's Order Report, found in the EMR under the Orders Tab, revealed orders, with an original order date of 11/25/25, for the resident to receive Basaglar KwikPen (Long-Acting Insulin) 10 units Subcutaneously (SC) routinely each morning at 8:00 AM and to receive Insulin Lispro (Short Acting Insulin) 14 units SC routinely three times daily before meals. Review of R114's Medication Administration Record (MAR), dated 12/01/25 through 12/12/25 and found in the EMR under the Orders Tab, revealed the resident was receiving his insulin as ordered. During an interview with LPN4 on 12/11/25 at 9:05 AM, she stated she was not aware the insulin pens needed to be primed and she had never primed the resident's pen prior to the administration of his insulin. During an interview with the Director of Nursing (DON) on 12/11/25 at 10:57 AM, she stated insulin pens were expected to be primed with two units of insulin prior to administration of the insulin to ensure an appropriate dose of the insulin was administered. Review of the facility's undated Using Insulin Pen Delivery Systems Document indicated, Prime (the pen) before each injection, hold upright and prime the pen to remove air bubbles and to ensure the needle is open and working.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (Residents (R) R102) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 35 sampled residents. The facility failed to offer R102 and/or their representative the opportunity to be vaccinated with one dose of Prevnar 15 (PCV15), PCV20, or PCV21 after the final pneumococcal vaccination. This practice had the potential to increase the risk for this resident to contract pneumonia. Findings include:A review of R102's electronic medical records (EMR) titled Resident Face Sheet, located on the resident's dashboard, indicated the facility admitted the resident on 08/09/23. The resident was over the age of 65 at the time of his admission. A review of R102's EMR titled Preventive Health located under the Resident tab indicated the resident received the PPSV23 on 08/18/23. There was no evidence in the resident's clinical record to document that he shared in clinical decision making for the opportunity to receive the PCV15, PCV20, or the PCV21 vaccination. During an interview on 12/12/25 at 1:45 PM, the Infection Preventionist (IP) verified that she missed offering R102 the PCV15, PVCV20, or the PCV21 vaccination. Review of a facility policy titled Resident Vaccination Policy dated 03/04/25 indicated .Residents and/or their responsible party will be asked about prior vaccinations at admission. Prior doses.pneumococcal.and other vaccines will be documented in the immunization portal in the electronic health record. There was no evidence in the facility's policy that addressed the CDC recommendations for the pneumococcal vaccinations. Review of the CDC website https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, dated 10/26/24 indicated .Based on shared clinical decision- making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both .PCV13 (but not PCV15, PCV20, or PCV21) at any age and .PPSV23 [Pneumovax 23]at or after the age of [AGE] years old.

R2 was admitted to the facility on [DATE], according to the resident's admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab. The resident's diagnoses included Anoxic Brain Damage and Persistent Vegetative State. Observations of R2 on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM, revealed grab bars raised on both sides of the resident's bed. The resident was laying in her bed in a vegetative state and unable to move her body. Observations of R2 laying in her bed in a vegetative state and unable to move her body were conducted on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM. Grab bars were raised on both sides of the resident's bed during all of the observations. During an observation of R2 conducted along with Licensed Practical Nurse (LPN5) on 12/10/25 at 1:30 PM, LPN5 confirmed 1/4 grab bars were in the raised position on both sides of R2's bed. Review of R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/25 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status (BIMS) assessment was not completed due to the resident's poor cognition and inability to communicate. The assessment indicated the resident was totally dependent upon staff to complete all of her Activities of Daily Living (ADLs) including movement in bed and transfers in and out of bed. The assessment indicated the resident did not have bed rails in place on her bed. R2's Physician's Order Report, dated 12/13/25 and found in the EMR under the Orders Tab, revealed no orders for the resident's use of bed rails. Review of the facility documentation revealed no assessment had been conducted prior to the installation of the bed rails. During an interview with the Maintenance Director (MD) on 12/12/25 at 11:00 AM, he stated beds were inspected for overall safety routinely, however rails applied to any given resident's bed were not inspected at the time of installation or routinely thereafter to ensure the physical safety of the bed rails on each resident's bed. During an interview with the Regional Director of Operations on 12/12/25 at 11:05 AM, she confirmed the physical safety of beds with rails applied to them were expected to be assessed when rails were initiated for any resident, and then routinely thereafter to ensure physical safety of the rails and bed. Review of the facility's Bed Rail Policy revised/reviewed on 12/03/25 indicated, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the resident's functional abilities; and If a bed or side rail or bar is used, the facility will: a. Evaluate the potential risks associated with the use of bed rails including the risk of entrapment, prior to bed rail installation using the Bed Rail Safety Checklist,. d. Ensure appropriate dimensions of the bed, based on the resident's size and weights, e. Ensure correct installation of bed rails, including adherence to manufacturer's recommendations and/or specifications, f. Ensure correct use of an installed bed or side rail, g. Ensure scheduled maintenance of any bed rail in use according to manufacturer's recommendations and specifications.

2. Cross refer to F610, F658 example 2 Review of R5's clinical record revealed: 1/20/23 - R5 was admitted to the facility for long term care. 1/18/25 - R5's care plan for Behavioral Symptoms. Resident is a threat to self and/or others R/T (related to) episodes of aggression and elopement attempts was updated with an intervention for 1:1 observation for safety. 2/11/25 - The quarterly MDS assessment documented that R5 was cognitively impaired with a BIMS score of 5; independent for toileting/showering/dressing/ambulating; active diagnoses included, but were not limited to: dementia, seizure disorder and depression; history of falls; current medications include antipsychotic, antidepressant and anticonvulsant; and the use of a wander/elopement alarm. 3/20/25 3:53 PM - A nurse's note by E4 (LPN) documented, this writer was made aware by staff that resident fell and got himself back to sit in his chair. Pt (Patient) assess (sic) no apparent injury noted. Resident stated he was trying to sit on his chair. Pt denies injury upon assessment . It should be noted that there was no documented evidence that R5 had another fall in the facility after 3/20/25. Review of the facility's 1:1 documentation for R5 that was provided to the surveyor lacked documented evidence of R5 being supervised by a staff person on Sunday, 3/23/25, from 7:00 AM through 3:00 PM and on Monday, 3/24/25, from 12 AM through 7:30 AM. 3/24/25 9:03 AM - A social services note documented, Resident observed attempting to leave the building by pushing and banging on the door. Resident continues to state to not like it her (sic) and wants to leave. Resident alert and verbal able to make needs known however has impaired cognition with a dx (diagnosis) of dementia. Resident was redirected by staff and brought back to his room where he remains on 1:1 for supervision. 3/24/25 9:59 AM - A progress note by E5 (NP) documented, . Patient was seen and examined . nursing staff concerned due to altered mental status and bloody drainage from the left ear. He is status post fall. No visible injury apart from bloody ear, which nursing staff reported that he scratched himself. He is unable to answer my questions at this time. Awake and sitting on a WC (wheelchair) . Plan: Perforated eardrum/ bloody drainage- Acute, suspected otoscopic exam revealed perforated eardrum . Since patient is post fall with AMS (altered mental status), will transfer to ED (emergency department) to more immediate imaging . Altered mental status- Acute . He is unable to answer and follow verbal commands . 3/24/25 10:25 AM - A nurse's note by E6 (UM/LPN) documented, Resident noted with increased confusion, need additional assist with adls (activities of daily living) and unsteady gait. Also note blood to right ear. Resident is s/p (status post) fall. [E5, NP] in house to evaluate with new order to send resident to ER for further eval (evaluation) . 3/24/25 11:04 AM (arrival time) - The hospital record documented, . Patient . presenting with AMS . was unable to answer orientation questions . ED provider called [facility] . Reported that since this AM he has not been acting like himself, reportedly able to ambulate although dragging his right leg . They stated he has been compliant on all his seizure medications and no seizure activity was noted today. Denied significant head trauma . Reportedly noted to have slurred speech . He was noted to have bleeding from his right ear, at which point a trauma alert was called . Dried blood in and around the R (right) ear . Head CT [CT scan results]: 1. Right temporal hemorrhagic contusion. 2. Right temporal bone fracture . with 7 mm epidural hematoma . and traumatic pneumocephalus . 3/25/25 10:37 AM - A progress note by E6 (UM/LPN) documented, IDT (Interdisciplinary team) met to review residents (sic) plan of care. Resident . with comorbities than (sic) include seizure disorder . dementia . alert and oriented with a BIMs of 5 . continent of bowel and bladder, self propels wheelchair and requires supervision for ADLs. On 3/20/25 resident sustained a witnessed fall during attempt to transfer from wheelchair. Per witness statement resident stood from wheelchair and fell to knees. Resident was able to independently get up from floor. No apparent injuries observed at this time . 3/25/25 6:49 PM - An IDT note by E2 (DON) documented, . Long-term care resident . past medical history of weakness, vascular dementia, MDD, CKD, Seizures, Neuropathic intracranial hemorrhage and hypotension. He is alert and orient (sic) he is able to make his needs known. He self-propels on a wheelchair. He is independed (sic) for ADLs. On 3/24/25 he was noted with blood and tissue in his ear, and he stated that he had scratched his ear. He was also noted with a change in condition, slurred speech with increased weakness. He was assessed by the NP who gave orders to send [R5] out to the hospital for further evaluation. Resident had a CT scan completed which indicated Right temporal hemorrhagic contusion . 5/2/25 2:49 PM - During an interview, E6 (UM/LPN) stated that she did not recall any complaints or issues with R5 on Friday, 3/21/25, the day after he fell (3/20/25). E6 stated that she did not work over the weekend. E6 stated on Monday dayshift, 3/24/25, when I came in, R5's 1:1 [E8, assigned CNA] pulled me into his room saying R5 was erratic and trying to hit her. E6 stated that R5 was on the toilet and he could not get up on his own, which is not how he normally is. E6 stated, I knew something was wrong. E6 stated that she was trying to put him in his wheelchair and she noticed blood on his ear. E6 stated that R5 told me that it was a scratch. E6 stated that R5 participated in the scheduled smoking breaks and he did not go out for the 8:30 AM scheduled smoking break. E6 stated Between us trying to get him settled and [E5, NP] seeing him and sending him out, R5 did not have time to got to the smoking break. Normally he went to every smoking break. That day he was not asking to go to the smoking break. Review of the facility's timecard records revealed that E6 (UM/LPN) clocked in on Monday, 3/24/25, at 8:19 AM. The offgoing nightshift nurse, E9 (LPN), worked a double shift and was assigned to a different hallway for 3/24/25 dayshift. According to the facility's 7-3 C.N.A. Assignment Sheet Date: 3/24/25, E6 was the assigned nurse for the entire hallway where R5's room was located. 5/5/25 12:41 PM - During an interview, E8 (CNA) confirmed that she was the assigned 1:1 CNA for R5 on Monday dayshift, 3/24/25. E8 stated that she did not talk to anyone when she took over his care nor received report from previous CNA or a nurse. E8 stated there was nobody sitting outside his room from night shift. E8 stated that when R5 got up, he was kind of not himself and she noted his ear was bleeding. It was dried blood. E8 stated that From the beginning, he was talking about [name of country] . he wants to go home. E8 stated that [R5] walked to the front door by pushing his wheelchair. When he got to the front door, [R5] went off. [R5] threw the wheelchair at me. Someone opened the front door because they did not see him. Then three of us pulled the door closed and [R5] came back at me. E8 stated that [R5] was not himself . he was out of it and aggressive. E8 stated that after the front door, he walked himself back and sat down on his bed. The nurse [E6, UM/LPN] cleaned his ear again. Then the [NP] came and saw him and sent him out. E8 stated that the first time [R5] had his ear cleaned up was before the door incident and the second time it was cleaned up was after the door incident. E8 stated that when [R5] acts up, he kicks and uses his hands. E8 stated that she has never seen him bang his head. According to the facility's timecard records, E7 (assigned 1:1 CNA for Sunday nightshift, 3/23/25-3/24/25) clocked out on Monday, 3/24/25, at 7:00 AM. E8 (assigned 1:1 CNA for dayshift) clocked in on Monday, 3/24/25, at 7:21 AM. The facility lacked evidence that R5 had 1:1 supervision. 5/5/25 12:02 PM - Finding was reviewed with E1 (NHA) and E2 (DON). 