Every finding on record at Regency Healthcare & Rehab Center

Based on interview and record review, it was determined that for one (R11) out of five residents reviewed for unnecessary medications, the facility failed to have evidence of ongoing antibiotic stewardship implementation when R11's antibiotic usage was not reviewed after not meeting facility antibiotic prescribing criteria. Findings include:CDC (Center for Disease Control and Prevention) guidance dated 2015, entitled, The Core Elements of Antibiotic Stewardship for Nursing Homes states, .Standardize the practices which should be applied during the care of any resident suspected of infection or started on an antibiotic. These practices include .implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for an antibiotic.A facility policy entitled, Antibiotic Stewardship-Staff and Clinician Training and Roles included, .2. The DON will monitor individual resident antibiotic regimens.3. The IP will audit and the DON will provide feedback to providers on antibiotic prescribing practices.Review of R11's clinical record revealed:12/27/24 - R11 was admitted to the facility.4/15/26 8:25 AM - An Encounter Note entered in R11's clinical record documented, .UA [urine analysis] was positive for UTI [urinary tract infection] and [R11] was ordered Sulfamethoxazole-Trimethoprim Oral tablet [antibiotic] 800-160 MG [milligrams] twice a day for 7 days.4/17/26 1:00 AM - An Encounter Note entered in R1's clinical record documented, .[R11] is seen for follow up UTI.was started on [antibiotic].however now susceptibility is back and shows organism is Klebsiella pneumoniae [bacteria].change antibiotic to Amoxicillin-Pot Clavulanate 500-125 mg twice daily for seven days.6/25/26 1:45 PM - During an interview, the surveyor asked E6 (IP, LPN) what antibiotic surveillance criteria does the facility use. E6 stated, We use McGreer criteria.6/26/26 9:00 AM - Review of the facility's resident antibiotic surveillance tracking form for 4/2026 revealed it was documented that R11 did not meet McGreer criteria for the Sulfamethoxazole-Trimethoprim Oral Tablet or Amoxicillin-Pot Clavulanate Oral Tablet antibiotic medications prescribed.6/26/26 10:30 AM - During an interview, the surveyor asked E2 (DON) how the facility reviews residents prescribed antibiotics that do not meet McGreer criteria. E2 stated, I am not involved with antibiotic stewardship, E4 handles that. Nursing does meet with the providers and we discuss the residents at morning meeting.6/26/26 10:45 AM - During an interview, the surveyor asked E1 (NHA) how residents are reviewed when prescribed an antibiotic that does not meet McGreer criteria. E1 stated, Residents who do not meet the criteria are reviewed during our weekly high-risk meeting and again at monthly QAPI [quality assurance] meeting. The surveyor requested documentation of R11's antibiotics review. E1 stated, I will look for the documentation.6/26/26 11:15 AM - E1 gave the surveyor a facility document entitled, Progress Note, that documented, .Resident: [R11] Date: 4/15/2026.UM reviewed UA [urinalysis] with provider. UA was positive for UTI and resident was ordered Sulfamethoxazole-Trimethoprim Oral Tablet. No documentation was provided for the ongoing review of R11's antibiotic prescriptions after 4/15/26.6/26/26 12:15 PM - Findings were reviewed with E1 and E2.6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on interview, record review, and review of other facility documents, it was determined that for one (R32) out of three residents reviewed for abuse, the facility failed to ensure that R32 was free from verbal abuse from a staff member on 1/9/26. Based on review of the facility's evidence to correct the deficient practice and substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 1/11/26. Findings include:A facility document entitled Abuse Prevention Policy, dated 2001 and revised 4/21, included, Mental abuse is the type of verbal or non-verbal abuse conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds to residents within hearing distance, regardless of age, ability to comprehend or disability.R32's clinical record revealed:12/27/24 - R32 was admitted to the facility with diagnoses including, but not limited to, heart disease, right above the knee amputation, muscle weakness and food insecurity.12/31/25 - R32's annual MDS documented a BIMS score of 15, indicating a fully intact cognitive status. The MDS also documented that R32 was independent with eating and wheelchair mobility.1/10/26 5:01 PM - A facility incident report submitted to the Division included, Resident reported today, 1/10/26, that he asked a CNA for an extra sandwich to have after dinner while in the dining room eating on 1/9/26. He [R32] said that she [CNA] told him to get it himself and that if she did get him the sandwich that she would spit on it.6/25/26 1:00 PM - During an interview, the Surveyor asked R32 about the incident. R32 stated, I am okay. I get plenty of food to eat here. I just wanted to have a sandwich to eat later in case I got hungry later. That girl was rude, but the rest of the staff are nice. The Surveyor asked R32 whether there were any previous instances where a staff member had been rude to him about food or anything else. R32 stated, No, that was the only time.6/25/26 1:30 PM - During a combined interview, E1(NHA) and E2 (DON) stated, Abuse of any kind is not tolerated. We provided support to the resident, checked whether any other residents received similar treatment and educated the staff on abuse prevention immediately. The facility failed to ensure that R32 was free from abuse by the staff member.The facility's action plan included:Upon learning of the incident, the staff member was immediately removed from the schedule. DON completed a random audit of residents on 1/10/26 with no further deficient practice identified.The facility immediately initiated reeducation for all staff members on abuse prevention on 1/10/26.A review of risk management for 90 days was completed to assess that no additional incidents of abuse occurred, with no additional incidents identified.The facility conducted ongoing audits to monitor compliance.The facility conducted interviews for 3 residents for 5 days, then 3 residents per week for 3 weeks, and then monthly for at least 3 months until substantial compliance is achieved.The facility QAPI committee reviewed the results of the observations made by the DON/designee to identify any trends/conduct root cause analysis and develop a plan of action for follow-up and resolution if necessary.6/26/26 1:00 PM - Based on the Surveyor's review of the facility's investigation, documented response, completion of staff education from 1/10/26 to 1/11/26, staff interviews, and no further incidents of abuse, this deficient practice was considered past non-compliance with a compliance date of 1/11/26.6/24/26 11:00 AM - Findings were confirmed with E1 (NHA), and E2 (DON).6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on record review and interview, it was determined that for one (R26) out of 20 residents reviewed for care plans, the facility failed to develop a person-centered care plan for an identified need. Findings include:Review of R26's record revealed:7/30/25 - R26 was admitted to the facility with diagnoses including atrial fibrillation, VTE (Venous Thrombosis and Embolism) and dementia.7/30/25 - An order for Eliquis (an anticoagulant/blood thinner) 5 mg twice a day was entered into R26's medication profile.8/5/25 - R26's admission MDS (Minimum Data Set Screening Tool) documented under the High-Risk Drug Class section that R26 was receiving anticoagulation therapy.11/4/25 - R26's quarterly MDS documented under the High-Risk Drug Class section that R26 was receiving anticoagulation therapy.12/8/26 - An order to change the dose of Eliquis to 2.5 mg twice a day was entered into R26's medication profile.2/4/26 - R26's quarterly MDS documented under the High-Risk Drug Class section that R26 was receiving anticoagulation therapy.5/6/26 - R26's quarterly MDS documented under the High-Risk Drug Class section that R26 was receiving anticoagulation therapy.6/24/26 2:45 PM - Review of R26's EHR (Electronic Health Record) lacked evidence that R26's comprehensive care plan addressed anticoagulation therapy, including associated bleeding risks, monitoring needs, and interventions to reduce the risk of bleeding complications.6/24/26 3:49 PM - During an interview, E14 (RN, MDS Coordinator) reviewed R26's EHR and confirmed that R26 was receiving anticoagulation therapy which was not addressed in R26's comprehensive care plan. 6/24/26 3:55pm - Findings reviewed and confirmed during an interview with E1 (NHA).6/24/26 1:45 PM - Findings were reviewed with E1, E2 (DON) and E4 (DCS) during the Exit Conference.

Based on record review and interview, it was determined that for one (R67) out of 20 residents reviewed for care plans, the facility failed to review and revise a person-centered care plan for an identified need. Findings include: Review of R67's clinical record revealed: 3/15/22 - R67 was admitted to the facility with diagnoses including dementia and major depression disorder.2/24/26 - R67's annual MDS assessment documented that R67's cognition was moderately impaired. R67 had no mood and behavior issues during the review period and was not receiving antipsychotic medication. 2/24/26 - R67 was care planned for the use of antidepressant medication related to depression with interventions including administering medications per order and monitoring R67 for any changes in behavior or mood. 3/9/26 - R67 had a physician's order for aripiprazole 5 mg tablet by mouth once a day, an antipsychotic medication, for major depressive disorder.4/23/26 - A psychiatric encounter note documented that a gradual dose reduction of the R67's antipsychotic medication was evaluated during this visit and was not recommended at this time. 5/27/26 - R67's quarterly MDS assessment documented that R67's cognition was moderately impaired. R11 had no mood and behavior issues during the review period and was receiving antipsychotic medication. 6/24/26 - Further review of R4's care plan for major depressive disorder lacked evidence that it was reviewed and revised to address R67 receiving an antipsychotic medication and for its side effects to be monitored including involuntary movements, tremors, dry mouth, urinary retention, seizures, blurred vision, rashes, sedation, dystonia or rigidity.6/24/26 - A review of R67's Medication Administration Reports from April 2026 through June 23, 2026, revealed that R26 was monitored for side effects for taking antipsychotic medications including involuntary movements, tremors, dry mouth, urinary retention, seizures, blurred vision, rashes, sedation, dystonia or rigidity.6/24/26 11:00 AM - During an interview, E11 (LPN) confirmed that R67's care plan interventions did not include the use of antipsychotic medication and its side effects for monitoring. 6/25/26 1:30 PM - Findings were discussed with E1 (NHA) and E2 (DON).

Based on interview, record review, and review of other facility documents, it was determined that for two (R56, and R71) out of three residents reviewed for care and services in accordance with professional standards, it was determined that the facility failed to ensure that R56's medication pain patch was removed on the evening shift according to the physician's order. For R71, the facility failed to ensure that the bowel protocol was implemented when R71 did not have a bowel movement for 5 days. Findings include: 1. R56's clinical record revealed: 10/12/22 - R56 was admitted to the facility with diagnoses including, but not limited to, cardiovascular accident, and back pain. 10/6/25 – R56's pain care plan documented, [R56] has a potential for alteration in comfort related to pain. The interventions included, Assist with turning and repositioning as needed. Medication as ordered. 4/10/26 – R56's quarterly MDS assessment documented a BIMS score of 6, indicating a severe cognitive impairment. R56 required partial to moderate assistance from staff for repositioning in bed, and transfers between surfaces. 5/3/26 – R56's physician's orders included, Icy Hot External Patch 5% (menthol topical analgesic.) Apply to lower back topically one time a day and remove per schedule. Apply at 0900 [9:00 AM] and remove at 2000 [8:00 PM]. 6/23/26 8:00 PM – R56's clinical record documented that the patch was removed. 6/24/26 9:30 AM – During the medication administration, E7 (LPN) was observed removing a patch from R56's back. The patch was dated 6/23/26 and the time was 9:00 AM. The Surveyor asked E7 whether the patch should still be on at the current time. E7 stated, My computer screen only shows me what medications I should give on my shift. E7 checked the previous evening record, and stated, The order was signed off, the patch should have been removed last evening. 6/24/26 9:45 AM – During an interview, E15 (N/P) stated, The patch is mentholated and should not cause toxicity. But it might cause skin irritation. The manufacturer's instructions to apply in the morning and remove in the evening should have been followed. The facility failed to ensure that R56's medicated pain patch was removed per the physician's orders. 6/24/26 11:00 AM – Findings were confirmed with E1 (NHA), and E2 (DON). 2. The facility's undated bowel management policy entitled, Bowel Protocol included, Physician ordered bowel protocol includes: Milk of Magnesia (laxative).give if no bm (bowel movement) in 3 days.administer one suppository if no results from Milk of Magnesia within 24 hrs.Fleet Enema.give the following shift if no results from suppository. Call MD if no results from fleet enema by the end of the shift given. R74's clinical record revealed: 3/15/23 – R74 was admitted to the facility with diagnoses including neuropathy and cerebral infarction. 9/8/25 – An order was entered in R74's clinical record documented, Lactulose (laxative) Solution.BM PROTOCOL if no BM for 3 days give 30 mL (milliliters). 9/8/25 – An order was entered in R74's clinical record documented, .Bowel Protocol administer one suppository if no results from Milk of Magnesia or Lactulose within 8 hrs. 3/5/26 – R74's quarterly MDS assessment documented a BIMS score of 14, indicating an intact cognition. 3/5/26 – R74's updated care plan documented, .Potential for constipation.Resident will have a bowel movement every 3 days through next review.monitor consistency and frequency of bowel movements. 5/28/26 1:00 AM – An Encounter Note entered in R74's clinical record documented, .[R74] is seen today for complaints of constipation, no bowel movement x3 days. [R74] does have a long history of constipation. 5/28/26 11:06 AM – An Administration Note entered by E8 (LPN) documented, .Gave 30 mL of Lactulose during this shift, [R74] stated he did not have a BM in the last several days. BM protocol implemented. 6/23/26 4:09 PM – During an interview, R74 stated, I will not have a bowel movement for long periods of time. 6/24/26 9:00 AM – Review of R74's Documentation Survey Report for 5/2026 revealed that on 5/23/26, 5/24/26, 5/25/26, 5/26/26, 5/27/26 or 5/28/26, it was documented that R74 had no bowel movement. R74 did not have a bowel movement for over 5 days before the bowel management protocol was implemented. The bowel management protocol was implemented after R74 complained to staff of constipation. 6/26/26 8:16 AM – During an interview, E8 stated, The CNAs document the residents' bowel movements. If a resident does not have a bowel movement in 3 days, an alert in [EHR (electronic health record)] will trigger. The surveyor asked E8 who initiates the bowel protocol if a resident does not have bowel movement in 3 days. E8 stated, I would initiate the BM protocol. The surveyor asked E8 if R74 had complained of constipation or had any triggered alerts. E8 stated, I'm sorry, I don't remember. 6/26/26 8:30 AM – During an interview E9 (CNA) stated, I don't know the BM protocol but if a resident is not going, I would tell the nurse. We document the residents' bowel movements in [EHR]. I think the nurses get an alert if a resident has not had a BM. 6/26/26 12:15 PM – Findings were reviewed with E1 (NHA) and E2 (DON). 6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R4) of two residents reviewed for pressure ulcers, the facility failed to ensure that R4, a resident with a Stage IV pressure injury, received treatment and services consistent with professional standards of practice to promote wound healing and prevent infection during a wound dressing change. Findings include:The facility's Wound Care policy (2001) indicated that staff were required to assemble all necessary supplies before beginning the procedure; maintain a clean field; perform hand hygiene before and after glove removal; use appropriate personal protective equipment (PPE), including gowns and gloves as indicated; utilize a no-touch technique when providing wound care; wear sterile gloves when directly contacting the wound; and bring only the disposable supplies needed for the treatment into the resident's room. The policy further specified that disposable supplies taken into the room were not to be returned to the treatment cart. Cross refer F880A review of R4's clinical record revealed the following1/25/25 - R4 was admitted to the facility with diagnoses including left-sided paralysis and a Stage IV pressure injury to the sacrum.1/31/25 - The admission Minimum Data Set (MDS) assessment documented that R4 was severely cognitively impaired, required the assistance of two or more staff members for bed mobility and repositioning, was always incontinent of bowel and bladder, and had one unhealed Stage IV pressure injury present on admission.4/30/25 - A skin integrity care plan documented R4's healed Stage IV sacral pressure injury.1/3/26 - R4's annual MDS assessment documented no unhealed Stage IV pressure injury.4/29/26 - A wound assessment documented that R4's Stage IV pressure injury to the sacrum had reopened.5/1/26 - R4's significant change MDS assessment documented one unhealed Stage IV pressure injury. 5/1/26 - R4's care plan for impaired skin integrity and at risk for further breakdown related to incontinence and immobility was initiated with interventions to provide wound treatment to sacrum as ordered by the physician.6/10/26 - R4's physician order directed staff to cleanse the sacral wound with normal saline solution (NSS) or wound cleanser, pat dry, apply medical-grade honey fiber, and cover with a bordered dressing daily during the evening shift and as needed for dressing displacement or soiling.6/24/26 - A wound assessment documented that R4's Stage IV pressure injury to the sacrum was improving with delayed wound closure.6/24/26 4:00 PM to 4:30 PM - During R4's incontinent care and a wound dressing change, the following infection control concerns were observed:After R4 had a bowel movement, E13 provided incontinent care.Following completion of incontinent care, E13 repositioned R4 using the same contaminated gloves without performing hand hygiene.E12 removed gauze from an opened multiuse package, saturated the gauze with wound cleanser, cleansed the wound, applied the prescribed treatment, and completed the dressing change.The facility failed to provide wound care consistent with professional standards of practice for R4's existing Stage IV pressure injury when E13 failed to perform hand hygiene and change gloves after providing incontinent care and before repositioning R4 during the wound dressing procedure.6/24/26 4:33 PM - During an interview, E13 acknowledged, I did not change my gloves after I cleaned [R4], and I did not wear my PPE gown when I started providing care.6/24/26 4:38 PM - In an interview, E12 stated that she touched the privacy curtain with her gloved hand and that she did not wear the required gown for her PPE. E12 further stated and confirmed that E13 did not change her gloves after E13 completed R4's incontinent care.6/25/26 1:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON).6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on observations, interviews and record reviews, it was determined that for two (R4 and R56) of seven residents reviewed for infection control, the facility failed to implement an effective infection prevention and control program. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) for R4 during incontinent care and a wound dressing change despite an active physician's order and posted EBP signage. For R56, a resident with a multidrug-resistant organism (MDRO), the facility also failed to implement Enhanced Barrier Precautions during medication patch administration.The facility's Enhanced Barrier Precautions (EBP) policy, revised February 2025, stated that Enhanced Barrier Precautions are an infection prevention measure intended to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. The policy required staff to don gowns and gloves before performing high-contact resident care activities for residents with known MDROs or those at increased risk for MDRO transmission. High-contact care activities requiring gowns and gloves included providing hygiene, changing briefs or assisting with toileting, and performing wound care involving any skin opening requiring a dressing. Cross Refer: F686 A review of R4's clinical record revealed the following: 6/10/26 - R4 had an active physician's order requiring Enhanced Barrier Precautions. 6/24/26 3:50 PM - An Enhanced Barrier Precautions sign was observed posted outside R4's room. 6/24/26 4:00 PM - E13 (CNA) entered the room wearing gloves but did not don the required gown before repositioning R4. 6/24/26 4:01 PM - E12 entered the room, placed the wound treatment supplies on an overbed table lined with paper towels. E12 then performed hand hygiene with sanitizer, donned gloves, but did not wear the required gown. 6/24/26 4:00 PM - 4:30 PM - An observation revealed that E12 (LPN) and E13 (CNA) provided incontinent care following R4's bowel movement and completed a wound dressing change to the sacral wound without wearing the required isolation gowns, despite the resident being on Enhanced Barrier Precautions. 6/24/26 4:33 PM - During an interview, E13 acknowledged that she did not wear the required gown when providing incontinent care and changing R4's dressing. When asked about the purpose of the Enhanced Barrier Precautions sign posted outside the room, E13 stated, It is to protect myself. 6/24/26 4:38 PM - In an interview, E12 (LPN) acknowledged that she should have worn the required PPE gown while performing the wound dressing change. E12 stated, I saw the sign, but I did not see the PPE cart by the door, and I did not know the resident's PPE supplies were hanging on the bathroom door. I only realized I had not worn the gown after I finished the treatment. The facility failed to wear the required isolation gowns while providing incontinent care and wound treatment under Enhanced Barrier Precautions. 6/25/26 1:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON). 2. R56 clinical records revealed: 10/12/22 - R56 was admitted to the facility with diagnoses including, but not limited to, cardiovascular accident and back pain. 4/10/26 – R56's quarterly MDS assessment documented a BIMS score of 6, indicating a severe cognitive impairment. R56 required partial to moderate assistance from staff for repositioning in bed, and transfers between surfaces. 10/6/25 – R56's care plan documented, [R56] is on enhanced barrier precaution r/t [related to] MDRO. The interventions included, Wear gowns and gloves during high contact activities. (E.g. bathing, turning). 6/24/26 9:30 AM – During the medication administration, E7 (LPN) entered R56's room to administer a medicated patch to his back. E7 repositioned R56 in the bed and removed the current medicated patch from his back. E7 then applied a new patch to the area. E7's clothing came in contact with R56's bed linen both times during the repositioning and removal and administration of the patches. During an interview, E7 stated, I thought he was not on barrier precautions anymore. E7 failed to observe enhanced barrier precautions during R56's medication administration despite the obvious sign on the door, and the care plan for MDRO. 6/24/26 10:00 AM – Findings were confirmed with E1 (NHA), and E2 (DON). 6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on observation and interview, for two (R50 and R51) out of three residents reviewed for environment, it was determined that the facility failed to ensure the call system was accessible when each residents' call bell was observed closed inside the residents' bedside table drawers. Findings include:1. Review of R50's clinical record revealed: 6/13/19 - R50 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side.6/1/26 - A quarterly MDS assessment documented that R50 had an upper extremity impairment on one side and a BIMS score of 8, indicating a moderately impaired cognition.6/23/26 3:46 PM - R50 was observed laying in bed. R50's call bell was closed inside his bedside table drawer.6/23/26 5:01 PM - R50 was observed laying in bed. R50's call bell was closed inside his bedside table drawer. During an interview, the surveyor asked E10 (LPN) why the call bell was closed inside the bedside table drawer. E10 stated, I will take it out.6/26/26 12:15 PM - Findings were reviewed with E1 (NHA) and E2 (DON).2. Review of R51's clinical record revealed:7/20/23 - R51 was admitted to the facility with diagnoses including epilepsy and dementia.3/26/26 - A quarterly MDS assessment documented R51 had no upper or lower extremity impairments and a BIMS score of 5, indicating a severely impaired cognition.6/23/26 9:17 AM - R51 was observed laying in bed. R51's call bell was closed inside his bedside table drawer.6/23/26 3:46 PM - R51 was observed laying in bed. R51's call bell was closed inside his bedside table drawer.6/23/26 5:01 PM - R51 was observed laying in bed. R51's call bell was closed inside his bedside table drawer. During an interview, the surveyor asked E10 (LPN) why the call bell was closed inside the bedside table drawer. E10 stated, I will take it out.6/26/26 12:15 PM - Findings were reviewed with E1 (NHA) and E2 (DON).6/26/26 1:45 PM - Findings were reviewed with E1, E2 and E4 (DCS) during the exit conference.