5/6/25 1:40 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (RUPO). Based on interview and review of clinical records, hospital records and facility documentation as indicated, it was determined that for two (R1 and R5) out of five residents reviewed for accidents, the facility failed to ensure the environment remained as free of accident hazards as was possible and each resident received adequate supervision. For R1, the facility failed to ensure R1, a resident with cognitive impairment and care planned to wear a wandering device, received adequate supervision and assistive devices to prevent an elopement. On 4/21/25 at approximately 9:30 PM, R1 eloped from the facility via the facility front door. R1 remained unaccounted for until 10:20 PM when the police located and returned R1 to the facility. An IJ was called on 5/1/25 at 1:30 PM. The IJ was abated on 5/1/25 at 3:54 PM For R5, the facility failed to supervise a cognitively impaired resident who was on 1:1 (one to one) supervision for safety/behaviors. On 3/24/25, R5 was emergently transferred to the hospital for a change in condition and upon examination was identified with multiple injuries of unknown origin, including a non-displaced temporal bone fracture and small epidural hematoma. R5 was harmed. Findings include: 1. The facility's Elopement/Unauthorized Absence Policy: The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement, the facility will implement its policies and procedures promptly to locate the resident in a timely manner . Assessment: 1. All residents will be assessed for the risk of elopement using the Elopement Observation on admission, quarterly and as needed. The facility's Resident Observation Policy, last revised 5/28/21, stated, . B) DON will assign a staff member to complete appropriate observation/interventions which may include but are not limited to: every 15 or 30 minutes checks or 1:1 monitoring. Staff members will complete the observation/monitoring tool as follows: . C) If resident is on 1:1 monitoring, additional staff member assigned will remain with the resident in view at all times. Should the assigned staff member need to leave the area they are responsible to ensure the resident is directly observed during their absence by another staff member. Interim staff member will utilize observation/monitoring tool as above . [Manufacturer] Code Alert Wander Management User Manual - Resident Generated Alarms - Do not rely exclusively on resident generated alarms for resident care and safety . The most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment .The transmitter is placed on the wrist or ankle of the resident. If a transmitter is detected in an Exit Alarm Zone and the door is open, an alarm sounds at the exit. Depending upon which equipment you have installed, the Wander management Solution can automatically lock doors and deactivate elevators . The Wander management solution, by itself, cannot prevent the elopement of residents .Signal Strength 2. An alarm must occur when the transmitter is within 4-feet of the monitored door. If applicable, the door should also lock . [Manufacturer's] Technology, 2018. 1. Review of R1's clinical record revealed: Cross refer F658 example 1 and F842. 11/6/24 - R1 was admitted to the facility with diagnosis including but not limited to, dementia. 11/6/24 11:35 AM - E10 (LPN) documented on the admission elopement observation, No- clinically not at risk for elopement .No identified risks for elopement. 11/7/24 1:56 PM - R1's admission Minimum Data Set (MDS) assessment documented a Basic Inventory of Mental Status (BIMS) score of 9, which was reflective of moderate cognitive impairment. 11/19/24 - R1's baseline care plan documented Problem- Resident experiences wandering . Approach - . Safety/Wanderguard: electronic bracelet for safety - check placement every shift . 12/2/24 10:35 AM - E11 (MD) and E12 (Social Work Director) completed the DSAMH (Division of Substance Abuse and Mental Health) 24-hour Emergency Detention form on behalf of R1 stating that R1 was dangerous to self as evidenced by .exhibiting increasing delusions paranoia. He believes he has been kidnapped by the Russians. He refers to the staff as [NAME] .frequently combative. Physically aggressive with staff . The facility failed to complete a re-assessment of R1's elopement risk at this time. 1/19/25 9:21 PM - E17 (RN) documented in R1's EMR progress notes, Pt (patient) was seeing (sic) holding security band cut and in hand. Pt keeps band in closet in dirty clothes bin. Pt is refusing to wear band. Writer is unsure how pt was able to remove band. Incoming nurse to be informed, hopefully band can be reapplied during sleep . 2/3/25 -R1's quarterly MDS assessment documented a BIMS score of 00, which reflected severe cognitive impairment. Review of the March 2025 MAR (Medication Administration Record) on nineteen different occasions E18 (RN), E19 (RN) and E20 (RN) (out of a potential ninety-three shifts) documented that R1 had removed his wander guard during the month of March. 3/13/25 - The Court of Chancery (a Delaware court of equity that assigns guardianships) assigned R1 a guardian, stating R1 was a person with a disability by reason of mental or physical incapacity . and is in danger of substantially endangering his health . The facility failed to complete a re-assessment of R1's elopement risk at this time. Review of the April 2025 MAR on five different occasions E18 (RN) (out of a potential sixty-two shifts) documented that R1 had removed his wander guard prior to the 4/21/25 elopement. 4/21/25 at approximately 9:30 PM - R1 eloped from the facility by exiting via the unattended, alarmed front door of the facility per the report that the facility filed with the State Agency. Review of the facility's abatement plan revealed that the facility took the following immediate measures: - 4/21/25 9:30 PM - facility immediately initiated Code Green- elopement protocol. Staff searched the facility both inside and outside the facility. - 4/21/25 9:45 PM - the local police were called and made aware of the missing resident. Staff members continued searching the area by car. - 4/21/25 10:20 PM - R1 was located and returned to the facility by the [local] Police. R1 was found seated on the ground on the adjacent complex parking lot behind the facility. - 4/21/25 10:20 PM - Once in the facility, R1 placed on 1:1 supervision indefinitely. NP and Guardian notified of the elopement. - 4/21/25 - R1's care plan was updated for elopement. - 4/21/25 10:30 PM - DON (E2) entered the facility and checked exit doors ensuring that the door locking mechanism was properly functioning. A head count of all residents in the facility was also completed by the DON. - 4/21/25 10:45 PM - House wide education was initiated regarding elopement was initiated by the DON and continued until all staff were educated. - 4/22/25 2:30 PM- The Staff development nurse called all staff not scheduled and provided elopement education via the telephone. This was completed by 2:30 PM. - 4/22/25 - Elopement drills were completed on all 3 shifts. - 4/22/25 - Maintenance director audited all exit doors. - 4/22/25 - R1 evaluated by NP and Psych provider. - 4/22/25 - An Ad Hoc QAPI meeting to discuss the elopement incident was held. - 4/23/25 6:30 AM -The last elopement drill was completed with night shift. 4/22/25 6:12 PM - E2 (DON) reported to the State Agency, On 4/21/25 at approximately 9:30 PM, staff noticed that the front door alarm was going off. Staff immediately responded to the alarm and noted the wheelchair of [R1] in the lobby; staff quickly looked outside and did not note the resident. Elopement protocol initiated; the staff immediately completed a house wide search of the resident and he was not located. External search of the facility initiated and police were notified to assist in the search . Police officers located the resident in the neighboring apartment complex compound, seated on the ground and was returned to the facility by officers at approximately 10:20 PM . The facility failed to provide adequate supervision of R1 to prevent an elopement. R1 was outside the facility without supervision at night for approximately 50 minutes. 4/23/25 6:30 AM - The last elopement drill was completed with the night shift. 4/29/24 8:24 AM - During an interview, E13 (front desk receptionist) stated, The (front) door is locked 24/7. You have to be buzzed to be let in. 4/29/25 10:10 AM - During an interview, E2 stated that the facility does not have video footage of the elopement incident at the front doorway. 4/29/25 11:10 AM - During an interview, E14 (receptionist) stated, You need a code to get in and out. I work day shift. I typically arrive around 6:30 AM and stay until 3 PM. Then there is a part-time worker who is here until 7 PM. After 7 PM, to get in a person has to ring the doorbell and then a nurse or aide has to let them in. To get out you have to have the code to open the door. 4/29/25 7:02 PM - During a telephone interview, E15 (RN/ evening shift supervisor) stated, I was working as the supervisor. I was on the southside unit. The resident was on the northside unit. Two CNAs told me that he [R1] had eloped. I started a search. I told everyone to search the rooms. One of the nurse aides saw that the wheelchair was in the main lobby and that he [R1] was missing. I notified the police and then the DON. A couple of the CNAs got in their cars and drove around looking for him. One of the CNAs went to the Wawa area. The police came and I gave a description. We did not have picture because he refused a picture. Within 40 minutes he was located. When he was back in the building, he was really agitated. He did say that he fell. He refused everything. [E16, LPN] is regularly assigned to him. He was very disrespectful to her and he got in her space. No I don't remember hearing the alarm, I was in a little office on the Southside . I had no idea that he could walk that fast. Every time I saw him, he was pushing a WC. He is up walking at all times. He did have a Wanderguard on. Wanderguard should be checked every shift. I believe it was on his ankle. 4/30/25 10:26 AM - During an interview, E6 (LPN/unit manager) stated, [R1] had an order for the Wanderguard device . He would take it off a lot. He was not an exit seeker prior to that night. 5/1/25 11:39 AM - The surveyor with E1 (NHA) and E2 (DON) performed a demonstration of the front door locking system. Without a Wanderguard device, when the surveyor put pressure on the door handle, an alarm had an immediate two beeps and then beep approximately every second for 15 seconds continuously. Then at 15 seconds, the door lock released and the door could be opened. With the Wanderguard device, when the surveyor put pressure on the door handle, an alarm had an immediate two beeps and then beep approximately every second for 20 seconds continuously. Then at 20 seconds, the door lock released and the door could be opened. For this demonstration , E2 (DON) held the Wanderguard device and E1 (NHA) timed the alarm. Of note, the door alarm did not trigger an alarm when the Wanderguard device came within four feet of the sensors on the door. 5/1/25 1:30 PM - An IJ was called. 5/1/25 3:54 PM - The abatement plan that the facility would have staff at the front door 24 hours until the door locks could be adjusted, was accepted by the State Agency. 5/2/25 11:30 AM - The surveyor confirmed the abatement by reviewing the schedule and interviewing the day shift front desk personnel.

Based on interview and review of a clinical record and other documentation as indicated, it was determined that for one (R5) out of five residents reviewed for accidents, the facility failed to have evidence of a thorough investigation for a cognitively impaired resident who was identified at the hospital with multiple injuries of unknown origin. Findings include: Cross refer to F658 example 1 and F689 example 2 Review of R5's clinical record revealed: 3/20/25 - E4 (LPN) documented in a nurse's note that R5 fell while trying to sit on his chair in his room and had no injury. It should be noted that R5's 3/20/25 fall was witnessed and reported to the nurse by the assigned 1:1 CNA. R5's clinical record revealed that there were no other falls reported and documented after the 3/20/25 fall. 3/25/25 at 1:34 PM - The facility reported the following to the State Agency: On 3/24/25 [R5] was noted with a blood and tissue in his ear and he stated that he had scratched his ear. He was also noted with a change of condition, slurred speech with increased weakness. He was assessed by the NP [E5, contracted] who gave orders to send him out to the hospital for further evaluation. Resident had a CT scan completed which indicated Right temporal hemorrhagic contusion . 4/4/25 - The facility's five day follow-up report to the State Agency documented the following: - Describe any additional outcomes to the resident . No signs of psychological distress. [R5] was noted to have blood and tissue in his ear but did not express any psychological harm or distress. Resident scratched his ear. No additional mention is made regarding his perspective on any psychological distress. - Provide summary of information of investigation related to the incident from the resident's clinical record . The resident, [R5], was noted to have blood and tissue in his ear and a change of condition (slurred speech, increased weakness). After assessment, he was sent to the hospital, where a CT scan showed a Right temporal hemorrhagic contusion. - Description of conclusion: The investigation concluded that the incident likely resulted from [R5] fall a few days prior. The CT scan showed a Right temporal hemorrhagic contusion. It should be noted that the facility failed to inform the State Agency in the five day follow-up report all of R5's injuries identified in his hospital records, including a right temporal hemorrhagic contusion, right temporal bone fracture, small epidural hematoma and right hip bruise. Upon request of the facility's investigation in response to R5's injuries of unknown origin, the surveyor was provided the following documents: - 3/20/25 Event Report for the witnessed fall and two statements from E4 (LPN) and E13 (assigned CNA for 1:1); and - Typed statements from eight staff, dated 3/25/25, from phone interviews. There was no evidence that the facility's investigation included: - interviews/statements from other staff present on the shift and/or who relieved the 1:1 CNAs when they were on their breaks/lunch from 3/20/25 through 3/24/25; - review of timecards to ensure 1:1 staff were present and observing R5 during the timeframe; and - review and identification of the lack of CNA documentation, including the Point of Care Report and the 1:1 Observation/Monitoring Tool, from the 3/20/25 fall through 3/24/25 when R5 was transferred to the hospital. 5/1/25 at 3:01 PM - During an interview, E4 (LPN) confirmed that E13 (CNA) told her that R5 had fallen on 3/20/25 and it was witnessed. E4 said she was told that R5 was trying to get out of his wheelchair and fell to his knees. E4 stated that R5 did not have any injury. E4 stated, There was no blood or injury. 5/5/25 at 5:15 PM - During an interview, E13 (CNA) confirmed that she was the assigned 1:1 CNA when R5 fell on 3/20/25. E13 stated that she never saw him hit his head against anything. 5/5/25 at 12:02 PM - Reviewed findings with E1 (NHA) and E2 (DON). The facility failed to thoroughly investigate R5's injuries of unknown origin after a change of condition and emergent transfer to the hospital on 3/24/25. 5/6/25 1:40 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (RUPO).