Based on record review and interview, it was determined that for one (R11) out of two residents reviewed for ADLs (Activities of Daily Living) and one (R27) out of six residents reviewed for abuse, the facility failed to follow the plan of care. For R11, a soiled and wet dressing was not changed per the physician's order. For R27, the facility failed to ensure re-admission orders on 6/28/25 were reviewed by on call provider and transcribed accurately. Findings include: 1. Review of R11's clinical record revealed: 6/19/25 - R11 was re-admitted to the facility and required assistance with personal care. 3/26/25 - A review of R11's quarterly MDS assessment revealed that R11 had intact cognition. 6/20/25 - R11 had a physician's order to cleanse the right wrist skin tear with NSS pat dry apply Xeroform (gauze dressing for wounds with drainage) and CDD daily and PRN (when necessary) every evening shift. 6/26/25 9:00 AM - During an observation, R11 was seen from the shower room being wheeled to the nurses' station by staff. R11 was observed with a soiled and soaked dressing on the right wrist dated 6/25/25. 6/26/25 9:05 AM - R11 was observed calling E6 (RN) who walked by and asked the nurse if he was getting a treatment on the skin tear. R11 stated, I just had a shower and showed E6 his right wrist. 6/26/25 9:06 AM - E6 was seen and heard responding to R11 saying, The dressing was changed yesterday (6/25/25) by the wound nurse. If you want it change, it is scheduled for the 3-11 shift so that will be done this afternoon. E6 was observed walking away leaving R11 in the Nursing station. 6/26/25 9:10 AM - In an interview, R11 told the surveyor that he thought the nurse [E6] would change his dressing. R11 further stated, I raised my wrist so she can see that the dressing was soiled, wet and needed to get changed. She [E6] said the afternoon staff will do it. She just walked away, you saw her! 6/26/25 9:30 AM - In a follow up observation, R11's right wrist was still noted with the same soiled and wet dressing. R11 told the surveyor, She [E6] is not going to do anything about this now. 6/26/25 9:35 AM - During an interview, E2 (DON) confirmed that R11's skin tear dressing should be changed not just per schedule but also when it is visible wet or soiled. E2 further stated, . The nurse [E6] should change R11's soiled and wet dressing. 6/30/25 4:10 PM - Findings were reviewed with E1 (NHA) and E2 (DON). 2. Review of R27's clinical record revealed: 6/28/25 7:10 PM - A nurse's note by E9 (LPN) documented, Resident returned from the ER [emergency room] . Discharge dx [diagnosis] provided by the ER was cellulitis [infection] at the PEG tube site . Bacitracin [antibiotic] ointment is to be applied topically to the PEG site twice daily for 10 days for cellulitis . 6/28/25 11:37 PM - A physician's order by E9 was entered in R27's electronic medical record as apply to Peg-site BID [twice a day] x [times] 10 days Dx Cellulitis every day and evening shift for Dx Peg-site cellulitis for 10 days. The facility failed to accurately transcribed the ER discharge order in R27's electronic medical record. 7/1/25 10:30 AM - During an interview, R27 reported that nursing staff on the previous night shift was not aware of the new physician's order for her Peg tube area. 7/1/25 1:15 PM - During an interview, E9 (LPN) confirmed that he entered R27's physician's order for Bacitracin ointment. E9 confirmed that he did not review the ER discharge order with the facility's on-call provider before entering it in her medical record. 7/1/25 2:50 PM - During an interview, E11 (RN/House Supervisor) confirmed that she did not review or handle R27's readmission on [DATE] as E9 (LPN) stated that he would take care of it. E11 confirmed the facility's process when readmitting a resident from the ER/hospital to call the facility's on-call provider, review the discharge orders with the provider then enter the orders in the resident's electronic health record. 7/1/25 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E7 (RN Regulatory Nurse) and E8 (Clinical Services).