Based on record review and interview, it was determined that for one (R5) out of three residents reviewed for discharge, the facility failed to allow R5 to return to the facility and also failed provide a 30 day discharge to his family representative. Findings include: The facility's Bed Hold Letter Policy - It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold letter. Updated [DATE] The facility's admission Agreement- N. Bed Hold and Leave of Absence- . If Resident's primary pay source is Medicaid, and if the State within which the facility is located provides for paid hold/ leave days, the facility will hold the bed for the Resident up to ____________. If the resident's absence from the facility exceeds the days provided during a calendar year or the State does not provide for paid hold/leave days, the facility shall not hold the bed and the Resident will be discharged from the facility effective the first day following the last paid Medicaid hold/leave or in-house day . Where a Resident's paid leave days for a calendar year have been exhausted or the State does not provide for paid hold/leave days, the Resident will be entitled to re-admission to the facility, if desired, to the Resident's previous room if available or immediately upon the first availability of a bed in a semi-private room, if the Resident: a). requires the services provided by the facility; and b). is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. Last revised [DATE] Review of R5's clinical record revealed: [DATE] - R5 was admitted to the facility with diagnoses including but not limited to vascular dementia with psychotic disturbances. [DATE] - R5's care plan for Behavioral Symptoms. Resident is a threat to self and/or others R/T (related to) episodes of aggression and elopement attempts was updated with an intervention for 1:1 observation for safety. [DATE] 10:25 AM - E6 (UM/LPN) documented in R5's EMR progress notes, Resident noted with increased confusion, need additional assist with ADLs and unsteady gait. Also note blood to right ear . [E5 NP] in house to evaluate with new order to send resident to ER for further eval (evaluation) . [DATE] 11:43 AM - E22 (hospital MD) documented in [hospital] ED (emergency department) Physician Record, XXX[AGE] year old male .presenting with altered mental status . [DATE] - The facility mailed copies of R5's Return to Facility Anticipated form dated [DATE] and Bed Hold Notice to F2 (R5's brother who lived in Puerto Rico). The Return to Facility form stated that the reason for R5's transfer was an immediate transfer or discharge is required by the resident's urgent medical needs. The facility provided the surveyor with copies of the addressed envelope and postage for this mailing to Puerto Rico. [DATE] 10:55 AM - C4 documented in R5's hospital EMR, Pt off restraints since 4/1 at 2345 (11:45 PM) . once 24 hours without restraints pt able to return to [facility]. [DATE] 11:30 AM - C5 (hospital case manager) documented in R5's hospital EMR, As per rounds, pt has a safety sitter at this time and is not in restraints. Patient's psych medications were adjusted .As per facility, patient will need insurance auth (authorization) and PASRR prior to return. [DATE] 12:48 PM - C5 (hospital case manager) documented in R5's hospital EMR, As per rounds, pt agitated and now has wrist restraints . [DATE] 3:19 PM - C5 documented in R5's hospital EMR, Spoke with Admissions at [facility], pt does not need to be sitter free for return to their facility, he needs to be out of restraints for 24 hours .PASRR approved and uploaded to facility via Ensocare. [DATE] 8:56 AM - C5 documented in R5's hospital EMR, .Spoke with [facility] yesterday, pt needs to be restraint free X 24 hours prior to acceptance. Received Ensocare message from [facility] Just to reiterate, patient has no bed hold and currently I don't have a bed . [DATE] 11:08 AM - C5 documented in R5's hospital EMR, As per rounds, pt has been restraint free since 1400 (2 PM) yesterday. Updates sent to [facility] with inquiry about bed availability later today vs tomorrow if pt remains restraint free . [DATE] 1:08 PM - C5 documented in R5's hospital EMR, [Facility] declined patient at this time . [DATE] 3:20 PM - C5 documented in R5's hospital EMR, Spoke with Admission, they report they declined pt because they do not have a bed available at this time and will contact this writer when a bed becomes available. Called DE (Delaware) Ombudsman office at [phone number]. [DATE] 8:12 Am - C5 documented in R5's hospital EMR stating that the facility staff said, I have no idea when we will have a bed available . This patient requires a private room and a room close to the nursing station, which we do not have available. C5 also documented, F/u (follow up) with DE Ombudsman today due to facility declining pt return . [DATE] 2 :44 PM - C5 documented in R5's hospital EMR, CM (case management) received return call from Ombudsman's office, [C7] [phone number]. He reports he spoke with [facility]. Pt's bed hold expired and pt is planned for next available bed. [DATE] 10:49 AM - C5 documented in R5's hospital EMR, .Discussed during rounds, pt is back in restraints. Updates sent to [facility], no bed available at this time. Pt will need to be restraint free for 24 hours and will need room near nurse's station in order for facility to accept him back . [DATE] 10:33 AM - C5 documented in R5's hospital EMR, Discussed during rounds, pt will be out of restraints for 24 hours at 1400 (2 PM) today and is otherwise medically stable for return to [facility]. Updates sent to facility, facility continues to decline pt return due to no bed being available near the nurse's station. Called pt's LTSS case manager, she reports she is going to [facility] today and is requesting public guardianship for pt. [DATE] - R5's PASRR documented PASRR level I with no PASRR level II evaluation required. [DATE] 1:55 PM - This surveyor identified that there were two empty male beds in the facility XXXB [room number] and XXXB [room number]. Additionally, XXXA [room number] bed was a private room near the nurse's station but was currently under a bed hold. [DATE] 3:28 PM - C8 (complex cases case manager) documented in R5's hospital EMR, .Per Liaison, they [facility] are not accepting the patient back as they cannot meet his care needs and feel he is a danger to the other residents. Per Liaison, Administrator [E1] spoke with Ombudsman [C9] regarding this patient and was advised that this patient was not appropriate for their facility. Per Liaison, Administrator states the Ombudsman [C9] advised that [hospital] work with the LTSS CM (case manager) to place patient in an out of state facility. CM to submit OSEC referral as [facility] is the patient's residence . [DATE] 4:14 PM - This surveyor informed E1(NHA) and E3 (RUPO) at the request of the State Agency that the facility would need to accept R5 back and proceed with the 30 day discharge notice process. [DATE] 2 29 PM - C8 documented in R5's hospital EMR, CM received call from [facility] Liaison asking, if per the request of the building, she can come in and have the patient sign the 30 day notice. CM stated that she would have to follow up with manager .However the patient has vascular dementia compounded with a TBI (traumatic brain injury) and that he is unable to sign. CM also stated to her knowledge, a 30 day notice cannot be given to a patient while they are in the hospital . [DATE] 11:23 AM - During an interview, E21 (business office manager) confirmed that Medicaid was R5's payor source. [DATE] 2:38 PM - During an interview, E1 (NHA) confirmed that envelope mailed to F2 (R5's brother) on [DATE] contained R5's DMOST, the bed hold policy and all the transfer paperwork. E1 stated that there was no discharge paperwork contained in the [DATE] mailing packet. E1 stated the facility's policy for Medicaid residents was a seven day bed hold. [DATE] 5:38 PM - C2 (hospital psychiatry NP) documented in R5's hospital EMR progress note, .From a psychiatric standpoint, there are no barriers to discharge back to a long-term care facility. [DATE] - Upon conclusion of the survey, R5 remained in the hospital. [DATE] 1:40 PM- Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (RUPO).

Based on interview and record review, it was determined that for two (R1 and R5) out of five residents sampled for accidents, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by failing to have a registered nurse (RN) complete and document an RN admission assessment and post-fall assessment. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . RN . admission Assessments . Post Fall Assessment & Documentation . updated 10/11/24. 1. Review of R1's clinical record revealed: 11/6/24 - R1 was admitted to the facility with diagnosis including dementia. 11/6/24 11:35 AM - E10 (LPN) initiated R1's admission observations in the EMR. 11/6/24 12:30 PM - E10 (LPN) completed R1's admission observations in the EMR. 11/6/24 12:31 PM - E10 (LPN) completed R1's functional abilities assessment in the EMR. 11/6/24 12:39 PM - E10 (LPN) completed R1's TB (tuberculosis) screen in the EMR. 11/6/24 1:05 PM - E6 (LPN) completed R1's baseline care plan checklist in the EMR. 5/2/25 11:40 AM- A review of the EMR admission observations revealed the following information for each newly admitted resident were reviewed, assessed and documented on: language, hearing, speech and vision, nervous system, respiratory system, cardiovascular system, gastrointestinal system, genitourinary system, and musculoskeletal system, pain assessment, skin, infectious disease and resident preferences. Any section that included the word system had both a history and physical observation as part of the documentation. The facility failed to meet the professional standards of the Delaware State Board of Nursing by allowing LPNs to work outside of their scope of practice and complete R1's admission assessments. 5/2/25 2:15 PM - During an interview, E2 (DON) confirmed that the above listed documentation was all part of the admission assessment and that for R1's 11/6/24 admission, there was not an RN involved in R1's admission assessment process. 5/2/25 2:202 PM - E1 (NHA) stated, Those are not assessments. They are labeled in the EMR as observations. The facility was unable to provide evidence of any other documentation that could be identified as an admission assessment that was performed by an RN. 2. Review of R5's clinical record revealed: 3/20/25 3:23 PM - A nurse's note by E4 (LPN) documented, this writer was made aware by staff that resident fell and got himself back to sit in his chair. Pt (Patient) assess (sic) no apparent injury noted. Resident stated he was trying to sit on his chair. Pt denies injury upon assessment . 3/20/25 6:01 PM - The facility's event report for R5's fall was completed by E4 and documented the fall details, observations of pain and R5's body, neurological check, review of other body systems, possible contributing factors, interventions, therapy referral and vital signs. 5/2/25 at 2:19 PM - During an interview, E4 confirmed that after R5's 3/20/25 fall she completed the post fall assessment and documentation. The facility failed to ensure an RN performed and documented R5's 3/20/25 post-fall assessment. 5/6/25 1:40 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (RUPO).

Based on record review and interview, it was determined that for one (R1) out of four residents reviewed for accidents, the facility failed to have his advanced directive and copy of his DPOA (Durable Power of Attorney) readily accessible on his EMR during his 11/6/24 admission. Findings include: Review of R1's clinical record revealed: 6/21/23 - During a previous Facility admission, E5 (NP) completed the DMOST (Delaware Medical Orders for Scope of Treatment) form with R1, which stated Do not attempt resuscitation/DNAR. 11/6/24 - R1 was admitted to the facility with diagnosis including dementia. 11/6/24 11:48 AM - E6 (LPN) entered into R1's EMR a DNR (do not resuscitate) order. 11/7/24 9:44 AM - E11 (MD) signed the DNR order in R1's EMR. 11/7/24 1:56 PM - R1's admission Minimum Data Set (MDS) assessment documented a Basic Inventory of Mental Status (BIMS) score of 9, which was reflective of moderate cognitive impairment. 4/30/25 9:10 AM - A review of R1's EMR revealed no evidence of the DMOST form or the financial power of attorney document in R1's EMR. 4/30/25 10:35 AM - During an interview, E12 (SW director) stated, At admission, we were notified that R1 had a financial PO [person's name]. We did not get a copy of the Advanced Directive from the hospital or assisted living facility. 4/30/25 10:47 AM - During an interview, E21 (business office manager) stated, We never got a copy of the POA (power of attorney) since [financial POA] was paying the bill. He told us that he was applying for guardianship. The facility failed to obtain proof of R1's financial POA and R1's completed DMOST form. 5/6/25 1:40 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (RUPO).

Based on observation, interview, and facility policy review, the facility failed to ensure foods were labeled, dated, sealed, and stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 115 census residents. Findings include: Review of the facility's policy titled, Equipment Cleaning and Sanitation Policy, dated 08/25/20, revealed The food and nutrition services staff will maintain a clean and sanitary environment in food service areas. The policy did not address food storage policies and procedures. During initial observations of the kitchen on 11/24/24 beginning at 8:47 AM, the following was observed: -In the dry storage, there was a box with a plastic bag inside containing powdered thickener. The bag was sealed at the top; however, there was a large hole ripped in the bag. Pieces of debris and food wrappers were observed inside the box. There was no date to indicate when the package had been opened. -In the dry storage, there was a package of prepared tart crusts that was left open and unsealed. The crust was directly exposed at the top of the package. -In the dry storage, there was a large bag of panko breadcrumbs that were folded at the top but not sealed. -In the dry storage, there was a can of applesauce on the fourth shelf of the can rack that had a large dent near the top seal. -In the walk-in refrigerator, there were packages of croissants, sliced provolone cheese, and sliced ham that were left open and unsealed. -In the food preparation area, there were two squirt bottles of yellow liquid that were not labeled or dated. [NAME] (CK) 2 stated the squirt bottles contained oil and were not labeled or dated. -In the food preparation area, there were two boxes of corn starch that were opened and not sealed. CK2 stated the boxes were opened and unsealed. During follow-up observation of the kitchen with the Dietary Manager (DM) on 11/26/24 beginning at 12:18 PM, the following were observed: -In the dry storage, there was a box containing an open, undated bag of thickener. The DM confirmed the bag was left open and unsealed and did not contain an open date. He stated he would throw out the thickener. -In the dry storage, there was a tart crust package left open and unsealed. The DM confirmed the package was left open and unsealed and stated he would throw it out. -In the dry storage, there was a bag of panko breadcrumbs folded and unsealed. The DM confirmed the bag was not sealed and stated he would seal it in a plastic bag. -In the dry storage, there was a dented can of applesauce on the fourth shelf of the can rack. The DM stated the dented cans were to be stored on the top shelf of the can rack to be returned to the supplier. He stated the dented can of applesauce should not have been in the middle of the rack for use. The DM stated all foods were to be sealed and contain labels and dates as to when they were opened.

Based on observation, document review, and interview, the facility failed to ensure all pureed foods on the menu were served to the seven residents who received pureed diets out of a total census of 115 residents. This failure placed the residents on pureed diets at risk for hunger, dissatisfaction with meals, unplanned weight loss, and malnutrition. Findings include: Review of the undated Diet Counts (Census), provided by the facility, revealed there were seven residents who received a pureed diet. Review of the undated Fall Winter 24125 Diet Guide Sheet, provided by the facility, revealed lunch meal for a pureed diet on 11/26/24 consisted of pureed roast beef, pureed creamed spinach, pureed egg noodles, pureed bread, and pureed spice cake. During observations of meal service in the kitchen on 11/26/24 beginning at 11:44 AM, there were no pureed noodles or pureed bread observed on the tray line. All seven residents who received a pureed diet were served a meal of only pureed roast beef, pureed creamed spinach, and pureed cake. During an interview on 11/26/24 at 11:59 AM, the Dietary Manager (DM) confirmed there were no pureed noodles or pureed bread on the tray line or on the plates prepared for residents on puree diets. The DM stated [NAME] (CK) 1 had prepared the pureed foods. During an interview on 11/26/24 at 12:00 PM, CK1 stated he had not prepared any pureed noodles or pureed bread for the lunch meal and had served only pureed meat, pureed spinach, and pureed cake to the residents on pureed diets. During an interview on 11/26/24 at 12:00 PM, the DM stated he needed to provide additional training for CK1 since he was new to the position and typically did not work the breakfast and lunch shift. The DM stated the pureed noodles, and bread should have been prepared and served according to the menu.

Based on observation, interview, clinical record review, and review of the facility's policy and procedure, it was determined that the facility failed to ensure emergency equipment and competent staff were available for accidental [MEDICAL CONDITION] (trach) tube decannulation for two (R51 and R102 ) out of three active residents in the sample with tracheostomies. The lack of available emergency equipment, in addition to the lack of competent trained staff in [MEDICAL CONDITION] replacement, placed R51 and R102 at a high likelihood of serious harm. The Immediate Jeopardy (IJ) was identified on [DATE] at 1:35 PM and abated on [DATE] at 6:32 PM. Findings include: The facility policy and procedure entitled Emergency [MEDICAL CONDITION] Replacement Policy (Effective (MONTH) 19, (YEAR)) included: -Initial placement of the [MEDICAL CONDITION] and first tube change should be done by the physician. Replacement in an emergency situation may be performed by a respiratory care practitioner or nurse. -A second [MEDICAL CONDITION] of the same style and size, and one smaller size if applicable, should always be boxed at the patient's bedside and the obturator for the existing tube is at the bedside as well. This extra tube can be used if there is a malfunction with the airway device. 1. The following was reviewed in R51's clinical record: [DATE] - R51 was admitted to the facility with a [DIAGNOSES REDACTED]. R51 was a full code which signifies that R51 was to receive CPR in the event of cardiac/respiratory arrest. Review of the physician order [REDACTED]. [DATE] - R51's physician's orders [REDACTED]. Check Pulse Ox every 4 hours status [REDACTED]. [DATE] 12:52 PM - A physician progress notes [REDACTED].( his/her)[MEDICAL CONDITION] to a #4 but later desaturated and was taken to the ER. There [MEDICAL CONDITION] replaced with a #6 and oxygen saturation improved. (He/she) is now at 96%. [DATE] - A quarterly MDS documented that R51 was cognitively intact and required extensive assist of staff for activities of daily living. [DATE] 11:42 AM - In an interview and observation with E8 (RN), R51 was able to make needs known by forming unheard words, and the surveyor and staff were able to read R51's lips. R51 stated that Respiratory Therapy was coming that day to put in a [MEDICAL CONDITION]. [DATE] 12:05 PM - During an observation, E5 (RN, UM) looked in R51's personal treatment cart in the room, looked on R51's bedside table and was not able to locate a replacement trach. After approximately five minutes, E5 was able to locate a [MEDICAL CONDITION]#6 [MEDICATION NAME] was open and no longer sterile in R51's bedside drawer. In an interview with E5, it was confirmed that R51's [MEDICAL CONDITION] was found opened, and no longer sterile. Review of other equipment with E5 revealed that there was not a size [MEDICAL CONDITION] the bedside. E5 stated that he/she could obtain the emergency equipment from central supply, and confirmed that the resident room was lacking emergency [MEDICAL CONDITION] supplies. [DATE] 12:45 PM - E5 (RN, UM) proceeded to attempt to obtain a #6 Shiley [MEDICAL CONDITION]. [DATE] 12:53 PM - E5 (RN, UM) brought [MEDICAL CONDITION] size #5 to the surveyor and stated that he/she would go to obtain a size #[MEDICAL CONDITION]. [DATE] 12:58 PM - E5 (RN, UM) stated, (He/she) is down-sizing, so I have a size #5 for (him/her). E5 remained at the desk with [MEDICAL CONDITION] in his/her hand, and it had not been placed in the room. [DATE] 1:05 PM - The surveyor asked E5 (RN, UM) Do you have a size #[MEDICAL CONDITION] in the building? E5 replied, That's what I am going to find out. [DATE] 1:10 PM- A physician's orders [REDACTED]. [DATE] 1:10 PM - An interview with E5 (UM, RN), who began employment at the facility on [DATE], revealed that he/she has not had any education / skills competency regarding insertion of [MEDICAL CONDITION] since employment. [DATE] 1:08 PM - An interview with E8 (RN) the nurse assigned to R51, who began employment at the facility on [DATE], revealed that he/she has not had any education/ skills competency regarding insertion of [MEDICAL CONDITION] since employment. [DATE] 1:15 PM - In an interview with E5 (RN, UM) and E2 (DON) it was confirmed that the facility lacked evidence of a physician's orders [REDACTED].#[MEDICAL CONDITION] and one a size smaller at the bedside. [DATE] 1:16 PM - An observation was made of E5 (RN, UM) supplying R51's room with the emergency size #5 and #[MEDICAL CONDITION]. There were no sterile [MEDICAL CONDITION] in the room for one hour and nine minutes. [DATE] - An untimed physician's orders [REDACTED].#6 XLT. [DATE] - An untimed physician's orders [REDACTED].#6 Shiley [MEDICATION NAME] #5 Shiley XLTP. Ship to hospital with both trachs to hospital. [DATE] 1:18 PM - In an interview with E1 (NHA) he/she informed the surveyor that the facility had ordered back-up for the back-up to the ones (emergency trachs) that were in resident's rooms. The surveyor inquired of E1 when those back-ups were going to arrive at the building and he/she replied that he/she would have Central Supply have them sent overnight. [DATE] 1:55 PM - E1 (NHA) reported that the order for the size of R51'[MEDICAL CONDITION] received 15 minutes ago. [DATE] 2:05 PM - E5 (RN, UM) provided the surveyor with a physician's orders [REDACTED].#[MEDICAL CONDITION] size. [DATE] 7:00 PM - A clarification physician's orders [REDACTED].#6 Shiley [MEDICATION NAME] #5 Shiley XLTP. If dislodged do not re-insert. Send resident to ER (emergency room ) with both trachs. [DATE] 10:50 AM - An observation of R51's room revealed that on top of the treatment cart the Shiley #5 and #6 emergency [MEDICAL CONDITION] remained in place. [DATE] 1:11 PM - In an interview with E1 (NHA), it was confirmed that R51 did not have an order prior to [DATE] to send R51 out to the hospital if his/[MEDICAL CONDITION] dislodged, and to not re-insert an [MEDICAL CONDITION] at the facility. The facility failed to ensure that appropriate [MEDICAL CONDITION] and competent staff were available in the event of an unplanned extubation. [DATE] 4:30 PM- Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), and E4 (RDCS) 2. Review of R102's clinical record revealed the following: [DATE] - R102 was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. [DATE] (Revision date of [DATE]) - A care plan titled [MEDICAL CONDITION] had a goal that the patency of R102's airway will be maintained for the next 90 days. Interventions included: - Currently capping trial ([DATE]). - Administer oxygen per physician order. - Assess respiration: note the quality, rate, rhythm, nasal flaring, use of accessory muscle. - Consult respiratory therapist. - Encourage resident to cough out secretions. - Pass Muir valve per orders. - [MEDICAL CONDITION] care per protocol. [DATE] - The Quarterly MDS Assessment documented that R102 scored 12 on the BIMS test, thus, was assessed as moderately impaired for her/his thinking ability. [DATE] - A physician order [REDACTED].>1)[MEDICAL CONDITION] change two times a week and PRN. 2)[MEDICAL CONDITION] every shift. 3) Inner cannula (Trach tube) changed twice a day and PRN. 4) Suction PRN. 5) Compressor on 40 and Neb (nebulizer) bottle on 50 and concentrator on 2 L/M = 28% (Settings on a respiratory system to deliver oxygenation at 2 L/M). 6) Emergency traches (sic) in bag #4 Shiley. 7)[MEDICAL CONDITION]#4 Shiley changed monthly. 8) Weaned and capping ,[DATE] on 2 L/M. [DATE] from 12:47 PM to 12:59 PM - A joint observation of R102's room with E2 (DON) and E5 (RN, UM) revealed R102 in bed with his/[MEDICAL CONDITION] intact and with a cap. An Ambu bag was located hanging in a plastic bag at R102's bedside. E2 and E5 proceeded to locate the [MEDICAL CONDITION] by searching R102's bedside cabinet drawers and R102's closet. At 12:51 PM, the surveyor inquired if the tube may be located in the facility's Central Supply Room. In response to the surveyor's comment, both E2 and E5 exited R102's room and proceeded to the Central Supply Room, where E2 and E5 consulted with E36 (MR). Shortly thereafter, [MEDICAL CONDITION] was secured in the Central Supply Room by E2 and E5. [DATE] 1:00 PM - The [MEDICAL CONDITION] the same size and style was placed in a plastic bag and placed at R102's bedside. [DATE] 1:05 PM - An interview with E7 (RN), who was assigned to R102, revealed that he/she began employment at the facility earlier this year (2019) and has not had any education / skills competency regarding insertion of [MEDICAL CONDITION] since employment. [DATE] 1:10 PM - An interview with E5 (UM, RN), who began employment at the facility on [DATE], revealed that he/she has not had any education / skills competency regarding insertion of [MEDICAL CONDITION] since employment. [DATE] 3:50 PM - An interview with E30 (RRT) revealed that replacement of [MEDICAL CONDITION] should be completed by a licensed nurse that was provided both education and demonstrated competency [MEDICAL CONDITION] insertion. [DATE] 4:00 PM - A physician [MEDICAL CONDITION] care (frequency was not included in this order), pulse oximetry every 4 hours for 24 hours and every shift, and to remove [MEDICAL CONDITION] 24 hours later. [DATE] 5:00 PM - A Respiratory Note, by E30 (RRT) documented that R102 was receiving ,[DATE] L/M of oxygen and R102's oxygen saturation was 94% prior to removal (decannulated) of [MEDICAL CONDITION] on [DATE]. After decannulation, R102 had no shortness of breath or incidents at the time of the decannulation. Recommendations included 1) 24 hours later remove [MEDICAL CONDITION] 2) every 4 hours checking pulse oximetry for 24 hours then every shift 3)[MEDICAL CONDITION] care. The facility failed to ensure that the physician's orders [REDACTED]. emergency traches in bag #4 Shiley ., R102's emergency equipment. [DATE] 3:17 PM - An interview with E71 (Clerk/Scheduler) revealed, that late yesterday afternoon, on [DATE], he/she was provided a list of licensed nurses who had completed their education and competency for insertion of [MEDICAL CONDITION] on [DATE] and was instructed by E1 (NHA) to use this list to schedule the licensed nursing staff effective [DATE]. In addition, E71 was instructed to call the licensed nurses, who were not on the list and to tell them that they must complete the education and competency before they are scheduled to work. E71 confirmed prior to [DATE], in scheduling licensed nurses, E71 did not have any list of nurses who had education or competency for insertion of [MEDICAL CONDITION]. The facility failed to have a system in place, when scheduling a licensed nurse for each shift, to ensure which nurse(s) were educated and had completed competencies for [MEDICAL CONDITION] prior to [DATE]. [DATE] 3:00 PM - An interview with E1 (NHA) confirmed that the above policy and procedure failed to include that only licensed nurses, who had completed both education and competencies [MEDICAL CONDITION] were permitted to perform this intervention. Furthermore, E1 verbalized that the expectation was to have education and competency completed at the time of orientation for new employees and annually thereafter. E1 confirmed that new nurses hired have not had the education and competency, however, it was E1's opinion that the facility had an adequate number of staff who were competent to insert [MEDICAL CONDITION]. During this interview, the surveyor informed E1 that of the current 30 licensed nurses, 15 (50%) lacked evidence of education and competency, including the licensed nurses assigned to R51 (E8/RN) and to R102 (E7/RN) during the day shift (7:00 AM to 3:00 PM) on [DATE]. Additionally, the RN, Unit Manager (E5/RN), who was working during the day shift, where both R51 and R102 resided lacked evidence of education and competency. The facility failed to ensure: - appropriate [MEDICAL CONDITION] were available at the bedside for residents (R51 and R102) with tracheostomies. - an established system, when scheduling a licensed nurse for each shift, as to which nurses were educated with demonstrated competency for [MEDICAL CONDITION] for scheduling purposes. - an established system to ensure only licensed nurses with education and competency were assigned to those residents with tracheostomies in the event of an emergency, including [MEDICAL CONDITION]. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on [DATE] beginning at approximately 4:30 PM.