Based on interview and record review, it was determined that for one (R73) out of two residents reviewed for dental, the facility failed to provide the opportunity for follow up dental services. Findings include: Review of R73's clinical record revealed: 2/11/23 - R73 was admitted to the facility with diagnoses including dementia. 10/13/24 - A review of P1's (Dental) Report of Consultation documented, . Pt [R73] refused dental exam and treatment today .Recommendation: Pt would need pre-sedation prior to further treatment or dental exam. A handwritten note was also noted on the same consultation report documenting, . check oral cavity for follow up need .resident need a follow up, nursing to make apt (appointment). 11/19/24 - R73 had a physician's order to consult dental for evaluation and treatment as indicated. 11/25/24 - R73's annual MDS assessment revealed that his cognition was moderately impaired. 6/24/25 - During a telephone interview, FM1 (Family Member) stated, Dad [R73] never had any dental consults since last year. I was not notified. Last time I saw him, his teeth looked like never been cleaned by the dentist for a year now. 6/26/25 2:00 PM - In an interview, E1 (NHA) confirmed that R73's follow up dental appointment was not done until today and that [P1] will see him later today. 6/30/25 4:10 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for three (R23, R89 and R43) residents reviewed for care plans the facility failed to develop and implement person-centered care plans, that included measurable objectives and timeframes, to meet each residents' needs. Findings include: Cross refer to F641 and F676 1. R23's clinical record revealed: 11/8/24 - R23 was admitted to the facility. 11/9/24 7:41 AM - R23's admission evaluation documented: . 8. Preferred Language: SPANISH 9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES . 11/14/24 - The admission MDS assessment, under Section A, incorrectly documented that R23's preferred language was English. From 11/8/24 through 1/7/25, R23 lacked a person-centered communication care plan as a Spanish-speaking resident. 1/8/25 - Two months after R23 was admitted to the facility, a care plan was initiated for communication problem related to language barrier with an approach that included, but was not limited to, obtaining translation services. 1/13/25 - R23 was discharged to home. 2/4/25 2:00 PM - During an interview, finding was reviewed with E1 (NHA). 2. R89's clinical record revealed: 11/7/24 - R89 was admitted to the facility. 11/8/24 - A care plan entitled, Resident to attends (sic) activities of choice until next progress note. The goal was Resident will attend group activities of choice until next review. Approaches were: escort to activity as needed; provide independent activity material as needed; provide monthly calendar; and remind resident of upcoming activities and/or event. 2/4/25 at 2:00 PM - During an interview, finding was reviewed with E1 (NHA). The facility failed to develop and implement a person-centered activity care plan for R89 that included measurable objectives and timeframes to meet R89's medical, mental and psychosocial needs. 40264 Cross refer F690 3. Review of R43's clinical records revealed: 9/19/24 - R43 was readmitted to the facility with diagnoses including but not limited to dementia, bipolar disorder and insomnia due to mental disorder. 1/31/25 - A review of R43's fall incident reports from August 2024 through December 2024 revealed that R43 fell six (6) times related to his need for assistance with toileting on the following dates: - 8/13/24 11:40 PM; - 8/14/24 12:04 AM; - 10/17/24 12:45 PM; - 10/17/24 1:00 PM; - 10/18/24 5:10 AM and; - 10/21/24 10:10 AM. 1/31/25 - A review of R43's care plan lacked evidence that person centered care plan was developed to maintain or restore bladder and bowel continence after R43's multiple falls related to his need for toileting assistance. 1/31/25 5:00 PM - During interview, E1 (NHA) confirmed that an incontinence care plan was not developed for R43 and that the clinical team will be looking into it. 2/3/25 3:52 PM - In an email correspondence, E1 sent an attached file pertaining R43's incontinence care plan initiated on 2/2/25. The facility failed to ensure R43's person centered care plan interventions and a personalized toileting program was reviewed to address R43's falls related to R43's need to use the bathroom. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on clinical record review and interview, it was determined that for one (R43) out of one sampled resident, the facility failed to ensure the physician's order to administer quetiapine fumarate (Seroquel) . Findings include: Cross refer F600 Review of R43's clinical record revealed: 7/24/24 - R43 was admitted to the facility with diagnoses including dementia. 7/25/24 - R43 was care planned for receiving antipsychotic medication (to help manage his aggressive behaviors) and is at risk for behaviors and side effects. 7/30/24 - R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered. 11/7/24 - R43 had a physician's order for quetiapine fumarate (Seroquel) 50 mg give 1 tablet by mouth two times a day for bipolar disorder. 12/3/24 1:11 PM - A nurse progress noted documented, . quetiapine fumarate . med presently N/A (not available), reordered from pharmacy . 12/4/24 10:15 AM - A nurse progress note documented, . quetiapine fumarate . med not delivered from pharmacy despite being reordered. Spoke to pharmacy and they stated that 'the claim was paid and it will be sent on our evening delivery'. will pass in rpeort . 12/4/24 1:37 PM - A nurse progress note documented, . quetiapine fumarate .awaiting delivery of med . 12/5/24 9:36 AM - A NP encounter note documented, .Of note, patient (sic) quetiapine (sic) 50 mg tablets not delivered by pharmacy and missed PM dose yesterday as well as AM and PM doses today, per nursing staff pharmacy reported to be delivered this evening. Will plan to administer additional 50 mg doses at bedtime with routine 200 mg order . 1/31/25 12:34 PM - Review of R43's December 2024 MAR revealed that R43 missed three (3) doses of quetiapine fumarate 50 mg 1 tab on 12/3/24 at 2 pm. The following day, 12/4/24, R43 missed two more doses at 8:00 AM and 2:00 PM, for a total of three missed doses. 1/31/25 2:40 PM - In an interview, E4 (LPN/UM) confirmed that R43's quetiapine fumarate 50 mg doses were not administered on 12/3/24 at 2:00 PM and on 12/4/24 at 8:00 AM and at 2:00 PM. 1/31/25 3:10 PM - During interview, E1 (NHA) confirmed that the physician was not notified right away on 12/3/24 when the quetiapine fumarate medication was not available. 1/31/25 5:00 PM - Findings were discussed with E11 (NHA). 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on observation and interview it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of operation. The presence of a certified food protection manager reduces the risk for a foodborne outbreak especially for vulnerable populations. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. 1/29/25 11:00 AM - Review of the kitchen staff work schedule provided by E23 (District Food Service Manager) revealed that only one staff person E22 (Food Service Manager) out of three (E22, E23 and E25) who possessed valid Food Protection Manager certificates from an Accredited Food Safety Program was scheduled to work from 12/1/24 through 12/28/24. E22 was scheduled to work seventeen days out of twenty-eight on the December 2024 kitchen staff schedule and eight days out of fourteen on the partial January 2025 schedule. E23 and E25 (Dietary) were not listed to work any days on the December 2024 or January 2025 kitchen staff schedule. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on interview, record review and review of other facility documents, it was determined that for two (R42 and R43) out of eight residents reviewed for abuse, the facility failed to ensure that R42 was free from resident - to - resident physical abuse by R43 and R43 was free from physical abuse by R42. Findings include: A review of the facility's abuse policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicated, . The resident abuse, neglect and exploitation prevention program .1. Protect residents from abuse . by anyone including , other residents; . Cross refer F600 Ex. 2., F684 and F690 1. A review of R43's clinical record revealed the following: 5/25/22 - R43 was initially admitted to the facility with diagnoses including dementia. 7/30/24 (revised 1/31/25) - R43's behavioral care plans included, physical aggression/abuse against others including, hitting resident on arm, throwing water on a resident and repeated episodes of aggression. R43's care plan approaches included, Administer medications as ordered, allow resident time to calm down and reapproach, approach in calm, quiet manner, offer reassurance and support, psych consult, when necessary, remove resident from situation, and redirect when aggression is observed. 7/31/24 - R43's admission MDS (Minimum Data Set) assessment revealed that R43's cognition was severely impaired with a BIM's score of 5. R43 had no mood symptoms however R43 had verbal and physical behavioral symptoms occurring 1-3 days during the review period. 9/19/24 - R43 was readmitted to the facility from a hospitalization with diagnoses including but not limited to dementia, bipolar disorder and insomnia due to mental disorder. 10/2/24 - R43's significant change MDS assessment revealed that R43's cognition was moderately impaired with a BIM's score of 9. R43 had no mood or behavioral symptoms exhibited during the review period. 10/15/24 - R43 was care planned for new disruptive behavior related to throwing objects at other residents and interventions included ensuring the safety of R43 and others and establishing boundaries and limits with R43. 11/4/24 - A psych note documented, . returned from psych hospitalization . on 9/19, [R43] was admitted for 13 days due to agitation and disorganization . 11/4/24 9:41 PM - A nurse's progress note documented, [R43] picked up a cup of water and threw it on another resident (unidentified). [R43] redirect with 1:1 . 11/5/24 12:22 AM - A facility incident report submitted to the State Agency documented that on 11/5/24 at 11:50 PM, .[R42] was at the nursing station when another resident [R43] threw a plastic cup of water at his head . 11/5/24 - R43's behavior care plan intervention was updated to include offering R43 with activities that will entertain . enjoys watching TV. 11/9/24 4:33 PM - A facility incident report submitted to the State Agency documented that on 11/9/24 at 3:34 PM, .[R43] was sitting in (sic) a chair in front of the Nurse's Station while watching TV . raised his arm and hand while holding a cup of water and threw the water on [R42] . R42 was seated next to R43 (left side). 11/9/24 (revised 11/13/24) - R43's behavior care plan intervention was updated to include close observation. 11/17/24 5:05 PM - A facility incident report submitted to the State Agency documented that on 11/17/24 at 3:45 PM, .[R42] was just sitting down at the nurses station watching TV, when the other resident approach (sic) him and threw a cup of water on him. 11/18/24 - R43's behavior care plan intervention was updated to include monitor [R43] when giving beverages to attempt to avoid aggressive behavior with throwing beverage at other residents. 12/13/24 - An untimed facility incident witness statement by E21 (former DON) documented, .[R43] was seen to have a toilet seat cover from a commode at the nursing station. [R43] was seen putting the toilet seat cover behind his back in his wheelchair and began to wheel himself to his room (which is next to the nursing station). [R42] was walking around the nursing station and passed [R43]. [R43] was seen speaking to [R42] however unknown what was said. [R43] then took the toilet cover from behind him and hit [R42] in the left shoulder . 12/13/24 - R43 was care planned for aggression from another resident related to being hit with a commode toilet seat and resident hitting another resident with commode. R43's intreventions included safety measures - including strategies to reduce the risk of infection, falls, injury initiated as appropriate. 1/31/25 - R43's behavior care plan intervention was updated to include [R43] to go to (psych hospital) when needed as ordered. The facility failed to ensure that (R42) was free from physical abuse by R43 when on multiple occasions on 11/5/24, 11/9/24 and 11/17/24 R43 threw water on R42. In addition, on 12/13/24, R43 hit R42 with a toilet cover on R42's left shoulder. 1/31/25 5:00 PM - Finding was discussed with E1 (NHA). Cross refer F600 Ex. 1 2. A review of R42's clinical record revealed the following: 3/15/18 - R42 was admitted to the facility with diagnoses including but not limited to depression, anxiety disorder and dementia. 3/16/18 - R42 was care planned for impaired cognition and interventions including but not limited to, . Needs supervision/assistance with all decision making. 9/18/24 - R42's quarterly MDS (Minimum Data Set) assessment revealed that R42's cognition was severely impaired with a BIM's score of 3 and no mood or behavioral symptoms during the review period. 11/13/24 (revised 12/23/24) - R42 was care planned for physical behaviors as evidenced by slapping a resident in the face .physical aggression . getting a cup of water thrown on him by another resident and being hit by another resident and then hitting back in the head. R42's interventions included: analyze times, places, circumstances, triggers and what de-escalates behavior and document and R42 to be moved to another unit to ensure [R42's] safety. 11/18/24 - R42 was care planned for alteration in comfort related to receiving aggressive behavior from another resident. Interventions included but not limited to ensuring that R42 feels safe and removing R42 from situation (12/30/24). 12/13/24 8:55 AM - A facility incident report submitted to the State Agency documented that on 12/13/24 at 12:30 AM, . [R42] was observed suddenly hitting another resident [R43] over the head with a bedside commode toilet seat without provocation . 12/13/24 - An untimed facility incident witness statement by E21 (former DON) documented, . [R42] then took the toilet cover (from R43) and hit [R43] in the head . 12/13/24 - R42 was care planned to refrain from initiating aggressive behavior with interventions including: - remove and or distract [R42] if possible if his demeanor changes and is showing signs of aggression or anger; - [R42] encouraged to refrain from initiating aggressive behavior from others - Safety measures . imitated as appropriate and; - Speak calmly to resident. The facility failed to ensure that R43 was free from physical abuse by R42 when on 12/13/24 R42 hit R43 with a toilet cover in the head. 1/31/25 5:00 PM - Finding was discussed with E1 (NHA). 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on record review and interview, it was determined that for three (R23, R53 and R89) out of three residents reviewed for communication the facility failed to ensure eash residents' MDS assessments accurately reflected their status. Findings include: 1. Cross refer to F656 and F676 R23's clinical record revealed: 11/8/24 - R23 was admitted to the facility. 11/9/24 7:41 AM - R23's admission evaluation documented: . 8. Preferred Language: SPANISH 9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES . 11/14/24 - The admission MDS assessment, under Section A, documented that R23's preferred language was English. 2/4/25 at 1:30 PM - During an interview, E14 (RNAC) reviewed the 11/14/24 admission MDS and confirmed the MDS should have indicated Spanish as the preferred language. 2. R53's clinical record revealed: 11/16/24 - R53 had an active physician's order for depakote an anticonvulsant medication every 12 hours. 11/25/24 - An acute progress note by E24 (NP) documented to continue with depakote. 11/28/24 - The quarterly MDS assessment, under Section N, lacked evidence that R53 was taking depakote during the last 7 days. 2/4/25 at 1:30 PM - During an interview, E14 (RNAC) reviewed the 11/28/24 quarterly MDS and confirmed the inaccuracy. 3. R89's clinical record revealed: 11/7/24 - R89 was admitted to the facility with diagnosis of a stroke. 11/9/24 - R89's Physical Therapy evaluation documented that right and left lower extremities range of motion were impaired. 11/13/24 - The admission MDS assessment documented R89's no functional limitation in range of motion for lower extremities. 2/4/25 at 1:30 PM - During an interview, E14 (RNAC) confirmed the MDS inaccuracy. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on record review and interview, it was determined that for one (R69) out one resident reviewed for mood/behavior, the facility failed to coordinate with the PASRR program under Medicaid and refer the resident for an assessment. Findings include: 1. R69's clinical record revealed: 12/17/24 - A PASRR Level 1 Screen was completed by the hospital and documented that R69 had no mental health diagnosis known or suspected and no current mental health medications prescribed. 12/27/24 - R69 was admitted to the facility. 1/13/25 - A psychiatric evaluation documented, . past psychiatric history of depression and anxiety . review of psychotropic med (medication) regimen and management of mood/behaviors . Does endorse feelings of anxiousness intermittently . Available records prior to facility admit reviewed and appreciated. Reportedly w/ (with) lengthy psych history and diagnosis of anxiety as well as depression . noted h/o (history of) paranoia. Resident was previously treated in the past with Olanzapine [antipsychotic] . 1/13/25 - A physician's order prescribed mirtazapine medication daily for R69's depression. 1/14/25 - A physician's order prescribed xanax medication two times a day and as needed for R69's anxiety. 1/15/25 - R69 was care planned for anxiety and depression with approaches that included, but were not limited to, administering medications as ordered. 1/29/25 - A psychiatric note documented, . seen today at request of facility staff due to worsening anxiety . Recommendations: 1. Continue mirtazapine . for depression . benefits greater than risks at this time. 2. Continue xanax . for anxiety . 5. Plan to contact out patient psych provider . for additional history/verification, may need to consider resume olanzapine/alternative AP [antipsychotic] as there is evidence of potential underlying psychotic process . 1/31/25 at 1:45 PM - During an interview, E9 (SSD) was asked if he submitted a referral to the PASARR office to have a Level 1 screen completed for R69. E9 replied no. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on record review and interview, it was determined that for one (R23) out of three residents reviewed for communication, the facility failed to provide Spanish-speaking translation/interpretation services during nursing care for R23. Findings include: The facility's policy and procedure entitled Translation and/or Interpretation of Facility Services, revised November 2020, stated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility . 6. Competent oral translation of vital information that is not available in written translation . shall be provided in a timely manner . 10. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual . Cross refer to F641 and F656 11/8/24 - R23 was admitted to the facility. 11/9/24 at 7:41 AM - R23's admission evaluation documented: . 8. Preferred Language: SPANISH 9. Do you need or want an interpreter to communicate with a doctor or health care staff? YES . 12/22/24 at 2:38 PM - A nurses note documented, Reported to me that resident is on the floor. Resident lying on the floor on her left side, able to move all extremities . Resident unable to state what happened due to language issues . 12/23/24 at 9:43 AM - A nurses note documented, At 0300 (3 AM) resident CNA came to the nurses station stating resident was lying on the floor in her room. Supervisor and nurse immediately rushed to room . Resident was observed lying on the floor on her stomach next to the bed. Resident could not explain where and what she was doing. Resident only speaks Spanish . The facility lacked evidence that nursing staff were utilizing translation services, including during the 12/22/24 and 12/23/24 post-fall assessments. 2/4/25 at 2:00 PM - During an interview, E1 (NHA) was asked for evidence of nursing staff utilizing translation services for R23. E1 provided a list of eight transactions for translation service payments with dates and times from the corporation. Neither date of 12/22/24 or 12/23/24 were listed on this document nor was there documentation in R23's clinical record that translation services were provided. 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on record review, observation and interview, it was determined that for one (R43) out of three residents reviewed for bowel and bladder, the facility failed to evaluate R43's decline in urinary continence and failed to maintain or restore continence after R43's multiple falls related to his need for toileting assistance. Findings include: Cross refer F600 and F684 A review of R43's clinical records revealed the following: 7/24/24 - R43 was admitted to the facility with diagnoses including but not limited to dementia. 7/25/24 - R43 was care planned for ADL (Activities of Daily Living) deficit related cognition with interventions including assisting R43 to attend activities of choice. In addition, R43 was set up for care and supervise/verbal dues (sic) to assure he follow thru. 7/25/24 - R43 was care planned for falls related to .poor safety awareness .with interventions including offering toileting before going to bed (8/14/24) and reminding R43 not to go to the bathroom without help (10/25/24). 7/31/24 - R43's admission MDS assessment revealed that R43's cognition was severely impaired and was always continent of urine and bowel during the review period. 9/6/24 (revised 1/22/25) - R43 was care planned for behaviors as evidenced by urinating on the floor and also defecating on the AC (air condition) unit. R43's interventions included encouraging R43 to call for assistance when he is ready to use the bathroom and providing R43 with a urinal. 9/19/24 - R43 was readmitted from the psych hospital from 9/6/24 through 9/19/24 9/19/24 - A facility Bladder and Bowel Continence Evaluation - Readmission Assessment documented: Is resident completely continent? - No Functional Mobility, Manual Dexterity, Toileting Ability - Extensive Assist Bowel Continence - Occasional Bladder Continence - Occasional Resident toileting preference - Brief List any further important details - none 9/25/24 - a facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented: How long has the resident been incontinent - don't know Has a trial of a toileting program attempted? No Current toileting program or trial - No Bowel - continent of stool - no Is a toileting program currently being used .? - No Program initiation: urinary TP - No .bowel TP - No Do not initiate program, why? - (no answer) 10/2/24 - R43's significant change MDS assessment revealed that R43's cognition was moderately impaired and was frequently incontinent of urine and bowel. R43 was not on a toileting program during the review period. 10/3/24 - A facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented: How long has the resident been incontinent - don't know Has a trial of a toileting program attempted? Unable to determine Current toileting program or trial - No Bowel - continent of stool - no Is a toileting program currently being used .? - No Program initiation: urinary TP - No .bowel TP - No Do not initiate program, why? - (no answer) 11/14/24 - R43 was care planned for risk for skin break down as evidenced by incontinence and limited mobility with interventions including incontinent care after each incontinent episode. 1/2/25 - R43's quarterly MDS assessment revealed that R43's cognition was moderately impaired and was always continent of urine and occasionally incontinent of bowel during the review period. 1/3/24 - A facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented: How long has the resident been incontinent - N/A - continent Has a trial of a toileting program attempted? No Current toileting program or trial - No Bowel - continent of stool - yes Is a toileting program currently being used .? - No Program initiation: urinary TP (Toileting Program) - No .bowel TP - No Do not initiate program, why? - continent of bladder and bowel 1/31/25 - A review of R43's fall incident reports from August 2024 through December 2024 revealed the following: - 8/13/24 11:40 PM - Resident was found sitting on the floor at the bathroom door with his feet facing his bed . - 8/14/24 12:04 AM - Resident fell out of wheelchair onto his left side .Stated he was trying to take himself to the bathroom .had recent fall related to toileting himself . - 10/17/24 12:45 PM - Resident was transferring self from bed to go to the bathroom without asking for assistance, he fell before reaching to the bathroom, he reported hitting his head .was going to the bathroom fell and hit his head. - 10/17/24 1:00 PM - Resident was found on the floor next to the bathroom in his room. Resident stated he was trying to use the bathroom and he fell . stated that he hit his head and he was nauseous .sent resident to hospital for further evaluation . Resident is being offered a commode and a medical review is underway due to resident frequent falls .Where Changes made to the care plan? Yes offer commode. Resident to be toileted via commode. - 10/18/24 5:10 AM - Resident sitting on buttocks at the foot of the bed. I was trying to use the bathroom . - 10/21/24 10:10 AM - Resident lying on the floor by the bathroom door trying to go to the bathroom. 1/30/25 9:31 AM - During an obsevation, R43 was observed sitting on the bench in front of the nurse station while watching TV. E3 (ADON) and E4 (LPN/UM) were observed talking in the nurses station. 1/31/25 9:33 AM - In a follow up observation, R43 stood up with unsteady gait, transferred self on the wheelchair and propelled his way to his room. R43 parked his wheelchair outside the bathroom, stood up, entered the bathroom unassisted and unsupervised. The sound of the toilet flushed was heard. R43 came out the bathroom and with unsteady gait turned to sit on the wheelchair. R43 was seen self propelling back to the nurses station. 1/31/24 9:35 AM - During interview, E6 (LPN) stated that R43 is continent of bowel and bladder and is able to go to the toilet but will still require staff supervision. E6 added that R43 was a high fall risk and has impulsive and aggressive behaviors that could be harmful to himself, to the other residents or to the staff. We have to be careful when we are around him cause he gets agitated so easily and he is not compliant with asking for assistance when using the bathroom. The facility failed to evaluate R43's toileting decline and initiate a personalized toileting program to address his falls while attempting to use the toilet. 1/31/25 5:00 PM - Findings were discussed with E1 (NHA). 2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).