Based on record review, interview, review of hospital records and other facility documents as indicated, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for two (R5 and R6) out of 15 sampled residents. For R5, the facility failed to ensure adequate supervision by failing to comprehensively assess R5's continence status and failing to develop a toileting plan. Despite knowing that R5 did not utilize the call bell, continued to self transfer to toilet, and had poor safety awareness due to dementia, there was no evidence that safety checks were implemented for this resident in an attempt to minimize falls and injury. This deficient practice resulted in harm to R5 when he/she transferred independently and sustained a pubic ramus (pelvic) fracture. For R6, the facility failed to provide adequate supervision on the night of R6's fall (10/14/18) due to decreased staff availability to supervise. R6 sustained harm when he/she fell walking to the bathroom independently without supervision, because no staff members were available to answer his/her call bell, and he/she acquired a subdural hematoma. Findings include: The facility's policy titled Fall Prevention & Management, dated (MONTH) 2010, stated .The facility will review each resident fall when they occur by following these steps: 1) Assess the resident for any injury and provide immediate treatment when necessary .2) Establish new interventions and place on the fall care plan .3) Communicate the new intervention for the resident to the staff. 4) Implement safety checks if resident is at very high risk for another fall .7) Chart all information relative to the fall and all notifications in the medical record. 8) Complete a new Fall Risk Assessment with each fall . 1. Review of R5's medical record revealed the following: 1/10/15 - R5 was admitted to the facility with [DIAGNOSES REDACTED]. 12/15 - A care plan was initiated for risk of falls or fall related injury due to a history of falls, multiple risk factors including medical, musculoskeletal, cognitive and sensory, and medications. Interventions included: report falls to physician and responsible party; incontinence or toileting plan; educate/remind resident to request assistance prior to ambulation; remind resident and reinforce safety awareness; appropriate footwear; referral for therapy screen as needed; low bed; call light within reach. 3/17/17 - R5 had a physician's orders [REDACTED]. 3/27/18 (date reviewed & updated) - The Maintenance ADL & Safety Care Plan & Communication Tool (CNA Kardex) stated R5 was an assist of one to two staff for transfers. The Kardex also stated R5 was an assist of one for toileting per request, he/she wore a brief and was frequently incontinent of bladder. 6/15/18 (Review date)- R5 had a care plan for refuses or resists care and not asking for assistance with ADLs, transfers and reaching. Interventions included: make physician aware of refusal, if refusing or resisting try again later, safety measures as ordered, and educate/remind resident and/or responsible party of the risks. 7/9/18 - A quarterly MDS assessment stated R5's daily decision making skills were severely impaired, he/she required extensive assist of one staff for transfers and toilet use, and did not walk in his/her room or the corridor. The MDS stated R5's balance while moving from a seated to standing position, walking, and transfer between bed and chair or wheelchair was not steady, but able to stabilize without staff assistance. The MDS also stated that R5 was frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding during the seven day assessment review time period) and that a trial of a toileting program had not been attempted. 7/13/18 7:00 AM - An Event Report stated R5 was found on the floor next to his/her bed wrapped in his/her bedding. There were no injuries noted. Neuro checks were initiated and a therapy screen was requested. R5 was found to have a urinary tract infection at this time. There was no evidence that a fall risk assessment was completed post fall. 7/13/18 - Both the fall care plan and CNA Kardex were noted as reviewed with no changes. 7/14/18 12:30 AM - An Event Report stated R5 had an unwitnessed fall. The facility investigation revealed that R5 was found sitting on the floor on the left side of his/her bed. R5 stated that he/she had gone to the bathroom and fell on the way back. There was no evidence that a fall risk assessment was completed post fall and there were no new interventions added to R5's fall care plan. 8/21/18 7:25 AM - A facility Event Analysis Worksheet stated that R5 was found on the floor with no injuries. R5 stated that he/she slid to the floor while trying to transfer to the wheelchair. The worksheet stated the floor was wet and that the Resident needed to be toileted. There was no evidence that the facility assessed R5's continence status at this time to develop a toileting plan in an attempt to minimize further falls. Additionally, there was no evidence that the facility completed a fall risk assessment post fall and no evidence that new interventions were added to the care plan. Additionally, despite R5's known history of falls, known history of self transfer and not utilizing the call bell, the facility did not implement safety checks according to the facility policy for fall prevention and management. 8/22/18 - An OT Screening Form stated that R5 exhibited problems with muscle weakness of arms/legs and transferring to and from the toilet. Under the comments section was written, Patient has had decreased strength and activity tolerance along with decreased safety awareness for all txfers (transfers) and ADLs making him/her an increased risk for falls. 9/12/18 - The OT Therapist Progress & Discharge Summary stated that services originated on 8/23/18. The end of care summary on 9/12/18 stated that the goal was met for self care toileting and the patient performs all toileting tasks with supervision to contact guard assist (contact with patient due to unsteadiness). The summary also stated that R5 transfers to/from toilet/commode with supervision (needs verbal cueing but no physical assist). 10/1/18 - An annual MDS assessment stated that R5's daily decision making skills were severely impaired and extensive assistance of one staff was required for transfers and toilet use. The MDS stated that R5's balance while moving from a seated to a standing position, walking, and transfer between bed and chair or wheelchair was not steady, and R5 was only able to stabilize with staff assistance. The MDS assessment also stated that R5 was occasionally incontinent of bladder (less than 7 episodes of bladder incontinence during the seven day assessment review time period) and that a trial of a toileting program was not attempted. The CAA Summary portion of the MDS triggered falls as a potential problem area for R5. 10/1/18 - A care plan was initiated for falls characterized by a history of falls/injury related to gait/balance problems, and impaired cognition. Interventions included: assist of 1 with all transfers; assist with mobility as needed; bed in lowest position; non skid foot wear when out of bed; fall risk assessments per routine and prn; provide assistance with toileting; reinforce need to call for assistance; and therapy to screen and treat as necessary. 10/2/18 - A care plan was initiated for bladder incontinence related to impaired mobility and an overactive bladder. Interventions included: resident uses disposable briefs, change frequently and prn; and Voiding Routine: the resident likes to be toileted upon rising in the AM, before meals and at bedtime, uses a bed pan while in bed. 10/3/18 - The CNA Kardex continued to state, Assist of one to toilet per request and stated R5 was a stand by assist (SBA) for ADLs and transfers. There was no evidence that a toileting plan, based on a comprehensive continence assessment, was developed for R5. 11/15/18 9:30 PM - An Incident/Accident Report/Investigation stated R5 was found on the floor in his/her room on his/her left side with complaints of pain to the left knee and severe pain to the lower back. The investigation report stated the floor was dry and erroneously stated that R5 did not have any falls in the last 31-180 days. R5 had on a dry pull up but it was down around his/her knees and the resident needed to toilet. It further stated that R5 required assistance with ADLs, but would not ask. The investigation summary stated, Resident fell .Resident was attempting to get to toilet, briefs were around knee (sic). Due to the resident's dementia he/she still feels that he/she can be independent .He/She requires additional assistance. Resident has no toileting plan in place. Resident now requires assistance with ADLs. The report stated that R5 was sent to the ER for evaluation. 11/15/18 - R5 was hospitalized post ER evaluation. Review of the hospital record revealed R5 sustained a pubic ramus (pelvic) fracture from the fall. 11/21/18 - R5 was readmitted to the facility post hospitalization . 11/21/18 - The nursing admission/readmission evaluation was completed. Section 2 of the evaluation included a fall evaluation which only consisted of 2 questions including the reason for the assessment and if there was a history of falls. The evaluation did not identify the severity of R5's risk for falls. There were no other fall risk assessments found in the medical record going back to 7/1/18. 11/21/18 to 11/24/18 - Upon R5's re-admission, an Evaluation for Continence and Retraining/Scheduled Toileting was started. The evaluation stated that a diary was to be kept for 72 hours and the resident was to be checked every hour with specific codes used to record findings. Review of the diary revealed that only seven (7) entries were made for the entire 72 hour time period. The facility failed to accurately complete the bladder evaluation. 12/4/18 - The CNA Kardex continued to state that R5 required assist of one to toilet per request. The facility failed to ensure adequate supervision of R5 by failing to comprehensively assess R5's continence status and failing to develop an individualized toileting plan. Despite knowing that R5 did not utilize the call bell, continued to self transfer to toilet, and had poor safety awareness due to dementia, there was no evidence that safety checks were implemented for this resident as per facility policy for fall prevention and management, in an attempt to minimize falls and injury from falls. This deficient practice resulted in harm to R5. Findings were discussed with E1 (NHA) on 2/6/19 at approximately 5:30 PM. On 2/7/19 at approximately 9:30 AM, during an interview with E2 (acting DON) and E3 (Risk Manager), E2 stated that R5 failed the continence evaluation and confirmed the facility was lacking thorough documentation. It was pointed out to E2 and E3 that the continence assessment (11/21/18 - 11/24/18) was not completed. E3 stated that other things were reviewed, such as CNA documentation. The surveyor requested a copy of the CNA documentation, however nothing was provided. 2/7/19 at approximately 3:45 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (acting DON), E3 (Risk Manager), and E20 (Regional Director of Clinical Services). 2. Review of R6's clinical record and facility documents revealed: 2/13/18 - R6 was admitted to the facility with [DIAGNOSES REDACTED]. 2/13/18 - A care plan was developed for R6, which included one that stated R6 was at risk for falls and another that stated R6 had an ADL self-care deficit. Interventions included that R6 required the assistance of one staff member during transfers. 8/13/18 - A quarterly MDS assessment stated that R6 was cognitively intact and required extensive assistance of one staff member for transfers and toileting. In addition, it was documented that R6 did not walk in his/her room or the corridor during the 7 day look back period. 10/13/18-10/14/18 - Review of the staffing on the night shift (11:00 PM-7:00 AM) on 10/13/18 to 10/14/18 revealed there were two nurses and three CNAs in the 100, 200,and 300 halls. At 6:00 AM, it was documented that one CNA went home, leaving two CNAs and two nurses for the three halls. 10/14/18 6:40 AM - The facility's Incident/Accident Report, completed by E11 (LPN), stated that R6 had an unwitnessed fall where she was found on the floor next to the bathroom door .on (sic) a supine position .Resident was noted with a hematoma to posterior of her head. It was documented in the report that R6 called for help and his/her call bell was within reach. The report also noted that the physician was notified at 8:00 AM, which was an hour and 20 minutes after R6 fell . 10/14/18 5:25 PM - An incident report was submitted to the State that stated R6 got out of bed and fell trying to get to the bathroom on 10/14/18 at 6:40 AM. R6 had normal neuro checks and a raised area on the base of his/her skull. R6 was sent to the hospital per NP orders. The hospital was called and stated that R6 was being admitted with a subdural hematoma. 10/14/18 - The CNA assigned to R6 on night shift documented in his statement that when R6 fell he was in another room providing care. 10/14/18 - Review of the facility's Root Cause Analysis of R6's fall revealed that on the morning of her fall R6's call light was activated and R6's assigned CNA was on another hall, providing care to a resident. The other CNA was in the 200 hall and the two nurses were in the 100 and 200 hall. The third CNA was noted to have already left the building when R6 fell , therefore there were no staff members in the 300 hall where R6 resided. The root cause of the fall was determined to be that R6 had an episode of diarrhea, did not want to soil his/her bed, R6 pushed his/her call bell, but staff response was not fast enough due to staff caring for other residents. 10/18/18 - A follow up to the 10/14/18 incident was submitted to the State and documented that R6 had a CT scan at the hospital showing at 2 mm subdural hematoma. A repeat CT scan showed no change in size and R6 returned to the facility on [DATE]. The root cause was identified as R6 did not want to soil his/her bed and staff response to his/her call bell was slow. Staff were to be educated on answering call bells. 2/6/19 1:25 PM - During an interview R6 stated that on 10/14/18 he/she rang his/her call bell because his/her stomach hurt and he/she needed to get to the bathroom. R6 stated that his/her roommate even rang his/her call bell because it was taking so long. R6 stated that he/she waited at least 10 minutes for someone to answer his/her call bell. When nobody came to the room R6 stated that he/she could not wait any longer, so he/she got up to go to the bathroom and ended up falling. 2/7/19 1:30 PM - Findings were reviewed with E2 (interim DON) and E3 (Risk Manager). The facility failed to ensure that R6's call bell was answered timely in order to prevent an accident, as evidenced by a fall on 10/14/18 at 6:40 AM. R6 sustained harm when he/she fell walking to the bathroom independently, because no staff members were available to answer his/her call bell, and she acquired a subdural hematoma.

Based on observation and interview, it was determined that the facility failed to have an adequately equipped system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. The immediate jeopardy (IJ) was identified on 3/8/18 at 3:08 PM and abated on 3/8/18 at 6:30 PM. Findings include: 3/8/18 at approximately 1:00 PM - During an interview with E10 (DOM) , E10 stated upon his employment in (MONTH) of 2014, he was informed by the previous DOM of a dead spot in the residents bathroom call bell reset switch. If the reset switch was not properly turned off and was set in the dead spot position, if another resident in the same room activated the bedside call bell, it deactivated the light in front of the resident's room and deactivated the centralized call box at the nurses station, which indicated the room where the call bell was activated from the bed. Based on this situation, if this occurred, the staff would not know which resident(s) activated the call bell and the staff would have to go room to room to determine which resident(s) activated the call bell. 3/8/18 from approximately 1:10 PM to 1:25 PM - Three surveyors toured the building and checked the call system in room [ROOM NUMBER] and confirmed the presence of the same issue. 3/8/18 at approximately 2:00 PM - Interview with E10 revealed he had spoken with the manufacturer of the call system and there was no way to fix the problem with the switch. 3/8/18 at 3:08 PM - Interview with E1 (NHA) was conducted. E1 was advised of the malfunctioning switch and that it was an IJ citation. Findings were confirmed with E1. 3/8/18 approximately 6:15 PM to 6:30 PM - The facility provided a listing of all residents in the facility with their room numbers and identified those residents who were not capable of using a call bell. Observations were completed of every resident in the facility to verify that a manual call device had been provided for each resident capable of using it. Random residents interviewed expressed an understanding of the need of the alternate call device. Additionally, for all residents the facility instituted every 15 minutes staff observation and check to ensure residents needs were met. 3/14/18 approximately 4:30 PM - Findings were reviewed with E1, E2 (DON), E3 (ADON), E15 (RNC) and E16 (RVP). New nurse call system switches were installed to permanently correct the malfunction on (MONTH) 15, (YEAR) at 8:00PM