Based on interview, and record review, it was determined that for one (R2) out of three residents reviewed for accidents, the facility failed to provide a safe environment by having two staff members present to assist with turning when R2 received a shower on 10/25/24. R2 sustained harm due to the traumatic removal of the nephrostomy tube during care and needed to be transported to the hospital for emergency treatment. On 10/26/24, R2 was again sent to the emergency room for evaluation of the injuries to his face, torso and lower extremeties. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, this deficiency was determined to be past non-compliance as of 10/29/24. Findings include: R2's clinical records revealed: 2/26/16 - R2 was admitted to the facility with diagnoses including traumatic brain injury, tracheostomy, enteral tube feeding and neuromuscular dysfunction of the bladder (which required the use of a nephrostomy tube for the drainage of urine from the bladder.) 2/29/16 - R2's care plan documented, . [R2] is totally dependent on staff to provide shower .totally dependent on staff for repositioning and turning 10/27/17 - R2's care plan documented, .2 person assist [assistance] with turning and repositioning . 4/16/19 - R2's clinical records documented, 2 person assist [assistance] with bed mobility and transfers. 6/10/24 - R2's Treatment Administration Records (TAR) documented, Nephrostomy Care every shift and PRN (as needed). 8/19/24 - R2's quarterly MDS documented, Dependent, on staff for all activities of daily living. 10/1/24 - R2's Activities of Daily Living (ADLs) documented, Bath/Shower x (times) 2 person assist. 10/25/24 9:32 AM - A clinical progress (E2 DON) documented, IDT (Interdisciplinary Team) note LATE ENTRY s/p [status post] potential fall in shower, that resident is to be a 2 person [assistance] during shower care. 10/25/24 10:50 AM - R2's clinical records documented, Resident was assessed to have a dislodged Nephrostomy tube r/t repositioning during shower 10/25/24 11:48 AM - A clinical progress note (NP) documented, .Resident was receiving a shower when his nephrostomy tube got displaced, nursing staff also report that while turning patient inquired [acquired] multiple scratches to his feeding base [tube feeding site], mild abrasion. Will be sent out to the ER for replacement of tube. The facility failed to identify that R2's plan of care for two person assistance during his shower was implemented. 10/26/24 3:14 PM - R2's clinical records documented, . Family present with concerns of abrasions noted to residents left temple, forehead, above left eyebrow, and toes to b/l [bilateral] feet . mother and father expressed concerns of the number of staff present during shower, and appearance of shower bed . 10/26/24 6:38 PM - R2's clinical records documented, CNA today at around 1745 [5:45 PM] reported to the supervisor, that in the afternoon hours, she was told by the CNA who was taking care of resident yesterday, that resident fell in the shower room. resident noted with bruises and scratches on the left side of the face, right toes and right shoulders. immediately after receiving this information, On call for MD/POA made aware, new order to send resident to ER for evaluation. resident left facility via 911 ambulance to [NAME] hospital at 1815 [6:15 PM] pm . The facility's failure to ensure that R2's plan of care for two person assistance during the shower was implemented caused him to to go the emergency room twice, on 10/25/24 and 10/26/24. 10/26/24 7:05 PM - A facility reported incident submitted to the Division documented, A fall was reported that on 10/25 resident [R2] fell in the shower room and an aide picked him up without telling anyone. The facility's root cause analysis of the incident determined that the aide attempted to turn the resident to put a brief on him in the shower bed with the rails in the down position and R2 almost slid off. He hit the tiled wall of the shower and sustained the various injuries. 10/27/24 1:20 PM - R2's clinical records documented, . Nickel sizes bruise, yellow in color noted to left temporal [temple] area, abrasion to eyebrow 1.9 cm by 1 cm, abrasion to left cheekbone 2.7 cm by 3 cm, abrasion to right cheek 0.8 cm by 0.4 cm, abrasion to right knee 3.0 x 0.7 cm, abrasions to left second, third, fourth and fifth toes, nails to second and third toes [nails] broken, toes to right foot noted with then abrasions . 12/31/24 11:30 AM - During an interview E5 (CNA) stated, I helped [E7] put the resident [R2] on the shower bed. We used the Hoyer lift, and he [E7] took him to the shower room. I did not go into the shower room with him. 12/31/24 12:00 PM - During a telephone interview E6 (CNA) stated, E7 (CNA) asked me to bring some towels to the shower room. I brought the towels and took the dirty ones out. The Surveyor asked E6 if she helped E7 during R2's shower. E6 stated, No, I had my own residents to take care of. 12/31/24 12:30 PM - During an interview E3 (LPN) stated, I was called to see the resident (R2) in the shower room because his toes and face were bleeding. I noticed that the nephrostomy tube looked longer than it usually looked. I told the aide to put him back to bed so I can look at it again. I then saw that the tube was laying on the bed, and I knew that he needed to go to the hospital to have another one put in. The Surveyor asked E3 if R2 was wearing a brief when he was assessed in the shower room. E3 stated, I don't think he was wearing a brief because I would have had to pull it down to see the nephrostomy tube site on his back. The facility failure to provide 2 persons assistance for R2, a completely dependent resident during the shower caused the nephrostomy tube to become dislodged. This required R2 to be sent to the hospital for a new nephrostomy tube placement. 12/31/24 2:30 PM - An interview with E1 (NHA) revealed that E7 was suspended pending the investigation and will be terminated upon return. The facility completed audits of all residents and verified their transfer statuses. The facility also had in-servicing training with signatures for the trainings that began on 10/26/24 and completed on 10/29/24. The facility's in-service training documentation included: Transfer mobility Kardex, shower gurney and siderails. Based on the review of the facility's investigation, documented response, documented completion of in-service training and audits, staff interviews and no further incidents related to injuries or accidents of residents who received showers with the required number of staff members, R2's accident was determined to be past non-compliance harm. The plan of correction was initiated on 10/26/24 and completed on 10/29/24. 12/31/24 3:17 PM - Findings were reviewed at the Exit conference with E1 (NHA), E7 (Corporate Director of Rehab) and E8 (RN Risk Manager).

Based on record review and interview, it was determined that for one (R5) out of three residents reviewed for pharmacy services, the facility failed to obtain and administer three ordered medications (lacosamide, clonazepam, perampanel) to R5 from 12/27/24 to 12/29/24, which resulted in multiple missed doses of each medication. Findings include: Cross refer F710 R5's clinical record revealed: 12/27/24/ 11:14 AM - C1 (hospital physician assistant) documented in R5's interagency discharge orders, . Discharge Diagnoses: fracture of right radius (arm) . seizure . Medication Orders Upon Discharge: . lacosamide 200 mg - 1 tablet by mouth two times a day . perampanel (Fycomba) 6 mg - give 1 tablet by mouth at bedtime for seizure prevention . clonazepam 1 mg - take 1 tablet by mouth every 12 hours . 12/27/24 Friday - R5 was admitted to the facility with diagnoses, including but were not limited to, seizures and anxiety disorder. 12/27/24 - E10 (MD/ Medical Director) ordered in R5's EMR (electronic medical record), . clonazepam 1 mg- give 1 tablet by mouth every 12 hours for anxiety . Fycomba (perampanel) 6 mg - give 1 tablet by mouth at bedtime for seizure prevention . lacosamide 200 mg - give 1 tablet by mouth two times a day for seizures . 12/27/24 6:36 PM - E9 (agency RN) documented in R5's EMR, . Reason for admission- per resident/caregiver: Fracture to wrist, S/P (status post) fall at home . Review of R5's December 2024 Medication Administration Record (MAR) revealed the following medications were not administered to R5: - on Friday, 12/27/24, one dose of Fycomba, Clonazepam and Lacosamide; - on Saturday, 12/28/24, one dose of Fycomba, two doses of Clonazepam and two doses of Lacosamide; and - on Sunday, 12/29/24, one dose of Fycomba, two doses of Clonazepam and two doses of Lacosamide. Instead, E11 (LPN) and E12 (LPN) were documenting 9 or 3, which according to the MAR legend 9 means other/see nurses notes and 3 means out of the facility. 12/27/2024 11:03 PM - E13 (RN) documented in R5's EMR health status note, . but no C2 (control prescription form) forms were sent to pharmacy except for the oxycodone prescription. The pharmacy reported that they had not received prescriptions for the resident's seizure control medication. The on-call provider from [medical practice] was updated on the situation, and a review of the medications was conducted. The writer [E13] provided the pharmacy's phone number and fax number to the provider so that the missing prescriptions could be sent to the pharmacy. The facility's failure to obtain and send the necessary C2 forms to the pharmacy to ensure delivery of these three medications during the weekend resulted in R5 missing three doses of Fycomba (anti-seizure medication), five doses of clonazepam (anti-anxiety medication) and five doses of lacosamide (anti-seizure medication). 12/29/2024 6:24 PM - E12 (LPN) documented in R5's EMR health status note, [name] NP (nurse practitioner) was called again regarding the following meds that need scripts, clonazepam, lacosamide, midazolam and Mycomba (sic). She stated that she called the pharm (pharmacy) and they sent the C2 form to complete and refax. She's unable to do that so she recommended the forms will be filled out in A.M. Resident made aware. Review of R5's C2 forms for Fycomba, Clonazepam and Lacosamide revealed the forms were completed and sent to the pharmacy on Monday, 12/30/24, on the fourth day after admission. The facility lacked evidence that the required C2 forms were completed upon R5's admission on 12/27/24. C2 forms are required to be completed and sent to the pharmacy with the prescriber's signature and DEA (Drug Enforcement Administration) number before medications can be delivered to the facility. 12/31/24 2:10 PM - During a telephone interview, C2 (pharmacy tech at [pharmacy]) confirmed that [pharmacy] received the C2 form via fax for clonazepam on 12/30/24 and lacosamide on 12/31/24. At the time of the call, the pharmacy did not have documentation of receiving the C2 form for Fycomba. 12/31/24 2:35 PM - During an interview, E1 (NHA) confirmed that the code 9 on the MAR legend stood for other/see nurse notes and that R5 had not received the medication. 12/31/24 3:17 PM - Findings were reviewed at the exit conference with E1 (NHA), E7 (Corporate Director of Rehab) and E8 (RN Risk Manager).

Based on interview, record review and review of other facility documentation it was determined that for one (R37) out of twelve residents reviewed for abuse, the facility failed to prevent abuse. For R37 sexual abuse by a staff CNA (Certified Nursing Assistant). An immediate jeopardy (IJ) was identified starting on 6/5/23. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 6/10/23. R37 had sustained psychosocial harm as R37 was still affected by the abuse. Findings include: A facility policy and procedure titled Identifying Types of Abuse documented . 1. As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents . 2. Abuse of any kind against residents is strictly prohibited . 3. Abuse towards a resident can occur as staff to resident abuse . 4. Sexual abuse is non-consensual conduct of any type with a resident . 5. Abuse may result in psychological, behavioral, or psychosocial outcomes. 1. Review of R37's clinical record revealed: 3/8/22 - R37 was admitted to the facility with a diagnosis of stroke, left side weakness, and difficulty in walking. 3/23/23 - R37's annual MDS assessment documented R37 required extensive physical assistance of two staff persons for bed mobility, transfers, dressing, toileting, and personal hygiene. Additionally, R37 required limited physical assistance of one staff person for locomotion on the unit. 6/19/23 - Review of R37's quarterly MDS assessment revealed R37's cognition was intact. The facility investigation documented the following timeline for R37's allegation of sexual abuse on 6/5/23. 6/4/23 10:57 PM - E21 (CNA) clocked in for the 11:00 PM - 7:00 AM shift for work. 6/5/23 8:00 AM - E21's shift ended. 6/5/23 10:30 AM - R37 reported to E1 (NHA) and E18 (SW) that E21 (CNA) had sexually abused R37 multiple times since a week or two before Mother's Day. In addition, R37 stated, [R37] was emotionally distraught (distressed) and wanted counselling. 6/5/23 11:00 AM - E19 (HR) called E21, during the verbal interview E21 had been suspended pending the facility investigation related to R37's allegation that E21 had sexually abused R37. 6/5/23 10:51 AM - The facility submitted a report to the State of Delaware for a staff to resident allegation of sexual abuse. 6/5/23 1:00 PM - The facility initiated mandatory educations related to abuse, and the importance of staff to resident appropriate conversations and staff to resident relationships. 6/5/23 1:22 PM - E3 (PA) examined and interviewed R37. 6/5/23 1:50 PM - R37's family had been notified by the facility of the allegation of sexual abuse. 6/5/23 2:54 PM - R37 was transported to the hospital for further evaluation and treatment. 6/5/23 4:08 PM - The facility notified the police department. 6/5/23 4:12 PM - R37 had a sexual assault examination performed at the hospital. 6/5/23 4:15 PM - All current residents interviewed to identify concerns related any type of inappropriate sexual behavior from staff. 6/5/23 11:15 PM - R37 was transported back to the facility from the hospital. 6/6/23 1:15 AM - Police officers were dispatched to the facility to interview R37. 6/7/23 - A care plan initiated for R37 titled Bedside Care documented . 1. Two female staff to always provide care. 12/11/23 11:41 AM - During an interview R37 stated, E21 had sexual intercourse with [R37] on the weekends when E21 was scheduled to work. In addition, R37 revealed E21 attempted to have R37 perform oral sex on E21. Further into the interview R37 had become emotionally upset and tearful. R37 revealed that the sexual contact with E21 occurred multiple times. 12/11/23 12:32 PM - An interview with E1 revealed being notified of R37's allegation of sexual contact with E21. In addition, E1 revealed R37 reported being in a sexual relationship with E21. 12/12/23 10:42 AM - During a phone interview E21 confirmed, E21 had sexual contact with R37. Additionally, E21 revealed, the sexual contact happened more than one time. 12/13/23 10:06 AM - 10:17 AM - Staff interviews with E13 (Receptionist), E11 (CNA) and E20 (LPN) confirmed staff educations had been provided on different types of abuse, staff to resident appropriate conversations and staff to resident relationships/boundaries. In addition, staff interviewed verbalized indicators of sexual abuse, and the steps of reporting the allegation. Review of the facility's action plan and audits to identify concerns related to inappropriate sexual behaviors from staff continued for four weeks and monthly for three months and until no issues had been identified. Additionally, audit results were reviewed at weekly QAPI meetings. It has been determined that the facility abated the IJ on 6/10/23. Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON) pn 12/15/23 at 3:00 PM.