Based on observation, record review, interview, and review of other facility documentation as indicated, it was determined that the facility failed to provide the necessary treatment and services, to promote healing of a pressure ulcer (PU) for three (R10, R12 and R11) out of 15 sampled residents. R10 developed an avoidable PU to the sacrum and failed to be provided the necessary treatment to promote healing of a pre-existing area to R10's right heel. R12's pressure ulcer worsened due to a failure to provide care and services to promote healing of a pressure ulcer. R11 developed an avoidable PU of the right buttock and the facility failed to establish individualized interventions for pressure reduction resulting in worsening of the PU. Findings include: The facility's policy entitled Wound Prevention and Treatment Overview, indicated: Prevention Protocols- was to assist clinicians to identify those who are at risk of skin breakdown by measuring key areas and other individualized factors that put the resident/patient at risk. Early identification will assist the facility in developing an individualized plan of care. Procedure: 1. The Braden scale will be completed within the first 8 hours of admission. 2. An initial care plan will be initiated by selecting the interventions to reduce risk. 3. The licensed staff will complete the weekly and as needed Skin Checks which may identify changes in resident that could trigger a change of condition or care plan review. 4. The resident will be monitored using the Braden Risk on a quarterly basis and PRN if there was a change in condition. Suggested interventions: Moderate Risk: For residents with Braden score of 14-18, the facility to select the appropriate following interventions: -Skin hygiene and inspection-Inspect the skin daily for early signs and symptoms of breakdown. -Activity/Mobility-Implement an individualized turning schedule if applicable to include observation of skin after each turning interval and increase frequency of turning if area of redness was noted. Position body with pillow or other supportive device. Avoid positioning on trochanter when possible. Provide pressure redistribution surface for bed or wheelchair per the facility's support surface selection. High Risk: For residents with a Braden score of 0-13, the facility to select the following interventions: -Skin hygiene and inspection-Inspect the skin daily for early signs and symptoms of breakdown. -Activity/Mobility-Implement an individualized turning schedule if applicable to include observation of skin after each turning interval and increase frequency of turning if area of redness was noted. Position body with pillow or other supportive device. Avoid positioning on trochanter when possible. Provide pressure redistribution surface for bed or wheelchair per the facility's support surface selection. -Skin protection - Use a sheet to reposition the resident in bed, protect heels as needed, apply Skin Prep for protection. -Nutrition - obtain dietary consult if deficiencies are noted. Evaluate interventions. 1. Review of R10's clinical record revealed the following; 1/10/18 - R10 was admitted to the facility with multiple [DIAGNOSES REDACTED]. 1/10/18 - An initial weekly skin assessment form documented R10 as having bruising on the heel measuring 3.5 cm x 1.9 cm; which heel, right or left, was not documented. 1/10/18 - Admission assessment documented R10's Braden score as 11 (0-13 is high risk), current skin condition PU, discoloration, bruises and scab right calf and a circle drawn over right heel with no description. Additional skin impairment risk factors documented were short term memory loss and incontinence of bowel and bladder. The following were checked under the Braden risk score: therapy screen for cushion, position with support devices, float heels, turn and reposition, pressure relieving mattress, barrier cream if incontinent. 1/10/18 - Admitting orders for PU documented on the POS included house barrier lotion to perineal area each shift; may keep at bedside; CNA may apply; weekly skin assessment on Wednesday; Braden Scale on admission and weekly for 4 weeks; Skin Prep no sting apply to bilateral heels every evening; in house wound care consult as needed; apply heel protectors to both feet every shift. 1/10/18 - The CNA care plan documented R10 as dependent for turning and repositioning and to be turned and repositioned as needed. 1/10/18 4:00 PM - A nurses note documented R10 as having maroon colored discoloration to the right heel. 1/11/18 - WCD documented a stage 1 to the right heel 3.5 cm x 1.9 cm x 0 with pink red shiny moist granular appearance skin. Note the presence of granular tissues indicates the wound was not a Stage 1. 1/12/18 - A care plan for wounds and at risk for wounds was initiated. The goal was to prevent wounds from developing, promote wound healing, treat wound infection and prevent additional wounds. Interventions included: - Treatment as ordered. - Monitor vital signs. - Support surface to bed. - Float heels with heel protectors. - Monitor sacrum daily. 1/17/17 - WCD documented a DTI right heel 3.5 cm x 1.5 cm x 0 with necrotic skin. 1/17/17 - An admission MDS assessment documented R10 as severely cognitively impaired; requiring extensive assistance of two staff persons for bed mobility and toileting; incontinent of bowel and urine. R10 had one SDTI and was at risk for developing PU. Treatments included pressure reducing device for chair and bed, turn and repositioning program, PU care, and applications of ointments. 1/26/18 - WCD documented a DTI measuring 3 cm x 9 cm x 0 having necrotic skin to the gluteal area. 1/27/18 - WCD documented to the right buttock a stage 2 PU measuring 0.4 cm x 0.4 cm x 0 having new skin /superficial ulcer that was not present on admission. 1/27/18 - WCD documented to the right buttock a second area above the other right sided area as a stage 2 PU measuring 2.8 cm x 1.4 cm x 0.1 cm having new skin /superficial ulcer that was not present on admission. 1/27/18 - WCD documented to the left buttock a stage 2 PU measuring 3 cm x 5 cm x 0.1 cm having new skin /superficial ulcer that was not present on admission and identified 1/26/18. 1/28/18 - Treatment orders were initiated for R10's sacrum. 1/29/18 - A physicians order was written for a wound culture during dressing change, wound location was not specified in the order. 1/29/18 - R10's treatment order to the sacrum was changed. 1/31/18 WCD documented both areas to the right buttock, the area to the left buttock and the area to the gluteus as merged to one area, DTI 10 cm x 8.2 cm x 0, no undermining, with necrotic skin. January (YEAR) - Review of CNA documentation for turning and repositioning revealed 20 dates from 1/10/18 -1/31/18 that lacked documentation that R10 was turned each shift. 1/10- 2/9/18 - Monthly Functional Care Summary documented R10 had a heel and sacrum DTI antibiotic in progress for wound. 2/1/18 - A physicians order was written for a dietary consultation related to increase protein needs for wound healing. 2/1/18 - A physicians order was written for an antibiotic for 10 days for suspected wound infection. 2/2/18 - Lab results of wound culture identified the presence of three infectious organisms. 2/5/18 - A care plan for infections was initiated for R10 that documented a bacterial infection location suspected wound, with the goal to treat the current infection x 14 days or until resolved, manage signs and symptoms for ten days or until resolved. Interventions did not include contact precautions but did include: - Monitor temperature. - Monitor labs. - Administer medications. - Monitor daily appearance of infected site, if visual. - Document administration of medications and route of administration. - Monitor for SE (side effects) and monitor for presence or absence of pain. 2/5/18 - A dietary recommendation was written for liquid protein 30 ml BID record % consumed. 2/6/18 - A physicians order documented a referral to a WCC for sacral wound, and to discontinue the previous antibiotic for a different antibiotic, and contact isolation. 2/11/18 - R10's care plan for wounds was updated to include a pressure reducing air mattress. 2/13/18 - A physicians order was written for narcotic (stronger than over the counter) pain medication every 4 hours PRN for severe pain prior to dressing changes. 2/13/18 - WCD documented to the gluteal a DTI 6 cm x 6.6 cm x 2 cm with undermining and slough in wound. 2/15/18- A physicians order was written for changes to the treatments for R10's sacrum and right heel and to continue to turn and reposition every 2 hours, carefully apply cushion when sitting in chair and return to wound center on 2/28/18. 2/20/18 - A physician's orders [REDACTED]. This physician's orders [REDACTED]. 2/25/18 - The Braden score documented 12 high risk. 2/26/18 - A consultation note from the WCC documented to continue to offload with supportive mattress, frequent turns and add waffle boot. February (YEAR) - Review of CNA documentation for turning and repositioning revealed 17 dates out of 28 days that lacked documentation that R10 was turned each shift. 3/5/18 - A consultation from the WCC documented continue to offload sacrum, side sleeping please, protect right heel for pressure from chairs. 3/6/18 - WCD documented to the gluteal area measuring 5.3 cm x 3.8 cm x 2.0 cm with undermining 2.5 cm and slough. March (YEAR) - Review of CNA documentation for turning and repositioning revealed 9 dates from 3/1/18 -3/13/18 that lacked documentation that R10 was turned each shift. During an interview on 3/9/18 at 1:13 PM with E3 (ADON) it was confirmed that R10 developed an avoidable pressure ulcer to the sacrum and experienced worsening of a pressure area to the right heel and that implementation of nutritional recommendations to assist in promoting wound healing were implemented 15 days after the recommendation and the expected time frame for implementation was 24 hours. R10 was admitted with an area of discoloration to the right heel and an intact sacral area. Initial orders included the intervention of turning and repositioning each shift but CNA documentation lacked evidence that R10 was turned at that frequency. Dietary supplements recommended for wound healing were not implemented until 15 days following the recommendation. 2. Review of R12's clinical record revealed the following; 1/29/18 - R12 was admitted to the facility. 1/29/18 - Admitting orders for PU documented on the POS included turn and reposition, skin prep to bilateral heels every evening, barrier cream to peri-area every shift, air mattress, weekly skin assessments, and Braden Scale on admission and weekly for four weeks. 1/29/18 - An admission assessment completed for R12 was absent a Braden Scale and documented skin as cool, dry, moist and a bruise to the right arm. 1/29/18 - A care plan problem was initiated for a wound to sacrum and risk of PU with .contributing factor, pressure and a goal to prevent wounds, promote healing, prevent infection treat wound infection and included interventions: - Monitor vital signs. - RD consult PRN. - Monitor labs as ordered. - Standard Precautions. - Support surface to bed and chair, type: pressure reducing. - Float heels with heel protectors. - Air mattress - Monitor daily: wound location, dressing observation. Monitor weekly location, stage, length, drainage, odor, tunneling, undermining. 1/29/18 9:45 PM - A nurses note documented R12 as having redness noted to buttocks area. 1/29/18 - a physician's orders [REDACTED]. January (YEAR) - Review of R12's TAR was absent documentation that indicated an admission Braden Scale was completed. January (YEAR) - Review of CNA documentation for turning and repositioning each shift revealed 3 out of 3 dates from 1/29/18-1/31/18 that lacked documentation that R12 was turned each shift. 2/2/18 - An admission MDS assessment documented R12 as severely cognitively impaired with risk of developing a PU and requiring extensive assistance with bed mobility, toileting and was incontinent of bowel and urine. R12 had a risk of developing a PU and treatments included a pressure reducing device for bed and chair. 2/5/18 - The first documented Braden scale for R12 was 11 high risk. 2/12/18 - An initial wound identification form documented R12 as having a SDTI, Stage 1 discolored skin dark purple measuring 1 cm x 1 cm to the buttocks present on admission. 2/13/18 - WCD documented a sacral DTI 2.5 cm x 1.5 cm x 0 having necrotic skin. 2/18/18 - A weekly skin assessment documented a Stage 2 PU to the sacrum of R12. 2/18/18 - E17 (RN) wrote a physician's orders [REDACTED]. 2/24/18 - WCD documented a sacral DTI 4 cm x 5 cm x 0 having necrotic skin. February (YEAR) - Review of the CNA documentation for turning and repositioning each shift revealed 25 out of 28 dates from 2/1/18-2/28/18 that lacked documentation that R12 was turned each shift. February (YEAR)- R12's TAR was absent documentation of dressing change completion for 2/27/18. 3/8/18 - A physician's orders [REDACTED]. March (YEAR) - Review of the CNA documentation for turning and repositioning each shift revealed 8 out of 14 dates from 3/1/18-3/14/18 that lacked documentation that R12 was turned each shift. During an interview on 3/8/18 at 11:38 AM with E17 (RN) it was confirmed that she transcribed the treatment order for R12 written on 2/18/18 without a location or frequency. E17 then stated It was written as a recommendation, we had an NP (unknown, no E#) here and she said I don't know what the treatment should be, I haven't seen the patient so I looked at the wound book at the nurses station and wrote a recommendation and left it out to be signed. E17 was unable to recall the name of the NP. During an interview on 3/8/18 at 12:21 PM with E22 (RN) it was confirmed that the Admission Braden Scale for R12 was completed 7 days late. During an interview on 3/9/18 at 1:28 PM with E3 (ADON) it was confirmed that a Braden Scale assessment for R12 should have been completed on admission. E3 then confirmed that the physicians order for treatment to R12's sacrum written on 3/8/18 was a clarification of the order written on 2/18/18 and stated that E17 wrote it for every other day but it should have been daily. E3 confirmed variations in staging of R12's sacral wound on 2/13/18 as a DTI to 2/18/18 as a Stage 2 as incorrect and stated we did a house sweep of assessments and started a new skin sheet but it (sacrum) was initially a DTI. E3 also reported that a pressure reducing mattress was not implemented for R12 until 3/8/18 and confirmed that R12's sacral wound worsened. During an interview on 3/9/18 at 1:36 PM with E3 (ADON) it was explained that the facility process for obtaining treatment orders is to notify the physicians and obtain a telephone order to use the house wound protocol to be signed by the physician within that week. E3 stated that E17 (RN) should have followed up with a supervisor or DON when unable to get the NP to authorize a treatment order for R12's sacral wound. E3 then confirmed that the physicians order written on 3/ 8/18 was a clarification of the order written on 2/18/18 and stated that E17 wrote if for every other day but it should have been daily. R12 was admitted to the facility on [DATE] with redness to the buttock area that worsened to an unstageable PU. Review of the clinical record indicated that measures put in place to promote healing on the initial POS were not documented as completed by staff such as turning every two hours and an air mattress. A physician's orders [REDACTED]. On 3/8/18 the order was re-written for clarification. Review of wound care documentation revealed inconsistency with staging according to acceptable wound care guidelines for staging and descriptions. 3. Cross refer F600. Review of R11's clinical record revealed: 9/28/17 - admitted to the facility with [DIAGNOSES REDACTED]. 9/28/17 - Initial Nursing Assessment documented that she had no skin impairment, however, R11 had a bruise located in the right buttock. Initial nurse's note documented skin intact and small discoloration (bruise) noted in upper right buttock. 9/28/17 - admission orders [REDACTED]. Record review lacked evidence of a Braden Scale upon R11's admission. 9/28/17 - A care plan for wounds and at risk for wounds, with initial date of 9/28/17, with most recent review date of 12/24/17, documented that R11 was at risk due to moisture from incontinence. Goal was that R11 would not develop a wound. Interventions included treatment as ordered, T & R every (frequency of this intervention was not documented), support surface to bed-Low air loss air mattress, support surface to chair-wheelchair cushion, and elevating of heels when in bed. Although the facility identified the need for T & R, the facility failed to have a system to identify the specific frequency for T & R to be performed by the staff, for a resident who was assessed as requiring extensive assistance of staff for bed mobility. Additionally, a weekly skin check was not included as an intervention. 9/28/17 - CNA Maintenance ADL and Safety Care Plan and Communication Tool (The facility's CNA care plan), documented T & R as needed and transfer with assistance of two staff. 10/5/17 - The Admission MDS assessment stated R11 was independent in daily decision making, required extensive assistance of two staff persons for bed mobility, transfer, toileting. In addition, R11 had an indwelling suprapubic catheter and was always incontinent of bowel. The resident had no PU and was at risk for developing PU. Treatments included pressure reducing devices for chair and bed as well as application of medication or ointment. Intervention for a T & R program was left blank, thus, it could not be determined whether the facility identified the need for an individualized T & R program for R11. 10/9/17 through 11/20/17 - Weekly Skin Assessment, no new skin area of impairment. 12/24/17 - Braden score was 14, indicating moderate risk for the development of a PU. 12/27/17 - The Quarterly MDS assessment indicated that R11's condition remained unchanged with the exception that R11 now required increased assistance with transfer, from extensive to requiring total assistance. Although R11 was assessed as moderate risk on 12/24/17 and had a change in transfer, from assistance of staff to total assistance on the 12/27/17 MDS assessment, record review lacked evidence of a reassessment of interventions for prevention of PU. Record review lacked evidence of weekly skin assessment after 11/20/17 to 2/17/18, approximately three months. 2/1/18 through 2/17/18 (51 shifts) - CNA report documented the following: - Skin observation: 21 out of 42 shifts (2/1/18-2/14/18), lacked evidence this intervention was completed. From 2/15/18 through 2/17/18, there was no evidence that skin observation was completed during these three days. - T & R: 28 out 51 shifts, there was lack of evidence R11 was T & R. - Preventive Skin Care: 28 shifts out of 51, lacked evidence this intervention was provided. 2/7/18 - physician's orders [REDACTED]. 2/13/18 - Initial Occupational Therapy Evaluation, completed by E23 (OT), indicated reason for referral included decreased activity tolerance and risk for sacral excoriation and wheelchair positioning. R11 required total assistance for bed mobility and transfer. R11 sits in power wheelchair (PWC) with fair positioning but with frequent complaints of discomfort in hips. In addition, R11 verbalized the PWC was too small. The goal was for R11 to sit in PWC with good positioning with minimum reports of discomfort and with only occasional need for repositioning. 2/14/18 - OT Note by E23, documented the removal of a right lateral support and assisted nursing aid in positioning R11 in her PWC. Therapist assessed her response and R11 reported leaning to the left side. Therapist repositioned R11 and R11 reported increased comfort. Therapist educated R11 on communicating how the PWC feels with the new positioning. 2/15/18 - OT Note by E24 (OTA), documented R11 observed throughout day sitting in PWC. R11 did not complain of discomfort today and stated fine today which was not typical. R11 and E24 discussed positioning and comfort. R11 reported that her bottom hurts most of the time and that the PWC was too small. E24 advised current PWC was good fit and that the current cushion may need to be looked at. R11 reported she had experienced discomfort while sitting in the PWC many years ago and had mapping done in order to adjust the PWC. R11 was interested in having the mapping done again since it helped with comfort. R11 reported that the CNAs have been doing better with positioning in the PWC. 2/16/18 - OT Note by E25 (OTA) documented R11 reported discomfort with cushion today and feels that her chair is too small. E25's observation found chair was appropriate but R11 may benefit from a new cushion. COTA discussed this with E28 Director and OT for follow-up. 2/17/18 - OT Note by E23 documented that R11 was assessed for her comfort level seated in PWC and during mobility with PWC after therapist made adjustments removing the right lateral support. R11 reported she feels like she has more room and was more comfortable but was unhappy with her current cushion. Therapist informed R11 about assessing her cushion this week. 2/17/18 and timed 6:00 PM - Progress Note, by E14 (LPN) documented new PU of right inner buttock, described as an open wound measuring 1.0 cm X 0.8 cm with shallow, open wound bed with red/pink wound bed with no drainage. The wound was cleansed with normal saline and skin barrier applied. In addition, T & R was initiated. 