Based on record review and interview, it was determined that for one (R46) out of two residents reviewed for hospitalization s, the facility failed to follow the resident's physician's order for monitoring R46's lithium level. This caused a mental status change with a resultant hospital admission with a high serum lithium level of 2.43 resulting in harm to R46. Findings include: 5/25/22 - R46 admitted to the facility with diagnoses including but not limited to stroke with left-sided weakness, post-traumatic stress disorder (PTSD) and bipolar disorder. 7/11/23 - E2 (DON) entered a verbal order from E17 (MD) for lithium 300 mg by mouth every 12 hours for bipolar disorder with a serum lithium level to be drawn on 7/17/23. E17 also ordered lab (laboratory) work (CBC -complete blood count and CMP- complete metabolic profile) on 7/12/23 and 7/17/23. 7/12/23 10:48 AM - R46's lab work included a serum lithium level of < 0.3 along with the results of his CBC and CMP. The facility was unable to provide evidence/results of lab work including a serum lithium level that was drawn on 7/17/23. 7/17/23 - E17's (MD) progress note documented, . HPI (history of present illness) . I started pt (patient) on lithium and olanzapine due to aggression and behaviorial disturbances .Plan: 1.Bipolar 1 disorder - .check lithium, BMP (basic metabolic panel) in 3 months (October) . There was no mention in the note of a current lithium level. R46 was seen and evaluated by E3 (PA) on 7/19/23, 7/20/23 and 7/21/23. These notes documented, Patient was started on lithium and olanzapine recently and Patient had recent medication change for bipolar and now is on lithium. However, there was no mention in any of the three notes of R46's current serum lithium level. 7/24/23 10:44 AM - E17's progress note documented, .Pt aggressive behavior is controlled on current regimen of lithium and olanzapine. Last Lithium level is unremarkable .Plan: 1. Bipolar 1 disorder - . check lithium, BMP in 3 months (October) . The note did not document the date or result of R46's last lithium level. Despite R46 being evaluated by two different providers on five different dates between 7/17/23 and 7/24/23, neither provider inquired or documented about R46's ordered 7/17/23 serum lithium level that had not been obtained nor was a dated serum lithium level result included in any of the five notes. 7/24/23 - R46's Monthly Medication Review (MRR) documented the resident's record was reviewed but did not require any recommendations. 7/26/23 - R46 was admitted to the hospital for change in mental status and found to have a supra-therapeutic (a level higher than what is considered optimal for the desired therapeutic effect) lithium level of 2.43. The laboratory normal serum (blood) lithium level was 0.6 to 1.2 mmol (millimoles) /L (liter). Documentation from the Emergency department, given the significantly elevated lithium level, [R46] will be given lactated Ringer's (intravenous fuids) bolus and patient will require hospitalization for further observation especially of his mental status and vital signs. 7/26/23 3:00 PM - In R46's Emergency Medicine notes from the hospital, C4 (emergency room DO) documented, . Notified by the lab the patient (R46) with critically elevated lithium level at 2.43. Per our (hospital) lab standards, upper limit of normal is 1.2 mEq (milliequivalent)/ L (liter). Confirmed with staff at [facility] that the patient began to (sic) the medication 15 days ago .There is no reported interval history of volume losses from vomiting or diarrhea. Given the significantly elevated lithium level, will be given lactated Ringer's bolus and patient will require hospitalization for further observation especially of his mental status and vital signs . 7/26/23 7:18 PM - In R46's hospital History & Physical (H&P), C5 (Internal Medicine MD) documented, . Treatment Plan and Disposition: Altered mental status- likely secondary to supra-therapeutic dosage of lithium. As per papers from [facility], patient placed on lithium 2 weeks ago for his bipolar order (sic) with a dosage of 300 mg every 12 hours . 8/2/23 - Per psychiatry recommendation, his lithium was resumed on 8/2/23 at a lower dosage (150 mg twice daily) once his lithium level was within normal range. 8/3/23 -R46 was discharged back to the facility. R46 was hospitalized for eight days to monitor of his lithium level. 12/12/23 1:31 PM - During an interview, E2 stated that when a doctor gives a verbal order, the nurse confirms the order in Point Click Care (PCC) and then for lab work, the nurse enters the order in the [laboratory] website. When the doctor types the order in PCC, the order is listed as pending until the nurse confirms the order. E2 then furnished copies of the lab requisitions for the 7/12/23 and 7/17/23 lab draws from the [laboratory] website. When asked why the labs from 7/17/23 were not drawn, E2 replied, .well, you know you are dealing with someone who refuses care a lot. When asked what should happen if a resident refuses, E2 stated, . The labs would be rescheduled. When asked if there should be a note documenting the refusal, E2 replied,yes. The facility was not able to furnish any evidence that the provider was notified that R46 did not have his lab work (lithium level) drawn on 7/17/23. 12/12/23 1:18 PM - During a telephone interview, C1 ([laboratory] account manager) stated, I can see the requisition and there was a req for lab work on 7/17/23. I cannot see that the req was put in the binder. There is no way for me to tell if the req was printed and placed in the binder under the correct date. Our techs are told to come to the building and take the reqs (requisitions) in the binder for that day and draw those labs. I looked in both in the computer and the phone app to see if there is any documentation of refusal, I am not seeing any. Labs were drawn on 712/23 at 11:12 AM. On the 7/17/23 lab order, it says COMPLETE in our system. C1 stated that he thinks the ordered labs for 7/17/23 were completed on 7/12/23. C1 asked, Is there a chance that that all 3 reqs were placed in the binder under 7/12? Yes, but I cannot say that definitely. All I can concretely say is that labs were drawn on 7/12 and no labs were drawn on 7/17. 12/12/23 1:44 PM - During a follow up interview, E2 confirmed that there should be a note documenting R46's refusal (if he refused to have labs drawn) and that the provider was notified. E2 also stated, Normally, they (the lab) put in their app (application) that the resident refused but that is not listed in his record for that day. 12/12/23 3:15 PM - E2 provided a copy of the [laboratory] log which documented that the 7/17/23 labs were ordered and documented as complete without being drawn. So the error was on the lab personnel. 12/13/23 10:42 AM - During an interview, C2 (Phlebotomist) who was in R46's room drawing labs, If a resident refuses lab draws, we document it in out app (Lab Gen) and the nurse has to sign her name on the app. C2 stated that the surveyor could get a copy of that day's reporting from the [laboratory] office. 12/13/23 12:33 PM - During an interview, E3 (Physician Assistant) stated, We (the providers) order standing set labs (for drug monitoring) once a resident is stable on the medication. I like three lab levels that are in normal range to say they are stable on the medication. For a patient that we just started on a med, we order the lab level and then respond to that level . if the level is low, we increase the medicine and get a new level in 6 to 8 weeks. 12/14/23 11:44 AM - During a telephone interview, C3 (PharmD) confirmed that she did perform R46's MRR on 7/24/23. When questioned about medications that require serum level monitoring, C3 stated, Yes, I usually try to recommend interval monitoring (lab levels) on drugs that require monitoring. I would write it on my monthly recommendation. 12/14/23 12:27 PM- During a telephone interview, E17 (MD) confirmed that he ordered the lithium 300 mg PO every 12 hours with lab levels on 7/12 and 7/17. E17 stated that the only way he tracks lab results is from seeing them posted in PCC. The facility has a way to communicate with the lab that we do not have access to. With regard to monitoring, E17 stated, we try to order levels when we initiate the drugs but a lot can change in this population- they refuse the med, get sick have kidney failure so we order the levels at times that we feel are appropriate. We try to get levels once or twice a year. The pharmacist is good about reminding us in their monthly recommendations. 12/15/23 3 PM - Findings were reviewed with E1 (NHA), E2 (DON), E23 (Corporate risk manager) and E24 (Corporate Director of Clinical Reimbursement) at the exit conference.

Based on record review and interview, it was determined that for one (R51) out of nineteen residents reviewed in the investigative sample it was determined that the facility failed to ensure that R51's care was free of significant medication errors. The facility failed to obtain and administer numerous doses of the drug, Erivedge, which was ordered to prevent further growth of cancer. R51's disease progressed while off the medication per the oncologist resulting in harm. In addition, the facility failed to order the correct route of Erivedge administration. Findings include: 9/24/21- R51 was admitted to the facility with diagnoses that included left basal cell carcinoma (cancer) of the left eye. 10/15/21- A Physician's order for Erivedge capsule 150 mg Give 1 capsule via PEG-tube one time a day related to basal cell carcinoma of skin of left upper eyelid for 90 days. The order incorrectly documented that the medication should be given by the PEG tube when it was to be administered by mouth. 10/15/21 11:11 AM- E6's (LPN) note documented .Also resident's family member dropped off resident's oral medication for basal cell cancer and resident will take medication as ordered times 90 days. Physician aware. The Specialty Pharmacy patient education included with the medication documented, Swallow whole. Do NOT chew, open ot crush. 10/15/21- 1/12/22- Review of R51's MARs (Medication Administration Records) revealed the Erivedge order continued to incorrectly document the administration via PEG tube. 1/13/22 to 1/31/22- The MAR had X documented in signoff boxes for the Erivedge daily order. The MAR legend had no explanation of what X stands for. 2/1/22 to 3/5/22 (33 days)- There was no evidence in the medical records, including the MARs, that Erivedge was administered to R51. 3/4/22- C1's (Oncologist) Consult note documented, was treated with oral chemo (Vismodegib) but not sure if he is taking it now (not on med list) .Exam shows significant progression of disease .RECOMMENDATIONS: resume Vismodegib [Erivedge] 150 mg PO daily. 3/4/22- A Physician's order for Erivedge capsule 150 mg Give 150 mg by mouth one time a day for basal cell carcinoma for 90 days. 3/5/22 to 6/2/22- The MAR documented Erivedge 150 mg by mouth was being administered daily. 5/11/22- C3's (C1's Oncology Nurse Practitioner) encounter note documented a timeline of Erivedge therapy and stated within the History of Present Illness [DATE]: seen in follow up and had been off Vismodegib and was ordered to resume. MARCH 2022: seen in follow up and clinical had significant disease progression. Unfortunately was never started on Vismodegib (Referencing the missed doses from 1/13/22 to 3/4/22) for unclear reason. 'Not listed on med list' and unable to get in touch with nurse at the facility .IMPRESSION: .locoregionally (limited to a local region) advances left periorbital (tissues surrounding or lining the orbit of the eye) basal cell carcinoma with previous excellent response to Vismodegib .TODAY'S VISIT: resumed Vismodegib .PLAN: 6. Spoke with E28 (RN) at the facility. She confirmed he is taking his medication as directed. He is in need of refill as he has only four left in the bottle. 6/3/22 to 6/30/22- The MAR has X documented in signoff boxes of the Erivedge daily order. 7/1/22 to 2/6/23 (222 days)- Review of the medical records, including the MARs, lacked evidence that the Erivedge was being administered. 2/6/23 8:40 AM- C1's Oncology consult documented, Looks like medication was inadvertently discontinued .since then his disease has obviously progressed .RECOMMENDATIONS: Resume Vismodegib 150 mg PO daily. Script (prescription) provided with 5 refills. 2/7/23 to 4/4/23- The MARs incorrectly documented to administer the Erivedge by PEG tube instead of by mouth. 4/4/23- E22 (Medical Director) revised the Physician's order for Erivedge with an end date of Indefinite. 4/5/23 to 4/30/23- The MAR documented that Erivedge was being administered. 5/10/23 3:05 PM- During a telephone interview, C1 (Oncologist) stated that he wanted R51 to take Erivedge daily since R51's admission on 9/24/21. 5/11/23 11:25 AM- During an interview with E24 (LPN) regarding the process for obtaining the drug, E24 stated, At first the brother was bringing it in. He was getting it from the Specialty Pharmacy but once R51 was here LTC (long-term care), the Specialty Pharmacy could not supply the drug as he did not meet their criteria (financial). E24 reported she then contacted a local Specialty Pharmacy and had the Oncology office send them a new script. This pharmacy said they would fill the script automatically every 30 days. E24 stated she only gives the drug orally because you cannot crush that med. I read the insert. 5/11/23 12:42 PM- During a phone interview F1 (POA / power of attorney), stated that when R51 was first admitted to the facility, I would get the med from the Specialty Pharmacy in the mail and then bring it up to the facility. I did this for about 2 or 3 times (30 day supply) and then I was told by the Specialty Pharmacy that he [R51] no longer qualified because he [R51] was staying at the facility for long term care. F1 stated, At that point, the facility was going to take care of getting the medication. 5/15/23 2:24 PM- E3 (Corporate Director of Clinical Services) confirmed that the facility did not have a policy and procedure (P&P) for obtaining Specialty medications. E3 wrote down on a piece of paper the typical way that the facility obtained Specialty medications. The facility failed to have a P&P, including whose role it was to ensure that the process proceeded smoothly, to obtain Specialty medications. 5/16/23 12:53 PM- During an interview, E3 confirmed that she received the Specialty communication emails from the pharmacy regarding their inability to obtain and fill R51's Erivedge prescription and stated that she forwarded the email to the acting DON. The facility failed to do the following: - To ensure that R51 continued his palliative chemotherapy agent, Erivedge to relieve symptoms and hinder the progression of his cancer. - To ensure that the Erivedge order included the correct route of administration - To have a policy and procedure to obtain Specialty/restricted medications from Specialty pharmacies. 5/16/23 3:15 PM- Findings reviewed during the Exit conference with E1 (NHA), E2 (DON) and E3.

Based on record review, interview, and review of facility policy and procedure, it was determined that for two (R63 and R446) out of two residents reviewed for a change in condition, the facility failed to immediately identify a significant change in condition when R63 experienced a change in motor function of his left arm and hand from his baseline, beginning with the neurological evaluation (neurochecks) on 10/15/22 at 10:14 AM through 10/15/22 at 10:14 PM. On 10/16/22 at 7:50 AM, 911 was called by the facility to transfer R63 to the emergency room (ER). Emergency Medical Services (EMS) records indicated that the call was received by EMS on 10/16/22 at 7:50 AM, approximately 22 hours from the onset of a significant change of condition on 10/15/22 at 10:14 AM. The above failures resulted in harm when R63 experienced a significant decline in loss of function from his baseline and a delay of care for more than 22 hours. For R446 the facility failed to follow the practitioners' recommendations to remove a leg brace and apply an ace wrap and they failed to write a treatment order prescribed by the Surgeon and did leg treatments without an order. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, with a revision date of May 2017, stated, .1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): a. accident or incident involving the resident .d. significant change in the resident's physical/emotional/mental condition .g. need to transfer the resident to a hospital/treatment center .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in an accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status .e. It is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Cross refer F580, Ex. 1 1. Review of R63's record revealed: 11/1/21 - R63 was admitted to the facility. 8/9/22 - The quarterly MDS assessment documented that R63 was moderately impaired for daily decision making with a BIMS of 10. 10/14/22 11:30 PM - A neurocheck documented R63's baseline assessment, including that he was able to move all extremities and that his hand grips were equal. 10/14/22 11:45 PM - A Health Status Note by E12 (LPN) documented that R63 had an unwitnessed fall at approximately 11:30 PM in the shower room and reported that he did not hit his head, but had red spots on the back of his shoulders. R63 was able to move all extremities without limitation and no other injuries or bruising was noted. Vital signs (vs) were within normal limits and R63 had no pain or discomfort. 10/15/22 8:01 AM - A Health Status Note by E13 (LPN) documented that a call was placed to E19 (MD), the on-call Physician related to the resident's complaint of back pain due to the fall on 10/14/22 at 11:30 PM. E19 stated not to request an x-ray and instead to administer pain medication and continue to monitor the resident for pain. E19 also recommended that R63 to continue with PT/OT therapy as usual. In addition, the in house Supervisor was made aware. 10/15/22 8:46 AM - A Health Status Note by E15 (RN) documented that the facility was continuing to monitor R63's condition by conducting neurochecks. 10/15/22 10:14 AM - A neurocheck documented a change in which R63 was unable to move his left arm and his right hand grip was greater than the left. There was lack of evidence that the facility identified this as a significant change in condition and they failed to consult the Attending Physician during this period of time. 10/15/22 2:14 PM - A neurocheck continued to document R63's change in condition in which R63 was unable to move his left arm and his right hand grip remained greater than the left. There continued to be lack of evidence that the facility identified this as a significant change in condition and they failed to consult the Attending Physician. 10/15/22 6:14 PM - A neurocheck documented that R63 was unable to move his left arm and his right hand grip was greater than the left. 10/15/22 6:14 PM - A Health Status Note documented by E14 (Agency LPN) documented, Resident was assessed and was noted out of his baseline. Could not walk to bathroom. Resident requesting to use urinal. Unable to move left arm. VS (vital signs) stable. Notified supervisor. Despite the fact that the above note documented that a Supervisor was notified, there was lack of evidence that the Supervisor responded. Additionally, there was continued lack of evidence that the facility failed to consult the Attending Physician. 10/15/22 10:22 PM - A neurocheck continued to document that R63 was still unable to move his left arm and his right hand grip was greater than the left. Although E14 (Agency LPN) recognized that R63 was not at his baseline and notified the Nursing Supervisor the previous evening, the significance of the changes were not acted upon and the facility failed to consult the Attending Physician. Additionally, there was lack of further monitoring of R63's condition after the 10/15/22 10:22 PM neurocheck until R63's vital signs were obtained prior to being transferred to the hospital on 10/16/22 at approximately 8:40 AM (more than nine hours later). 10/16/22 8:40 AM - An Order Administration Note by E14 (LPN) documented that R63 was sent to the ER. 10/16/22 9:50 AM - A Health Status Note documented by E16 (Agency RN) documented, Primary nurse notified this supervisor that resident didn't look like himself. So I went and I assessed the patient, and noticed him not doing things he obviously always did. He usually walks, goes to the bathroom, now is using a urinal, and all of sudden he needs to be fed, all vt (sic) WNL (vs within normal limits) and he couldn't move his left arm and so I called 911. Review of the initial hospital records, dated 10/16/22 and timed 10:07 AM, documented a diagnosis of an intracranial hemorrhage (bleeding inside the skull that puts pressure on the brain) and plan to transfer the resident to another hospital. 11/1/22 1:43 PM - Review of the receiving hospital's Interagency Discharge Orders indicated that R63 was diagnosed with bleeding on the right side of the brain likely due to high blood pressure. 11/17/22 11:54 AM - A telephone interview was conducted with E18 (LPN, Unit Manager) who confirmed that R63 had a change in condition, as documented on the neurocheck dated and timed 10/15/22 at 10:14 AM in which R63 was unable to move his left arm and his left hand grip was weaker than the right hand grip. Due to the facility's delay in identifying the significant change on 10/15/22 at 10:14 AM, R63 experienced a delay in emergency care until 911 was called and E63 was transferred to the hospital on 10/16/22 at 8:40 AM, approximately 22 hours later. 40163 2. Review of R446's clinical record revealed: 8/12/22 - R446 was admitted to the facility with a broken left lower leg which required surgery, a seizure disorder and Cerebral Palsy. 8/18/22 - A surgical note provided to the facility related to R446's left leg wound ordered: Remove dressing/staples on 8/29/22 (prior to x-ray please). Incisions open to air. Dry dressing PRN (as needed) for any drainage. 9/6/22 2:05 PM - A Physician Assistant progress note included: Remove left knee stabilization brace since it is causing further irritation and pressure/pain, knee can be stabilized with ace wrap. Review of R446's Physician's orders revealed that the facility lacked evidence of an order to remove R446's left leg brace and to apply an ace wrap to R446's left leg. 9/7/22 11:06 PM - A Nursing progress note documented: Left lateral (leg) incision with open area draining serosang ([sic] appears like diluted blood) drainage, no odor. Area cleansed with NSS (normal saline solution) and clear dry dressing applied. Review of R446's September treatment record revealed that R446 did not have a Physician's order to apply a dressing to R446's left leg surgical wound. 9/12/2022 1:00 AM - A Practitioner progress note documented: Cellulitis is still present with some drainage but appears to be less swollen, Band-Aid is in place. R446's record continued to lack evidence of an order for any type of dressing to be applied to his left leg. 11/18/22 10:55 AM - During an interview, E27 (RCD) confirmed that the facility failed to follow a recommendation by the Practitioner and write an order to remove R446's leg brace and apply an ace wrap to R446's left leg. E27 also confirmed that the facility failed to write a treatment order as recommended by R446's Surgeon and that they completed two treatments to his leg without a Physician's order. 11/18/22 beginning at approximately 1:00 PM - Findings were reviewed with E1 (NHA), E26 (CRM), E27 (RCD), and E20 (ADON, RH).