2/17/18 - Weekly Pressure Ulcer Assessment documented a new stage 2 PU of right lower buttock was identified on 2/17/18 measuring 1 cm X 0.8 cm with no depth, no drainage. No signature of the staff who completed this assessment. Review of the facility's Treatment Guideline for Wound Care indicated for stage 2 PU, the treatment would include, cleansing area with normal saline (NSS), applying skin barrier wipe to periwound area, and apply [MEDICATION NAME]. Based on this protocol, the facility failed to follow the protocol by applying the skin barrier in the wound bed of the PU. Although R11 had a new PU of right buttock and R11 was unhappy with the current cushion, record review lack evidence that the facility identified the likely source of the pressure, which was likely from sitting in the PWC. This failure resulted in lack of reassessment of the interventions for pressure relief including the status of determining the need for a new PWC cushion. 2/18/18 - Order to cleanse left (incorrectly documented since the PU was on the right) buttock open area with NSS, pat dry apply Replicare daily and as need until healed. 2/19/18 - A clarification order to cleanse left (incorrectly documented again since PU was on the right) buttock open area with NSS, pat dry, apply Hydrogel, clean dressing daily until healed. 2/19/18 - OT Note by E23 documented R11 not getting up in PWC since she has a wound in her sacral area and when she was up in the PWC yesterday, R11 stated that the Hoyer cushion was rubbing her sacral area and made it worse. 2/20/18 - Weekly Pressure Ulcer Assessment documented stage 2 PU of right lower buttock with measurements of 1 cm X 1.3 cm with no depth, no drainage. No changes in interventions were documented. 2/22/18 - OT Note by E25 documented R11 verbalized discomfort in chair in sacral area and R11 reported that she received present cushion in 2013 and was open to acquiring new cushion to help relieve discomfort. Discussed with E23 (OT) and E28 (DOR). Printed out information on cushion for R11 and gave it to E28 to pursue. 2/23/18 - OT Note by E23 documented E23 communicated with E28 (DOR) and therapy assistant as well as with nursing as there have been different concerns expressed by R11 related to positioning in the PWC. 2/24/18 - OT Note by E23. R11 reported that she was remaining in bed due to pain after dressing change to the wound. 2/26/18 - OT Note, E26 (COTA), R11 expressed how she has not been turned yet today at lunch time. E26 found a CNA to help E26 turn R11 to right side of the bed with maximum assistance of two with pillow for support to keep R11 off the sore in the sacral area to prevent further skin breakdown. 2/27/18 - Weekly Pressure Ulcer Assessment, stage 2 PU of right lower buttock measuring 4.1 cm X 3 cm with no depth, no drainage, pink/red with shiny, moist appearance, with no pain. It was documented that the size of the wound worsened and T & R was one of the interventions. This assessment completed by E2 (DON). Despite the fact that the PU worsened in size, record review lacked evidence of reassessment of the effectiveness of the interventions. 2/28/18 - OT Note, E23 documented communication with R11 about plan to improve her positioning. R11 has had a recent wound that was believed to be from sitting up in the WC with Hoyer pad. E23 discussed with E28 (DOR) who was on the wound care team and who had recommended two hours only in the PWC to ensure wound would heal. E28 to report this to nursing. E23 told the nurse on second shift that R11 had been up past two hours this day and nurse verbalized that she will ensure that R11 gets back into the bed. 2/28/18 - Order for R11 was only to be out of bed for two hours every day until wound was healed. Review of the care plan and CNA plan of care documentation, lacked evidence that the facility had a system to incorporate this new intervention. 3/2/18 - OT Note, by E26, R11 was able to tolerate up in PWC for 3 hours today. Although there was an order for [REDACTED]. 3/3/18 - OT Note, by E23. Communicated with R11 about time up in PWC and reducing risk of making her wound worse. E23 communicated with CNA and assisted R11 in getting back to bed as well as positioning to stay to her left side to offload her sacral area to maintain skin integrity. 3/6/18 - Weekly Pressure Ulcer Assessment documented worsening of the PU. It was documented as a stage 2 of right lower buttock measuring 3.2 cm X 1.8 cm with no depth, no drainage, tissue type as slough, and no pain. Intervention of turning and repositioning was checked off. This assessment was completed by E6 (RN, UM). Record review lacked evidence that the facility identified that the PU was no longer a stage 2 due to presence of slough. This failure resulted in lack of reassessment of the interventions including treatment for [REDACTED]. 3/7/18 and timed 8:30 AM - Order indicated to discontinue current treatment to right buttock. New order to cleanse left (incorrect location) buttock with NSS, pat dry, apply [MEDICATION NAME], cover with gauze daily and as needed until healed. 3/9/18 and timed 3:15 PM - Clarification order for treatment to be provided to right buttock and not to left buttock. 3/13/18 - Weekly Pressure Ulcer Assessment documented stage 2 of right lower buttock measuring 3 cm X 1.8 cm with no depth, purulent drainage, tissue type as slough, and no pain. No to the question, worsening drainage despite the drainage becoming purulent. This assessment completed by E3 (ADON). 3/6/18 at approximately 3:16 PM - An interview with E6 (RN, UM North Unit) confirmed the care plan for wounds was not revised to include the actual PU of the right buttock. Additionally, the care plan failed to include the frequency of T & R as well as the need for weekly skin assessment. The CNA care plan also failed to include the frequency of T & R. When asked, what was the facility's system to update the care plan and the CNA care plan, E14 replied all licensed nurses are required to update the care plans. During the interview, it was unclear how E6 ensured provision of care and services, including the accuracy of the care plan and the CNA care plan. 3/8/18 at approximately 2:00 PM - An interview with E3 (ADON) revealed she led the facility's Wound Care Team which meets weekly on Tuesday. The team consisted of E3, E2 (DON), E28 (Director of Rehabilitation), and the Unit Manager. When asked if all interventions are reviewed and reassessed during weekly wound review, E3 was unable to provide surveyor a clear response. E3 was informed the care plan for wounds failed to include the actual PU of the right buttock as well as the T & R frequency. In addition, the CNA care plan lacked frequency of the T & R. E3 confirmed that the sling of the Hoyer lift did not cause the initial PU, however, the Wound Care Team determined that the sling caused the worsening of R11's PU. E3 confirmed that the low air loss mattress was obtained after the idenfication of the PU on 2/17/18. 3/9/18 at approximately 12:30 PM - An interview with E2 (DON) revealed that the facility ordered a new sling for the Hoyer lift since E2 related that the sling caused the worsening of R11's PU. E2 clarified that the Hoyer sling did not cause the initial PU of the right buttock. E2 confirmed the lack of weekly skin assessment, per facility policy. 3/13/18 at approximately 9:00 AM- An interview with E14 (LPN), the nurse who identified the new PU on 2/17/18 confirmed the skin barrier cream was applied directly to the PU since E14 mistakenly thought it was the skin barrier cream and not the skin barrier wipe. E14 additionally confirmed that although RN supervisor was notified, E14 does not recall whether the PU was assessed by the RN supervisor, however, E14 had completed the initial PU assessment. E14 related although he documented initiating the T & R every two hours, E14 was reinforcing the intervention already in place. When asked, what was the facility's system to update the care plan and the CNA care plan, E14 replied all licensed nurses are expected to do this. 3/13/18 at approximately 1:30 PM - An interview with E3 (ADON) confirmed that, despite weekly assessments documenting slough on 3/6/18 and 3/13/18, the staging of the PU remained at 2. E3 confirmed that the PU worsened with presence of slough but it was her understanding that one cannot change the stage of the PU. E3 related that she has not had any formal education on pressure ulcer prevention and management. 3/14/18 - OT Note, E23 documented R11 received a new PWC cushion. The new Vicair Cushion was rated for use with up to a stage 4 wound and R11 reported improved comfort. With this cushion, R11 was able to maintain position and equal distribution of weight while maintaining adeq

Based on record review, staff interviews, and hospital record review, it was determined that for one (1) resident out of five (5) residents reviewed (R2) the facility failed to provide adequate supervision to prevent accidents. R2 fell (unwitnessed) on 3/31/14 while trying to go to bed without staff assistance resulting in bleeding from a scalp injury located at the site of recent surgery and skin graft (an area where skin from one area of the body is used to cover another area of the body where skin has been removed). After this fall, the facility failed to develop and implement a plan for R2's supervision that included the times when he was not in the facility's monitored program for residents at risk for falls. This monitored program consisted of a group of facility residents at risk for falls being under direct supervision of a staff member during waking hours. There was no plan, however, instructing staff on the level of supervision R2 required at times when he was not in this monitored program. R2 then had a second unwitnessed fall on 4/27/14 after a staff member left the bathroom and turned her back to give R2 privacy while he was on the toilet. During this fall (4/27/14), R2 sustained a laceration (an injury in which the skin is broken) of the scalp at the site of recent surgery and a skin graft. R2 also reported pain of the head and neck while sitting on the floor right after this fall and he was transported to the hospital for evaluation, testing, and observation. R2 was readmitted to the facility two days later on 4/29/14. Findings include: R2's risk for falls was assessed by the facility and documented as follows: -Minimum Data Set (MDS) assessments (standardized assessment forms used in nursing homes) dated 3/24/14 and 4/8/14 indicated that R2 was not steady moving on and off the toilet and required extensive staff assistance with toileting (using the bathroom). "Extensive staff assistance" as defined on the MDS meant that R2 was involved with the activity but staff members were needed to provide weight bearing support. -R2 had medical [DIAGNOSES REDACTED]. -A care plan was initiated by the facility on 2/13/14 for R2's fall risk related to pain, incontinence, and weakness and called for staff to use alarms when R2 was in the bed or chair to alert staff when R2 attempted to get up. Record review, staff interviews, and observations revealed that it was the facility's usual practice to keep R2 under direct supervision when out of bed in order to prevent or reduce the risk of falls. During the first day of the survey (5/14/14), a group of residents including R2 was observed in a common area near the nursing station under the direct supervision of a staff member. E4 (CNA) explained to the surveyor on 5/14/14 at 3:25 PM that a CNA was assigned to stay with and supervise a group of residents at risk for falls from early morning until bedtime. E4 stated that the monitored program was called the Falls Companion program and had been started approximately 7 or 8 months ago and had been effective in reducing resident falls. Despite recognizing that R2 required direct supervision and attendance in the monitored falls group: -The facility failed to include R2's attendance in the monitored falls group in his care plan; -The facility failed to identify in the care plan how staff should supervise R2 when he was not attending the monitored falls program; and -The facility failed to instruct all staff on the level of supervision required when R2 was using the toilet. Staff interviews indicated that R2 required staff to be present for his safety while he used the toilet. For example: E5 (COTA) stated to the surveyor on 5/21/14 at 3:10 PM that R2 lacked safety awareness and when she worked with him she did not leave him alone (unattended) on the toilet. E6 (CNA) was the primary CNA assigned to R2 on the day shift. E6 (CNA) stated to the surveyor on 5/22/14 at 1:40 PM that R2 was at risk for falls and she (E6) would not leave him alone (unattended) on the toilet. This need for staff to be present for R2's safety when he was toileting was not recognized by all facility staff. For example, E11 (RN) was the unit manager on R2's unit and she stated to the surveyor on 5/22/14 at 11:40 AM that R2 was entitled to privacy in the bathroom and the staff sometimes stood outside the bathroom door. E8 (CNA) told the surveyor on 5/27/14 at 9:57 PM that until R2 fell from the toilet on 4/27/14, her usual routine was to leave the bathroom and stand outside the partially opened door while R2 used the toilet. E8 also stated that E9 (CNA) left R2 on the toilet and walked down the hall to the nursing station to tell E8 that R2 was left on the toilet. According to a nursing note dated 3/31/14 timed 8:45 PM E7 (RN) saw R2's wheelchair roll from his room to the hallway without R2 in it. E7 (RN) wrote that she arrived to the room to find R2 sitting on the floor with blood covering the back of his head and that she (E7) observed a 2 centimeter (approximately 3/4 of an inch) laceration with hematoma (swollen area of blood that has come out of blood vessels) at the upper part of the skin graft (an area where skin is used to cover a surgical wound) on the back of R2's head. According to this note, 911 (emergency medical services phone number) was called and R2 was transferred to the hospital for evaluation. A nursing note dated 4/1/14 documented that R2 returned to the facility at approximately 6:00 AM with no new orders. On 5/27/14 at 9:10 PM, E7 (RN) told the surveyor that on the evening of 3/31/14 she saw R2 in the hallway near his room sitting in his wheelchair while she (E7) was passing out medications to other residents. E7 (RN) recalled that R2 asked to go to bed and she told him that his CNA was busy and that he needed to wait. E7 (RN) stated that she told R2 to stay put and that he usually listened to her when she said this to him. E7 (RN) stated that R2 was in her sight as she gave out medications but she could no longer see him when he quickly moved his wheelchair into his room and got up out of his wheelchair without locking the brakes first. Care plan review revealed that it was important to R2 to choose his own bedtime and his preferred bedtime was documented as "whenever tired". Following R2's fall on 3/31/14, a fall screening form was completed on 4/1/14 by the facility's rehabilitation staff which identified: - a change in the area of balance and falls (indicated by a check mark in the "change noted" column) with a note that R2 had "impaired cognition and impulsive behavior" and had attempted to get out of his wheelchair unattended by staff and had fallen. -R2 had a continued need for the rehabilitation staff to provide treatment to promote safety and proper balance. Interview with E3 (ADON) on 5/22/14 at 1:50 PM confirmed that after R2's fall on 3/31/14 there was no change in his care plan or level of staff supervision. The care plan for R2 did not identify what the facility planned to do to supervise R2 and manage his impulsive tendency to get up without waiting for staff assistance. Approximately one month after his first fall, R2 had a second fall in the facility. According to an incident report dated 4/27/14 timed 10:50 PM, R2 tried to get up off the toilet by himself and lost his balance and fell . The nurse completing the incident report (E7) wrote that there was blood on the wall and R2 had a large amount of blood on the back of his head where his skin graft was. E7 (RN) wrote that she applied pressure to stop the bleeding. E7 (RN) also wrote that she observed blood in R2's mouth but due to R2's complaint of neck pain she stabilized his head (held it still with her hands) and did not conduct further assessment of his mouth. According to the incident report, 911 was called and R2 was taken to the hospital for evaluation. Interview with E8 (CNA) on 5/27/14 at 9:57 PM revealed that E9 (CNA) had assisted R2 to the bathroom and left him unattended on the toilet. E8 (CNA) stated that she (E8) was R2's assigned CNA that evening so when E9 (CNA) told her he had assisted R2 to the toilet (E8) left the nursing station and went down the hall straight to R2's bathroom. E8 (CNA) stated that R2 was not finished using the toilet so she waited with the bathroom door half open for R2 to finish. E8 (CNA) stated that this was her usual routine when caring for R2 because he tries to get up without help. E8 (CNA) stated that she turned her back to give R2 privacy and then heard a loud bump when R2 fell . E8 stated that she knew R2 from caring for him previous to 4/27/14 and stated that he (R2) needed to be reminded that he needed help because in his mind he thought he could do things for himself. E8 (CNA) stated that after the 4/27/14 fall she now remains in the bathroom with R2. Emergency Medical Services (EMS) documentation revealed that on 4/27/14 at approximately 11:21 PM responding EMS staff determined that R2 had controlled bleeding of the back of his head, pain of the back of the head, and pain and tenderness of the neck with the pain of the head and neck being reported by R2 as a 10 on a 1 - 10 scale. The hospital history and physical dictated on 4/28/14 documented that R2 had a laceration on his existing large scalp wound from prior surgery for [REDACTED]. The laceration was described as an area of bleeding over the scalp wound with irregular margins (edges). A facility nursing note dated 4/29/14 and timed 11:30 PM indicated that R2 was readmitted to the facility after sustaining a fall (on 4/27/14) with injury to the skin graft site of his scalp. The facility nurse documented that R2 forgets to call for assistance and tries to get up on his own and had an unsteady gait. A care plan change was made when a staff member checked the box for "close visual supervision". E2 (DON) stated to the surveyor on 5/22/14 at 11:40 AM that this change to the care plan was made after the 4/27/14 fall. Established policies and procedures related to falls were not followed by facility staff as evidenced by: -R2's care plan was not revised after he fell on [DATE] although the "Fall / Injury Management-Post Fall or Injury" policy / procedure called for staff to revise the care plan and / or facility practices to reduce the likelihood of another fall. -The "Resident Supervision" policy / procedure required the interdisciplinary team to determine when the level of supervision a resident received will change. Following R2's fall on 3/31/14, however, this did not occur. After a second fall on 4/27/14, a change to the care plan was made indicating that R2 required close visual supervision. -The "Fall / Injury Management- Post Fall or Injury" policy and procedure "recognizes that proper action following a fall includes.....addressing the contributing factors for the fall". R2's first fall (3/31/14) occurred when staff could not see him and he did not wait for staff assistance to go to bed. A change in R2's balance and falls status was identified by the rehabilitation staff in a post-fall screening form dated 4/1/14 that identified R2 as unsteady and impulsive. These contributing factors were not addressed by the facility following the 3/31/14 fall. Following R2's first fall on 3/31/14, the facility failed to implement changes to R2's care plan and level of supervision to ensure R2's safety. A second fall then occurred on 4/27/14 resulting in a laceration, head and neck pain, and a two day hospitalization . Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) at the exit conference on 5/28/14 at 1 PM.

Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal/oral hygiene for four (R1, R3, R6 and R17) out of 18 sampled residents and 9 subsampled residents. For R1, a resident who was dependent and who had diabetes, the facility failed to ensure the provision of toenail care by a professional. For R3, the facility failed to provide a bed bath using appropriate technique and failed to provide fingernail care on R3's left contracted (Abnormal shortening of muscle tissue, making the muscle highly resistant to passive stretching.) hand/fingers. The facility failed to ensure that the care and services were provided to R6 including brushing of the teeth resulting in heavy calculus (tartar/plaque) on all teeth which resulted in an invasion of the tongue space. The presence of the excessive tartar and calculus resulted in R6 being sent out for a two step procedure to remove the tartar and calculus and to smooth and polish his teeth. For R17, a resident who was unable to carry out activities of daily living there was lack of evidence to demonstrate that personal hygiene such as bathing/showers were provided. Findings include: 1. R6 was originally admitted to the facility for long term care on 3/31/10 and has been in the facility since. R6 had [DIAGNOSES REDACTED]. According to R6 ' s Minimum Data Set (MDS) quarterly assessment dated [DATE], cognitive skills for daily decision-making were severely impaired and needed extensive to total assist of staff for all activities of daily living (ADL). R6 had no physical or verbal behaviors. R6 was also on a long term [MEDICATION NAME] medication which was administered by a tube daily. According to E8 (nurse), R6 was mostly non-verbal but will speak softly once in a while. R6 was seen by D1(dental clinician) on 4/29/11 with findings that all posterior (back) teeth were missing and the lower anterior (front) teeth needed cleaning. R6 was seen again by D1 on 4/26/12 ( a year later) with findings that the lower teeth were covered with calculus/tartar. There was no record of documentation found to identify that R6 was seen regularly and/or more frequently by the dental clinician/dentist between 4/26/12 and prior to P3' (attending physician) request for consultation on 9/6/12. The facility updated a care plan on 4/17/12, 7/14/12 and 10/5/12 for " Potential or actual ADL/Mobility deficit r/t (related to)[MEDICAL CONDITION] evidenced by general weakness, easily fatigued and bilateral hand contractures. " The Personal Hygiene/Grooming/Dressing/Undressing interventions identified in the care plan included oral care daily and PRN (as needed), set up, cued and required physical assistance. Another care plan entitled Care Plan on Staff assessment of cognition dated 10/2012 had a goal that R6 ' s needs will be anticipated by staff 100% of time x 90 days. The interventions included: use structured daily living routine with ADLs; anticipate needs; assist resident in establishing daily routine. Despite the development of care plans for R6, there is no evidence that there were specific interventions to address the cleaning of the lower teeth. Interview with E3 (Director of Nursing, DON) on 2/18/13 at 4:30 PM, revealed "Use of structured daily living routine " in relation to mouth care included staff will brush the resident's teeth if resident was unable to do that independently. According to the documentation on the TAR (Treatment Administration Record), R6 was provided mouth care every shift since 04/03/12. Interview with E8 (nurse) on 2/21/13 at 10:45 AM, revealed that R6's mouth care was provided by the nursing staff with toothette oral swabs (sticks with soft foam heads that are gentle) which were used to rub around the inside of R6 ' s mouth instead of a toothbrush. R6 was alert and non-verbal. R6 was cooperative with ADLs. Sometimes he would push the staff during mouthwash, became resistant, and his body would stiffen up. He would not hit the staff. He followed commands. Additionally, an interview with R6's attending physician (P3) on 2/20/13 at 10:30 AM revealed that R6 developed gum " Hypertropsy" (enlargement and swelling of the gums), a side effect of prolonged intake of the medication [MEDICATION NAME]. On 2/21/13 at approximately 3:00 PM, it was confirmed that E3 (Director of Nursing) was aware of the prolonged ingestion of the [MEDICATION NAME] and it's effect on the mouth/gum/teeth to this resident. On 9/6/12 R6's P3 wrote a consultation request to a dental clinician (name of Dental Services) for R6 which stated, " Patient has calculus ( a form of hardened plaque) covering all teeth on mandibular (lower jaw). Patient is edentulous maxillary (upper jaw). Patient at risk for aspiration pneumonia! Large chunks of calculus (tartar) could break off and patient could choke or aspirate (breathe) into the lungs. Hygiene needed regularly in addition to daily TB (tooth brushing) " . On 9/6/12 In response to P3's request, D1(dental consultant clinician) wrote on his report the findings that R6 presented with heavy calculus covering all the teeth and invading the tongue space. Teeth have not been brushed in months. A Gross scale (full mouth debridement) was performed with caution -needs fine scale (to remove remaining buildup and polish) procedure to smooth the teeth. His recommendation was " fine scale/evaluation next visit and evaluation with dentist". The facility revised R6 ' s care plan related to ADLs on 10/7/12 and included the intervention of Toothbrushing resident's teeth daily. R6 was scheduled for a follow-up dental appointment on 10/26/12. The 10/26/12 report of dental clinicians' findings stated, " Continued to debride calculus buildup on remaining mandibular teeth. Three people assisted to keep the patient still and smooth the teeth. The dental clinician (D1) recommendations included a follow up appointment in 6 months for oral exam and debridement; and toothbrushing daily to help maintain healthy tissues. On 10/26/12, P3 (attending physician) wrote an order to " Toothbrush resident's teeth daily to help maintain healthy tissues. Follow-up Dental appointment in 6 months for oral exam and debridement " . This order was transcribed in the 10/12 TAR (Treatment Administration Record) but was not dated. The 10/12 TAR had only one day signed off on 10/30/12 indicating that R6's teeth were brushed one time on the 7-3 PM shift since it was prescribed during the month of October, 2012. The facility failed to ensure that R6's teeth were brushed and/or had more frequent dental visits. This failure resulted in heavy calculus on all teeth which also invaded the tongue space. R6 required an outpatient two step procedure to debride and scale his teeth. 2. R17 had [DIAGNOSES REDACTED]. According to R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], this resident's cognitive skills for daily decision-making were moderately impaired, decisions poor; cues/supervision required. R17 required extensive assistance of staff with her activities of daily living (ADLs). The facility established a care plan for ADL/Mobility Plan of care dated 9/25/12. The interventions included to assist/encourage/provide per resident's preference bed bath and showers. Regarding her bathing/showers activities, she was totally dependent on staff of 2. R17 was scheduled for showers on Wednesday and Saturday at 3-11 PM shift each week. Review of the CNA's Bath Type Detail Report revealed that out of 18 showers scheduled for this resident from 12/01/12 through 01/30/13, she only received 6 showers. On the scheduled days for showers, bed bath was provided instead. However, there was no documentation to explain why R17 was given a bed bath instead of her scheduled shower. For example on 1/13/2013 at 01:23 AM, R17 was not scheduled to have a bath and therefore did not receive a bath. On 01/13/2013 at 02:31 PM (7-3 PM shift), the documentation on the CNAs Bath Type Detail Report stated "scheduled-but provided on other shift". On 01/13/2013 at 06:16 PM (3-11 shift) documented not scheduled. R17 did not receive personal hygiene services of a bed bath or shower for 24 hours/one day on 1/13/2013. The facility failed to ensure that R17, who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene regarding bathing/showers. This finding was discussed with E3(DON) and E1 (Administrator) on 02/21/2013 at the exit conference. 3. R1 had [DIAGNOSES REDACTED]. Review of R1's quarterly Minimum Data Set (MDS) assessment, dated 1/29/13, revealed following: R1 required extensive assistance of one person for personal hygiene and was totally dependent for bathing upon the assistance of one person. The ADL (Activities of Daily Living) care plan, developed on 2/23/12 and last revised on 1/26/13, had the interventions to provide nail care as needed and provide diabetic nail care as need by a licensed professional. On 2/7/13 at 7:15 AM an observation was made of E17 (Certified Nurse Assistant/CNA) providing a bed bath to R1. This observation revealed that R1 had long toenails. On 2/7/13 at that time, findings were confirmed by E17 who also stated that the Podiatrist (A doctor that deals with the diagnosis, treatment, and prevention of diseases of the human foot.) cuts the resident's toenails. On 2/11/13 at 8:10 AM, in an interview, E5 (Registered Nurse/RN) reviewed the ADL (Activities of Daily Living) Care Plan and confirmed that the care plan had the intervention to provide diabetic nail care as need by a licensed professional. On 2/11/13 at that time, E5 asked, "Is she a diabetic?" E5 then looked on the 2/13 physician orders [REDACTED]. E5 then proceeded to look in the book of appointments with the Podiatrist and E5 stated that R1 had not had any nail care from 10/12 to 2/13 since the resident's name was not on the list that she reviewed. E5 further stated, "I would expect the CNA to inform the nurse if the resident's toenails were long". Asked E5 if any staff had informed her of R1's long toenails during this past week and E5 stated, "No one had informed me". The facility's system failed to identify that R1, a dependent resident with diabetes, had toenails that were long, failed to inform nursing staff of the long toenails and failed to refer R1 to a Podiatrist to provide nail care by a licensed professional as per the ADL plan of care. On 2/7/13 at 8:10 AM, findings were confirmed by E5. 4A. R3 had [DIAGNOSES REDACTED]. Review of R3's annual Minimum Data Set (MDS) assessment, dated 11/27/12, revealed the following: R3 was totally dependent for bathing and for personal hygiene which required the assistance of two persons. On 2/11/13 at 10:20 AM, an observation was made of E15 (CNA) providing a bed bath to R3. After washing the resident's face, chest and right side, E15 proceeded to wash R3's genital/ perineal area. Next E15 went to the resident's left arm and chest area and was about to wash those areas with the same washcloth and water when the surveyor stopped E15. On 2/11/13, at the time of the bed bath, E15 confirmed the findings. The facility failed to provide a bed bath to R3, a dependent resident, using appropriate technique. On 2/11/13, findings were confirmed by E15 as noted above. 4B. On 2/11/13 at 9:55 AM, an observation with E7 (Licensed Practical Nurse/LPN) was made of R3's left contracted hand with two long fingernails. When E7 slightly opened R3's fingers on her left hand, there was a reddened palmer surface observed. On 2/11/13 at the time of the observation confirmed both the long nails and the reddened palmar surface. On 2/11/13 at 10:50 AM, E15 also confirmed two long nails on R3's left hand. The facility failed to provide nail care to R3, a dependent resident. Findings were confirmed on 2/11/13 by E7 at 9:55 AM and by E15 at 10:50 AM.