Based on interview and record review, it was determined that for one (R445) out of one resident reviewed for hydration, the facility failed to ensure that R445 received adequate hydration to prevent a hospitalization for dehydration and acute kidney injury (AKI). This resulted in harm to the resident. Findings include: The following was revealed in R445's clinical record: 9/28/22 - R445 was admitted to the facility with a history of a stroke affecting the right side, aphasia (unable to speak) and chronic kidney disease stage 3 due to intravenous (IV) contrast dye. 9/28/22 - The Hospital Discharge Summary included that R445 should have a BMP (a lab test to evaluate kidney and electrolyte levels, including sodium) one week after discharge and follow up with nephrology (kidney doctor) in two to seven days. The facility had no record of the labs being completed. 9/29/22 - A care plan was initiated and last revised on 9/30/22 included that R445 had potential for alteration in nutrition and hydration related to abnormal nutritional labs, mechanically altered diet related to a stroke, diet related to chronic kidney disease and diabetes. Interventions included: -Assist with meals as needed; -Encourage food and fluids as needed; -Monitor oral intakes and record; -Resident requires set up help with meals. 9/29/22 4:00 PM - The admission Nursing Assessment included that R445 had swallowing and chewing problems and a urinary catheter for urinary retention. 9/30/22 3:37 PM - A Physician note documented that R445 could feed himself with set up help. October 2022 fluid intake documented totals: 10/1 - 560 mL (milliliters), 10/2 mL- 720 mL, 10/3 - 480 mL, 10/4 - 60 mL, 10/5 - 840 mL, 10/6 - 840 mL, 10/7 - 720 mL, 10/8 - 1080 mL, 10/9 - 420 mL, 10/10 - 240 mL, 10/11 - 840 mL, 10/12 - 1090 mL, 10/13 - 240 mL, 10/14 - 600 mL, 10/15 - 480 mL, 10/16 - 260 mL on the 17th it was documented that R445 refused fluids. 10/3/22 - The History and Physical by the Physician documented that R445 currently required maximum assistance with ADLs. Encourage hydration (fluids) to monitor blood count, electrolytes and sugars. Routine labs were ordered. There was no evidence of labs to monitor the blood count or electrolytes for R445 in the clinical record. 10/4/22 - An admission MDS assessment documented that R445 was cognitively impaired, required extensive assistance of one person physical assist for eating / drinking and personal hygiene, used a wheelchair and had an impairment to the upper and lower limbs of one side of the body. The assessment also documented the resident did not have any swallowing difficulty. 10/14/22 1:38 PM - A dietary note documented that R445 had poor oral intake with a weight loss of six pounds from admission through 10/10/22 (12 days). 10/17/22 2:23 PM - A health status note stated, M.D. (Medical Doctor) notified to further evaluate resident; resident reportedly has decreased appetite; sleeping more; and is no longer transferring with one assist; resident's vitals (vital signs) are stable; resident responds to verbal and tactile (touch) stimuli; but more sleepy than usual. 10/17/22 2:35 PM - A change in condition note documented an altered level of consciousness, needs more assistance with ADL's, general weakness and swallowing difficulty. The Primary Care Provider instructed staff to send R445 to the emergency room . 10/18/22 - Hospital record review revealed that R445 was admitted with hypernatremia (elevated sodium level), elevated BUN, elevated creatinine and chronic kidney disease stage 4 (progressed from stage 3). 10/18/22 - The History and Physical on admission to the hospital was obtained and the following was described about R445's condition: Patient . with a history of chronic kidney disease a creatinine base line of 3.5 (normal 0.74 to 1.35), urinary retention, and recent stroke affecting the right side. R445 was just discharged [DATE] to a nursing facility. R445 is presenting to the emergency room with lethargy (sleepiness), altered mental status, low blood pressure, and poor oral intake. Also, R445's foley catheter had been recently removed. Laboratory values reported a Sodium of 173 (normal 135 to 145) Bicarb 17 (normal 22 to 32), BUN 195 (normal 6 to 24), Creatinine 10.5 (R445's baseline was 3.5), White Blood Count of 16.5 (normal 4.5 to 11). Nephrology was called for a critically elevated sodium level and IV fluid resuscitation was recommended. An intensive care unit (ICU) alert was called for persistently elevated sodium level and altered mental status. R445 was admitted to the ICU with toxic metabolic encephalopathy (acute confusion) due to severe hypernatremia (increased sodium), uremia/AKI. The Hospital Assessment and Plan included: Hypernatremia Increased sodium levels Likely due to significant dehydration (not enough fluid intake). R445 required multiple liters of fluid administered intravenously (to rehydrate). A kidney doctor was consulted related to the dehydration and hypovolemia (low blood plasma). 11/17/22 - An interview with E43 (Dietitian) revealed that R445's assessed fluid needs were calculated as requiring 1800 to 2000 mL fluid intake daily (in 24 hours). When asked about monitoring for changes or decreased fluid intake, E43 responded that he would look at that, but was unaware that R445 had a decrease in fluid intake and wasn't notified. 11/17/22 2:00 PM - An interview with E18 (Unit Manager) revealed that he would pass the information about decreased fluid and meal intake along at shift report and notify the Physician of any changes in the resident. There was no evidence in the clinical record that the facility responded to the decreased fluid intake until R445 became lethargic on 10/17/22. 10/13 through 10/16/22 R445 received a third or less of the assessed fluid intake of 1800 to 2000 mL. 11/17/22 1:50 PM - During an interview with E45 (CNA), it was revealed that CNA's document what fluids they give residents throughout the shift and what the resident drinks from the meal trays. The facility lacked evidence that R445, an alert and oriented resident with global aphasia (unable to speak), dependent for care and he required set up help, was not provided the necessary dietary calculated amount of fluid to maintain hydration. Based on the recorded fluid amounts totaled for R445, 14 of 16 days was less than half the amount of fluids required. This failure resulted in harm when R445 required treatment in the hospital for fluid and electrolyte imbalance, dehydration and AKI on 10/17/22. 11/18/22 beginning at approximately 11:46 AM - Findings were reviewed with E1 (NHA), E26 (CRM), E27 (RCD), and E20 (ADON, RH).

Based on interview, review of the clinical record and other resources as indicated, it was determined that for one (R3) out of three residents reviewed for urinary catheter, the facility failed to ensure that a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infection ([CONDITION(S)]). R3 was hospitalized from 2/25/22 to 3/3/22 for severe [CONDITION(S)], resulting in harm to R3. Findings include: The facility's policy entitled Catheter Care, Urinary, last revised September 2014, included, but was not limited to: General Guidelines to maintain a closed drainage system after insertion of urinary catheter; Input/Output by maintaining an accurate record of the resident's daily output; maintaining unobstructed urine flow; infection control by providing routine hygiene; changing catheter based on clinical indications such as infection, obstruction or when the closed system was compromised; complications by monitoring urine for unusual appearance and other signs and symptoms of [CONDITION(S)] or urinary retention. Review of R3's clinical record revealed the following: R3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/12/21 (last revision) - R3 was care planned for a foley catheter and was at risk for complications of usage. The interventions included: -dignity bag in place; -foley catheter bag to be changed monthly and PRN (as needed); and -foley catheter to straight drainage. Despite the interventions listed above, the facility failed to personalize R3's catheter care plan to address the following based on the standards of practice*: -monitoring of the foley catheter access site (i.e. urine leakage, skin irritation/routine hygiene); -monitoring urine output (i.e. color, odor, sediment, patency); -type of foley catheter being used (i.e. size, type, insertion date); -replacement of the foley catheter based on clinical indications: infection, obstruction; -device being used to secure the catheter to prevent movement, dislodgement, pain or trauma; -maintenance of the urinary drainage bag (keep below bladder level, do not place on floor, emptying schedule); -maintain a closed drainage system. *Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Preventions of Catheter-Associated Urinary Tract Infections 2009, last update: June 6, 2019. https://www.cdc.gov/infectioncontrol/guidelines/cauti. Despite the facility's policy stating to change a resident's catheter based on clinical indications such as infection, obstruction or when the closed system was compromised, R3 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 10/4/21 at 12:33 AM - A health status note documented by nursing stated that R3's urinary foley catheter was replaced in the hospital and the foley was draining clear urine. This is the last documented note in R3's clinical record indicating that his urinary catheter was changed. While facility nurses were documenting that foley catheter care was being provided every shift from 2/1/22 to 2/25/22, R3's eTAR lacked evidence of monitoring his urinary output for 73 out of 75 opportunities. From 2/10/22 to 2/25/22, review of R3's health status notes documented by nursing staff included a CBC lab result on 2/10/22: a declogging of R3's peg tube on 2/13/22 at the ED (Emergency Department) which only took one hour; a psychiatrist consult with a new medication order on 2/22/22; and behavior monitoring for new medication on 2/24/22. R3's health status notes lacked evidence of monitoring his foley catheter and the characteristics of his urine output. 2/25/22 at 11:27 PM - A nurse's note documented that R3 had a 'HI' blood sugar reading. Possible [CONDITION(S)]. Resident received routine blood sugar coverage. Resident noted with fever of 102. Nursing supervisor made aware. On call clinician . made aware. 911 called in. Resident is currently en-route to . hospital for further evaluation. RP . made aware. The facility's documentation in R3's clinical record lacked evidence of a nursing assessment, including updated vital signs and blood sugar, prior to R3 being sent to the hospital. There was no documented evidence of any issues with respect to R3's foley catheter and/or urine output. 2/26/22 - The hospital record revealed that R3's catheter was replaced in the ED with a 3-way foley in order to provide continuous bladder irrigation (CBI). At 7 AM, the hospital documented that R3's urine color description as having clots, cloudy, mucous, red, and sediment. 2/28/22 at 8:50 AM - An outside complaint was received by the State of Delaware's Division of Health Care Quality (DHCQ) triage regarding the filthy condition that R3 arrived in at the hospital on 2/25/22. During a follow-up interview on 3/22/22 at 10:53 AM with the hospital Nurse (H1), who was present when R3 arrived to the hospital, she stated that she was very familiar with R3 as he had been to the hospital many times. H1 stated that on 2/25/22, R3 arrived to the hospital in the worst condition that she has ever seen him. H1 stated that R3 smelled of rancid urine although he had a foley catheter. H1 stated that R3 appeared that he had not been cleaned in a long time. R3's fingernails were visibly dirty and his body was covered with a wax coating that occurs when someone has not been bathed. H1 stated that R3's foley catheter was filthy with body dirt on the catheter tubing and there was no evidence of any cleaning. H1 stated that the foley catheter was the same type that the hospital used and it looked old. In addition, H1 stated that when hospital staff were cleaning R3, he still had the hospital's catheter securing device, called a [MEDICATION(S)] (strap-free foley securement device with a special 360 degree swivel clamp to hold urinary catheters in place) which was found unsecured and loose in a crease between his groin and belly fold. H1 stated that R3's foley catheter was not secured upon his arrival to the hospital. 3/3/22 - The hospital record documented . sent from Regency for fever, lethargy/less responsive, blood sugar above 600 and foley output noted to have sediment . Work-up in ED noted to have vitals consistent with temperature 38.4 (Celsius equals to 101.1 degrees Fahrenheit), heart rate of 147 (normal 55 to 100), respiratory rate 42 (normal 12-20), elevated WBC count of 17.5 (white blood cell, normal 5.0-10.0 thousand) meeting [CONDITION(S)] criteria, also noted to have blood glucose in 600's (normal 74-99), aki (acute kidney injury) with creatinine 5.3 (normal 0.7-1.2), (elevated) lactic acid 3.6 (normal 0.5-1.0). Noted that foley he came in with cannot be flushed, which is replaced with evidence of frank pus draining, given a dose of . antibiotics, IVF (intravenous fluids) . 3/4/22 - A facility Physician's readmission note documented that R3 was admitted to the hospital secondary to fever and elevated blood sugar. In the emergency room patient noted to have an elevated WBC of 17.5 and an elevated creatinine of 5.3 and elevated lactic acid level and his Foley catheter could not be flushed and noted to have pus draining and patient was given IV antibiotics and initiated with IV fluids. Patient diagnosed with severe [CONDITION(S)] and blood cultures grew out [CONDITION(S)] pneumonia . In regards to acute kidney injury due to underlying [CONDITION(S)] and patient initiated with IV fluids . 3/15/22 at 4:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate Nurse) during the exit conference. The facility failed to ensure that R3, a resident with an indwelling catheter, received appropriate care and services to prevent an infection that resulted in R3 being hospitalized for severe [CONDITION(S)].

Based on record review, interview, and review of EMS (Emergency Medical Services) documentation, it was determined that for one (R1) out of three residents sampled for hospitalization , the facility failed to properly assess, monitor and provide respiratory interventions for a resident in respiratory distress. R1 was caused harm and further distress when he remained in respiratory distress without supplemental respiratory interventions (oxygen) until EMS implemented interventions upon arrival to the facility and was admitted to the hospital ICU in respiratory failure, intubated, and placed on a ventilator (a tube placed in the throat and put on a machine to breath). In addition, the facility failed to notify the practitioner of R1's refusal to have labs drawn (blood work). Findings include: Review of R1's clinical record revealed: 1a. [DATE] - R1 was admitted to the facility with a history of a [CONDITION(S)] and stroke. [DATE] 10:53 PM - EMS (Emergency Medical Services) documentation included, Dispatcher received the call at 2253 (10:53 PM) for mentioned location (the facility where R1 resided). Caller advised they needed an ambulance for a patient with change in mental status, crackling lung sounds, elevated respirations, and he was not acting normal . [DATE] 10:57 PM - EMS documentation revealed that EMS was dispatched to the facility where R1 resided. [DATE] 11:00 PM - E5 (LPN) documented R1's vital signs were as follows: temperature 98.0 Fahrenheit; pulse 140 beats per minute; and oxygen saturation 92%. R1's clinical record lacked evidence that R1's blood pressure and respirations were obtained. (A normal range for an adult's pulse rate is ,d+[DATE] beats per minute. A normal range for respirations (breathing) is ,d+[DATE] breaths per minute at rest. A normal blood oxygen saturation is ,d+[DATE]%). [DATE] 11:04 PM - EMS' initial documentation of R1's vital signs were as follows: Blood pressure ,d+[DATE]; pulse 127 beats per minute; respirations labored at 58 breaths per minute; and oxygen saturation was 62% on room air (without supplemental oxygen). R1 had an abnormal heartbeat and was unresponsive. Although the facility documented R1's oxygen saturation as 92% on room air at 11:00 PM, that was significantly inconsistent four minutes later when EMS arrived at the facility and recorded an oxygen saturation of 62%. This was a 40% drop in oxygen saturation in four minutes. R1's was using accessory muscles, had bilateral decreased breath sounds and increased respiratory effort. [DATE] 11:08 PM - A nursing progress note documented, Resident noted during last rounds unconscious and abnormal breathing, heart rate 140, respiration 30, noted with SOB (shortness of breath)/distress. MD (doctor) notified; resident sent to ER (emergency room ) for further evaluation. R1's clinical presentation was inconsistent with E5 (LPN)'s documentation that R1 had an oxygen saturation of 92%. Although the Practitioner was called, no order for oxygen use was requested for a resident in respiratory distress. [DATE] (Untimed) - A narrative note composed by EMS documented, .found the patient lying in bed. No staff was present in the room at the time and no care was being rendered to the patient. Despite the patient presenting in severe respiratory distress, no O2 (oxygen) was being administered to the patient. Staff finally came into the room and advised that the patient was last known normal at 9:00 PM . [DATE] 11:51 PM - Hospital documentation included, .presenting to the emergency department today from his (R1's) nursing home via (by) medic (EMS) for respiratory distress. Patient was found at his nursing facility satting (pulse ox) in the 50's on room air (no oxygen) without any interventions being performed. He had shallow rapid breathing in the 60's per minute. They (EMS) initiated BVM (bag-valve-mask - mechanical breathing) and brought him in for evaluation.R1 was intubated (a breathing tube placed) and placed on a ventilator (a machine that breaths for you). R1 was diagnosed with respiratory failure due to COVID-19 and was admitted to the hospital in the intensive care unit. [DATE] 9:55 AM- During an interview E2 (DON) stated that he was at the facility the night of ([DATE]) when R1 was sent out via 911. R1's nursing progress note from [DATE] at 11:08 PM was discussed and E2 confirmed that the note lacked evidence of any staff interventions prior to EMS getting onsite. E2 stated that staff sat R1 up and stopped his tube feeding, but did not mention that oxygen was provided. E2 stated that there was a set of vital signs with a pulse ox of 92% in R1's clinical record on [DATE] at 11:00 PM, but it was not included in the nurses progress note regarding what occurred prior to R1 being sent out to the hospital. E2 confirmed that R1 was not administered oxygen when EMS arrived and stated that EMS did not provide oxygen to R1 prior to leaving the building and was not being provided BVM (mechanical ventilation) prior to leaving the building. [DATE] 5:,d+[DATE]:20 PM- During an interview, SS1 (EMS) stated that he was at the facility [DATE] to respond to a 911 call for R1. SS1 explained that his observation and assessment of R1 revealed that R1 was in severe respiratory distress with respirations in the 50's and oxygen saturations in the 60's. SS1 stated that R1 was not being administered oxygen and was alone when EMS entered R1's room. SS1 stated they did not get a good report from facility staff regarding R1's baseline status. [DATE] 11:35 AM - During an interview, E8 (LPN) stated that if a resident had increased labored respirations of 30 per minute, an increased pulse of 140 beats per minute and the resident was in distress, it was unlikely that a pulse ox of 92% would be normal and/or correct with those signs and symptoms. E8 stated that if a resident presented with unusual or abnormal vital signs, she would get another nurse, the DON (Director of Nursing) or the ADON (Assistant Director of Nursing) to come in and evaluate the resident and confirm her assessment. E8 stated that if she had a resident with respiratory distress, she would stay with the resident and get someone like a CNA to get another nurse. I would then put oxygen on the resident, elevate the head of the bed and check the resident's code status (whether the resident wants CPR or not). [DATE] 12:26 PM - During an interview, E5 (LPN) (the nurse that was assigned to the resident the evening of [DATE]) stated that she went into R1's room on last rounds and it sounded like R1 was snoring loudly. R1 looked unconscious and had no response to sternal rub (a way of checking for a person's response). E5 stated that she elevated R1's head. R1's pulse ox was 92% and his respirations were elevated. E9 (agency CNA) was in the room. E5 stated that R1 had increased respirations and heart rate. E5 stated that she thought a pulse ox of 92% was normal for some people. E5 added that there was a CNA and E2 (DON) outside of the door. E5 stated that she was not in R1's room because she was the one who called 911, was getting the paperwork ready, and added there were a lot of people in there (R1's room when she left). E5 stated that R1 was never left alone, which is not consistent with documentation by the EMS crew. E5 confirmed that EMS applied oxygen to R1 while they were in the building. E5 stated that EMS and R1 were gone quickly. [DATE] 12:45 PM - During an interview, E9 (agency CNA) stated that the nurse E5 (LPN) wanted her to help in R1's room and she was in the room when EMS got there, but then left. E9 stated that prior to EMS arrival, while she was in R1's room, the nurse tried to get R1's blood pressure, but the blood pressure cuff did not work because it was too small for R1. E9 stated that E7 (LPN) went out of R1's room and got a hand pulse ox and checked him, but did not know what R1's pulse ox was at that time. E9 stated that she did not see oxygen started on R1 before EMS arrived, all she saw was R1's tube feeding. E9 stated that she remembers the nurse said that R1's pulse ox was low and that was why they called 911. E9 stated that it looked like R1 really wasn't breathing and was just lying there. There were two nurses working on the unit when this happened to R1 and it was E5 (LPN) and E7 (LPN) and E2 (DON) was outside of the door. [DATE] 2:00 PM - During an interview, E2 (DON) stated that the facility does not have standing orders for oxygen. E2 also stated that he did not know which Practitioner (Doctor or Nurse Practitioner) was notified of R1's change in status. [DATE] 4:50 PM - During an interview, SS2 (MD) reported that on [DATE] it was an on call service Practitioner that would have responded on that date and shift. SS2 stated that it is was unlikely that a resident would present with increased respirations of 30 per minute and a pulse of 140 and maintain a pulse ox of 92%. [DATE] 12:08 PM - An email composed by E2 (DON) included, I saw the resident from his doorway and did not see evidence of him in respiratory distress. Staff stated he was less responsive than usual. I asked for VS (vital signs) and was told (R1) Pulse Ox was 92% on R/A (room air). I directed staff to sit him upright, hold his TF (tube feeding) and call 911. I then went to the first floor to open the door and hold the elevator for EMS. [DATE] 1:,d+[DATE]:55 PM - During an interview, E7 (LPN) stated that E5 (LPN) called her to R1's room related to R1's decline. E7 said that R1 usually fights you when you are trying to give him his meds (medications), tube feeding and care. E7 stated there was a CNA in R1's room and E5 was calling 911. E7 stated that she went to her cart to get her vital sign equipment and took R1's vital signs; they were normal when she was in R1's room. E7 added that the resident was at his normal and not in any distress other than his change in mental status, then added that R1 was not in any respiratory distress. E7 stated that she thought R1's pulse ox was 97 or 98%. The surveyor inquired if the resident (R1) was not in distress then why was 911 called? E7 stated that it was because of R1's change in mental status. The surveyor read her E5 (LPN)'s progress note (dated [DATE] at 11:08 PM) in R1's chart and asked her about the difference in her assessment and E5's assessment. E5 stated, I don't know. R1 was fine other than his change in mental status when she was in the room. The surveyor then asked E7 whether E2 (DON) went in to assess R1 and she stated No, he (E2) was outside the door and then went down to open door for EMS and was never in the room and did not assess the resident. E7 stated that R1 was not panting or anything. When asked about the EMS vitals E7 stated she did not know what they were when EMS obtained them on arrival. E7 stated that EMS said Don't you apply oxygen to a patient that is in respiratory distress? Based on interviews of facility staff and EMS, it is unclear whether the facility assessments of R1 were adequate and correct due to discrepancies in the interviews and documentation. The facility lacked evidence of appropriate respiratory assessments, adequate monitoring, and necessary interventions, including the application of oxygen when R1 was found in respiratory distress. 1b. Review of R1's clinical record revealed: [DATE] - R1 was admitted to the facility with a history of a [CONDITION(S)] and stroke. [DATE] - R1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] - R1 had a physicians order for labs to be collected. The record lacked evidence that the resident refused lab work and what (if any) interventions were conducted, including notifying the ordering doctor. [DATE] 10:15 AM - During an interview, E4 (Corporate Clinical Nurse) confirmed that R1 was ordered to have labs drawn on [DATE] and that the results report received the following day documented that the resident had refused. E4 confirmed there was no evidence that the Practitioner was notified. E4 also confirmed that there was an additional order for labs on [DATE] and it was documented in R1's record as completed and then discontinued on the same day. E4 thought it was because R1 refused, but confirmed there was not a progress note to support R1's refusal. E4 confirmed that a lab result report from the [DATE] order was unable to be located. The facility lacked evidence that on the aforementioned dates, the Practitioner was notified of the refusal of ordered labs. Findings were reviewed at the exit conference on [DATE], beginning a 1:45 PM, via phone with E1 (NHA), E2 (DON) and E4 (Corporate Clinical Nurse).

Based on interview, record review and other documentation it was determined that for one (R3) out of three residents sampled for pressure ulcers, the facility failed to identify, assess and treat a pressure ulcer that was present on admission causing R3's coccyx pressure ulcer to significantly worsen which resulted in a delay in treatment causing harm to R3. Findings include: Review of the Agency for Healthcare Research and Quality, National Guideline Clearinghouse, included the clinical practice guidelines by the National Pressure Ulcer Advisory Panel dated 2014, which stated, .Pressure Ulcer Assessment .1. Assess the pressure ulcer initially and reassess it at least weekly .3. Assess and document physical characteristics . 7/17 (revision date) - Review of facility policy; Prevention of pressure ulcers/injuries revealed the following: - Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. - Conduct a comprehensive skin assessment upon admission including: any evidence of existing or developing pressure ulcers or injuries; inspect the skin on a daily basis when performing or assisting with personal care or ADL's. - Inspect pressure points (buttocks, hips, elbows, heels). 9/25/20 - Review of hospital records described that R3 had a stage 3 full thickness pressure ulcer to the coccyx that measured length 0.3 cm x width 0.3 cm, and did not document depth. It was verified by two hospital practitioners as a stage 3 pressure ulcer. In addition, R3 also had a left upper thigh stage 3 pressure ulcer measuring length 1.5 cm x width 2.6 cm that was full thickness, had necrotic tissue, slough and red tissue. The following was reviewed in R3's clinical record: 10/2/20 - R3 admitted to the facility from the hospital. 10/2/20 - An interagency discharge summary documented to follow up with the wound care center in one to two weeks. 10/2/20 - The initial admission skin assessment documented a stage 3 pressure ulcer to the left thigh measuring length, 9 cm x width, 9 cm x depth 0.25 cm. The facility failed to identify the stage 3 pressure ulcer to the coccyx. 10/2/20 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/2/20 - Hospital discharge instructions for care of the coccyx area documented to apply barrier cream every day. 10/3/20 through 10/29/20 - Review of CNA documentation indicated that the intervention for turning and repositioning every two hours was not completed for 12 shifts out of 81 shifts. 10/5/20 - R3's history and physical documented a [CONDITION(S)] that was treated with antibiotics and a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/9/20 - An admission MDS assessment documented that R3 was at risk for pressure ulcers and no pressure ulcers were identified. The MDS documented under ADL's that R3 was an extensive assist and required a two person physical assist for the following: bed mobility, transfers, walking, dressing, toileting and personal hygiene. R3 had a BIMS score of 15. 10/9/20 through 10/29/20 - Review of clinical records lacked evidence of a weekly skin assessment. 10/21/20 - R3's care plan for being at risk of skin breakdown included the following interventions: Pressure relief cushion to chair while out of bed, presssure relief to mattress to bed, provide prompt peri care for incontinence episodes, provide turning and repositioning every two hours, and skin observation every two hours. 10/21/20 through 10/29/20 - Review of CNA documentation indicated that the intervention to check the skin every two hours was not completed for four out of 25 shifts. 10/28/20 9:34 PM - A nursing progress note documented, Completed wound care to stage 3 (pressure ulcer) gluteal, sacral area; encouraged resident to change position more frequent and the rationale for offloading that area; will continue to monitor. 10/29/20 - A wound assessment documented a pressure ulcer to R3's coccyx as measuring length 9 cm x width 8 cm x depth 2.5 cm wound bed necrotic, bloody drainange, periwound with eschar tissue.Supervisor and Physician were notified and a new order was obtained. 10/30/20 - A wound assessment by another facility nurse documented a pressure ulcer to R3's coccyx as measuring length 15 cm x width 12 cm x depth 6 cm. The order was changed to a more aggressive treatment. Although R3 had a newly identified pressure ulcer of the coccyx by the facility, there was lack of evidence of the stage of the wound. The characteristics of the wound to include necrosis and eschar would be consistent with an unstageable pressure ulcer. 11/3/20 - A physician discharge summary documented that R3 was sent to the emergency room for abdominal pain. 11/4/20 - R3 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/7/20 - A hospital operative report documented a preoperative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .On admission, he (R3) was found to have an extensive unstageable sacral decubitus (pressure) ulcer with large amount of fecal spillage into the wound. 1/19/22 1:45 PM - During an interview, E6 (MDS Coordinator) confirmed that the initial admission skin assessment was inaccurate, the pressure ulcer to the coccyx area was not identified and was therefore not captured in R3's admission MDS assessment. E6 also confirmed there were no further weekly skin assessments performed since admission until 10/29/20 when the pressure ulcer was first identified by the facility and documented in R3's EMR. 1/21/22 1:05 PM - During an Interview E2 (DON) stated that it was unclear whether R3 was admitted with the pressure ulcer or if it was facility acquired. 1/24/22 12:45 PM (approximate) - During an interview, E1 (NHA) and E2 (DON) confirmed that the pressure ulcer to the coccyx was present on admission on 10/2/20 and was not treated until 10/29/20, nearly a month later. The facility failed to: - identify the coccyx pressure ulcer on admission. - ensure consistent implemention of preventative measures to include turning and repositioning every two hours, weekly skin checks, skin checks and observations every two hours, and the application of barrier cream. - identify skin changes before the coccyx pressure ulcer was initially observed on 10/29/20 with characteristics of an unstageable pressure ulcer. Findings were reviewed during the exit conference via telephone on 1/25/22 at 1:45 PM with E1(NHA), E2 (DON) and E4 (Corporate RN).

Based on observations, interviews and review of other documentation it was determined that facility staff did not wear appropriate PPE for 45 out of 83 residents. The facility failed to maintain a designated COVID-19 area that included dedicated staff. Nurse's were assigned to both COVID and non-COVID residents. Additionally, the facility allowed staff to work on both the 2nd floor (where the COVID unit was located) resident area and the 3rd floor resident area. The facility also failed to ensure the proper use of PPE when staff were sharing the same PPE for resident rooms in the non-COVID 2nd floor resident rooms. These failures put the residents at risk for contracting COVID-19. An immediate jeopardy (IJ) was called on 10/16/2020 at 6:27 PM and was abated on 10/16/2020 at 8:36 PM. Findings include: The facility Guidance for Infection Control and Prevention of Coronavirus Disease 2019 included, 2) Gowns a. put on a clean isolation gown upon entry into the resident's room and immediately perform hand hygiene. 4/2/2020 - The CMS memo titled COVID-19 Long Term Care Facility Guidance documented, If COVID-19 transmission occurs in the facility, healthcare personnel (HCP) should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. 4/30/2020 - The CDC Coronavirus Diseases website documented, Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. 10/3/2020 to 10/14/2020 - The facility line list confirmed that 12 residents were positive for COVID that resided on the 2nd floor. Additionally, 4 staff tested positive for COVID-19. 10/14/2020 to 10/16/2020 - The facility line list confirmed an additional 21 residents that were positive for COVID and 11 of those resided on the 3rd floor. Additionally, 5 staff members tested positive for COVID. 10/15/2020 12:07 PM - Observations revealed that on the 3rd floor full PPE, including gowns were not being worn by staff when in the resident rooms. 10/15/2020 around 1:00 PM - During an interview with E4 (RN), it was revealed that E4 was assigned to the COVID positive residents (contained in a designated section), as well as residents being observed for COVID and the naïve (negative for COVID) residents on the same unit. 10/15/2020 around 1:15 PM - It was observed in the 2nd floor observation rooms for new admissions and non-COVID rooms 206 through 223, there were two gowns hanging behind each door on a hook for staff to use to provide resident care. 10/15/2020 - Review of the daily staff schedule revealed that E4 (RN) was working day shift and was assigned to the COVID positive unit/residents. E4 was also scheduled as the supervisor for the entire facility on the evening shift. This would result in E4 going from the 2nd floor to the 3rd floor and having contact with other employees who were providing patient care. The house supervisor is the only RN in the building and would be expected to respond to patient emergencies. 10/15/2020 around 2:00 PM - During an interview with E1 (NHA), it was confirmed that E4 (RN) was assigned to the 2nd floor and COVID unit and was scheduled to work on the 3rd floor naive unit. 10/16/2020 12:26 PM - During an interview with A1 (Anonymous) it was revealed that staff were told to share the isolation gowns. A1 further revealed that staff were not wearing gowns for patient care on the 3rd floor. 10/16/2020 - Review of staffing schedules revealed that on 10/14/2020 and 10/15/2020, E4 (RN) was the 7-3 (day shift ) RN assigned to the 2nd floor caring for the COVID residents and non-COVID residents. It was further revealed that E4 was also scheduled as the house supervisor for the building on both 10/14/2020 and 10/15/2020 for the 3-11 (evening) shift. This practice would increase the risk or likelihood of transmission to additional staff and residents throughout the building. Review of staffing conducted on 10/16/2020 revealed that at least two other staff members, E7 (CNA) and E8 (CNA) worked on both floors. This practice increased the likelihood of transmitting COVID-19 by assigning staff to both the 2nd floor where the observation unit, COVID unit and non-COVID unit were located. Additionally, 3rd floor residents were at increased risk for contracting COVID by staff not using PPE on the 3rd floor for direct resident contact. 10/16/2020 2:11 PM - During an interview with E7 (CNA), it was revealed that E7 was a float and worked on both the second and third floors. It was further revealed by E7 that PPE was not required on the third floor with resident contact. According to the CDC, full PPE is to be worn in the facility when the facility has any positive COVID residents and/or staff in the facility. The facility failed to maintain a dedicated COVID unit; they allowed staff working in the COVID unit to work in other patient care areas with non-COVID residents. The facility also failed to utilize droplet precautions, a form of isolation with full PPE for all residents; staff shared PPE. These failures put the residents at increased risk of contracting COVID-19. 10/16/2020 at 6:27 PM - An immediate jeopardy (IJ) was called in the presence of E1 (NHA) and E2 (Corporate Nurse). 10/16/2020 8:36 PM - The IJ was abated after the following was completed: the facility corrected the improper isolation and the improper infection control techniques to prevent the spread of infection in the facility, initiated full PPE on the 3rd floor and the facility developed an appropriate plan to provide staff education and trained staff immediately before they reported to work. During the exit conference on October 20, 2020 at 10:30 AM, findings were reviewed with E1 (NHA) and E2 (Corporate Nurse).

Based on observations, interview and reviews of clinical records and other documentation as indicated, it was determined that for two (R73 and R74) out of three sampled residents for pressure ulcer (PU) review, the facility failed to ensure that each resident with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. For R73, the facility failed to stage her sacral PU upon admission; failed to obtain a wound care treatment order for her sacral PU until the third day after admission; R73's sacral PU declined from a Stage III to Unstageable and became infected, requiring oral antibiotic treatment. In addition, the facility failed to follow the plan of care by turning and repositioning R73 every two hours to promote healing of her sacral wound. Due to multiple facility failures with R73's sacral pressure ulcer treatment and services, the resident sustained [REDACTED]. Consequently, there was inappropriate treatment of [REDACTED]. Findings include: The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a revision date of 4/2018, stated the following: Assessment and Recognition. 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type . and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to the pressure ulcer . Treatment/Management. 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and [MEDICATION NAME] approaches, dressings (occlusive, absorptive, etc.), and application of topical agents . Monitoring. 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds . 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated . According to the National Pressure Ulcer Advisory Panel (NPUAP 4/2016), the stages of pressure injuries/ulcers (categorization system used to describe the severity of PUs): Stage I (1) - a reddened area of intact skin usually over a boney prominence, that when pressed does not turn white. This is a sign that a PU is starting to develop. Stage II (2) - skin blisters or skin forms an open sore. The area around the sore may be red and irritated. Stage III (3) - skin develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Undermining may occur. Stage IV (4) - ulcer has become so deep that there is damage to the muscle and bone and sometimes to tendons and joints. Unstageable - Tissue loss in which actual depth of the ulcer is unable to be determined due to the presence of slough (yellow, tan, gray, green or brown dead tissue) and/or eschar (dead tissue that is tan, brown or black and tissue damage is more severe than slough in the wound bed). Deep Tissue Injury (DTI) - Purple or maroon localized area of discolored intact skin. May be preceded by tissue that is painful, mushy, firm, boggy (wet, spongy feeling), warmer or cooler than adjacent tissue. 1. Review of R73's clinical record revealed: 1/20/2020 to 1/29/2020 - According to the hospital record, R73 had a Stage III sacral pressure ulcer, unstageable left heel pressure ulcer and deep tissue right heel pressure ulcer. 1/29/2020 untimed - Before R73 was transferred from the hospital to the facility, E36 (LPN) received report on R73 from the hospital and recorded that information on the facility's form entitled Hospital Report Sheet. E36 wrote under the Skin integrity/open areas: Intact, except for Stage III coccyx (sacral) area. 1/29/2020 at approximately 7 PM - R73 was admitted to the facility with a [DIAGNOSES REDACTED]. 1/29/2020 at 9:29 PM - The facility's Skin Only Evaluation form stated that R73 had an open lesion on the coccyx measuring 2 cm x 1.5 cm x 0.1 cm with an [MEDICATION NAME] wound bed and deep tissue injuries (DTIs) to the left and right heels. 1/29/2020 at 9:42 PM - The facility's Braden Scale assessment stated that R73 was at moderate risk for developing pressure ulcers, despite R73 having three pressure ulcers upon admission to the facility. 1/29/2020 - R73 was care planned for the following: - at risk for skin breakdown related to decreased mobility and incontinence. The approaches included: apply lotion to skin to prevent dryness everyday with morning and evening care and as needed; low air loss mattress - check function; monitor alterations in nutrition and notify MD and dietician; turn and reposition every 2 hours; and weekly skin assessments done by nurse. - incontinent of bowel and bladder with no memory recall and/or ability to retrain. The approaches included, but were not limited to: check and change every 2 hours for bowel and bladder incontinence; incontinence care after each incontinent episode, check skin for signs of irritation and breakdown; and moisture barrier cream after each incontinent episode. 1/30/2020 at 4:19 PM - The occupational therapy evaluation and plan of care stated that the assessment of R73's bed mobility (including rolling right, rolling left, laying supine to sitting up, and sitting up) was total dependence without attempts to initiate by R73. 1/30/2020 at 11:08 PM - The Weekly Skin Evaluation stated that R73's skin impairment sites were: sacrum had an open area and barrier cream was applied; right heel and left heel were deep tissue injuries and skin prep was applied. The facility failed to recognize that R73's open sacral area required treatment other than barrier cream, which was a care plan approach for when R73 was at risk for skin breakdown and incontinence care. 1/31/2020 at 12:03 PM - A verbal physician's orders [REDACTED]. While R73 was admitted to the facility on [DATE] with a open sacral area, the facility failed to obtain a physician's orders [REDACTED]. 2/3/2020 - The admission MDS assessment stated that R73 was cognitively impaired; required extensive assistance of one staff person for bed mobility; required total physical assistance of one staff person for toilet use; required substantial/maximal assistance when rolling left and right (staff lifts or holds trunk or limbs and provides more than half the effort); always incontinent of bladder and bowel; received routine and as needed pain medications; and had unhealed pressure ulcers which included a Stage III PU and two DTIs (areas not specified). 2/4/2020 - The Wound Care consultant's initial assessment stated: - R73 had fecal and urinary incontinence and poor bed mobility; - R73's sacral PU measured 1.8 cm x 2.5 cm x 0.2 cm, wound base 50% granular, 50% slough with moderate non-odorous serosanguineous drainage; - Recommendation: cleanse sacral PU with normal saline, apply Santyl to wound base daily and as needed, cover with foam dressing, continue repositioning in accordance to assessed needs, offload pressure on area. - Interventions in place: low-air loss support surface. 2/4/2020 at 4:30 PM - A verbal physician's orders [REDACTED]. 2/11/2020 - The Wound Care consultant's assessment stated: - R73's sacral PU measured 3.3 cm x 2.5 cm x 0.2 cm, wound base 30% granular, 70% slough with moderate non-odorous serosanguineous drainage; - Stage III PU of the sacrum was not improving; - Recommendation: cleanse site with normal saline, apply Santyl to wound base daily and as needed, cover with foam dressing, continue repositioning in accordance to assessed needs, offload pressure on area. - Interventions in place: low-air loss support surface. 2/18/2020 - The Wound Care consultant's assessment stated: - R73's sacral PU measured 2.0 cm x 2.8 cm x 0.2 cm, wound base 100% slough with moderate malodorous serosanguineous drainage; - Reclassified Stage III sacral PU to Unstageable as the wound base was not visible and was not improving; - Recommendation: cleanse site with normal saline, apply Santyl to wound base daily and as needed, cover with foam dressing, continue repositioning in accordance to assessed needs, offload pressure on area; - Interventions in place: low-air loss support surface. 2/18/2020 - A physician's orders [REDACTED]. 2/20/2020 - R73 was care planned for actual skin breakdown related to the sacral pressure site. The approaches included: assess skin and monitor pressure points every 2 hours - report any changes to the nurse; keep skin clean and dry; low air loss mattress with wedge - check function every shift; out of bed as tolerated/ordered; pressure relieving mattress; treatment as ordered; and turn and reposition at least every two hours while in bed, weight shift every hour while out of bed to chair and as needed. 2/21/2020 at 12:21 AM - The Weekly Skin Evaluation stated that R73's sacrum was unstageable and treatment was completed as ordered. 2/21/2020 at 12:30 PM - R73's sacral wound culture results stated that the wound was infected with two organisms. An antibiotic was ordered for R73's infected sacral PU to be administered for 14 days. 2/24/2020 - R73 was care planned for a wound infection on the sacrum. The approaches included: medicine/antibiotic as ordered; treatment as ordered, alert wound nurse and doctor if treatment was ineffective; and weekly wound measurements with the wound nurse nurse practitioner. 2/25/2020 - The Wound Care consultant's assessment stated: - R73's sacral PU measured 2.0 cm x 2.8 cm x 0.5 cm, wound base 70% slough, 30% granular with moderate malodorous serosanguineous drainage; - Unstageable sacral PU was stable; - Recommendation: cleanse site with normal saline, apply Santyl to wound base daily and as needed, cover with foam dressing, continue repositioning in accordance to assessed needs, offload pressure on area; - Interventions in place: low-air loss support surface. 2/26/2020 - Despite R73 having an infected, unstageable sacral PU, the physician progress notes [REDACTED]. 2/27/2020 - Observations by the surveyor during the day shift (7 AM to 3 PM) revealed: - at 7:59 AM, R73 was laying on her back in her bed. Observed a facility staff member enter the room with a meal tray and then closed the resident's door; - at 8:39 AM, R73 was laying on her back asleep with the head of the bed elevated approximately 45 degrees; - at 10:31 AM, R73 was laying on her back in bed and the head of the bed was no longer elevated. - at 11:06 AM, R73 was laying on her back and calling out. E37 (CNA) entered the room and talked to R73. - at 11:30 AM, R73 was still laying on her back in bed fast asleep. Observed that R73 was scooted down in the bed. - at 11:50 AM, R73 was laying on her back asleep. - at 1:43 PM, while the head of bed was elevated approximately 45 degrees, R73 was scooted down in the bed laying flat on her back. - at 1:48 PM, observed E37 (CNA) adjusting R73 in bed then E37 left the room. Observed R73 laying flat on her back. - at 2:06 PM, R73 was laying flat on her back. - at 2:39 PM, observed two CNAs (E37 and E40) exit R73's room with R73 in her wheelchair and placed the resident next to the nurse's station. 2/27/2020 - The CNA Documentation Survey Report for the day shift (7 AM to 3 PM) revealed that E37 (CNA) documented: - R73 was turned and repositioned every 2 hours during the day shift; and - R73 required total dependence of one staff person for bed mobility (turning side to side and positioning body while in bed). E37's documentation of turning and repositioning every 2 hours contradicted the surveyors multiple observations during day shift on 2/27/2020. 3/3/2020 - The Wound Care consultant's assessment stated: - R73's sacral PU measured 3.2 cm x 2.8 cm x 0.5 cm, wound base 50% slough, 50% granular with moderate non-odorous serosanguineous drainage; - Unstageable sacral PU was stable; - Recommendation: cleanse site with normal saline, apply Santyl to wound base daily and as needed, cover with foam dressing, continue repositioning in accordance to assessed needs, offload pressure on area; - Interventions in place: low-air loss support surface. 3/4/2020 at 4:50 PM - An observation of wound care treatment was completed by E38 (RN) and E39 (RN). R73 was repositioned by both RNs on the resident's left side. R73 appeared comfortable and went to sleep. During an interview, E38 was asked if R73 can turn herself and E38 stated no, staff have to turn R73. E38 stated that R73 does not like to stay on her side and will wiggle herself to lay on her back. 3/5/2020 at 10:17 AM - During a combined interview with E2 (DON) and E4 (ADON), E2 stated that the Wound Care Consultant Nurse Practitioner, who comes into the facility every Tuesday, stages the resident's pressure ulcers. The surveyor reviewed the following findings: - R73's sacral PU was not staged upon admission to the facility, despite the bilateral heels being staged as DTIs by the admitting RN and in accordance with the facility's Pressure Ulcer Clinical Protocol (last revised April 2018), which stated full assessment and recognition of the PU (included staging). R73's sacral PU was staged in the facility when the resident was evaluated six days later by the Wound Care Consultant Nurse Practitioner. - R73's sacral PU was treated with moisture barrier cream for the first 2 days after her admission until a 1/31/2020 physician's orders [REDACTED]. The facility failed to obtain a treatment for [REDACTED]. Moisture barrier cream was care planned on 1/29/2020 for R73's incontinence episodes and for being at risk for skin breakdown. R73 was admitted to the facility with skin breakdown, specifically a Stage III sacral PU. - R73's sacral PU worsened from a Stage III on 2/4/2020 to Unstageable on 2/18/2020 and became infected requiring antibiotic treatment for 14 days. - Multiple observations of facility staff not turning and repositioning R73 every 2 hours on 2/27/2020 by the surveyor. While R73's bilateral heel DTIs healed after being admitted to the facility, R73's sacral PU worsened and became infected. The facility failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of R73's sacral PU. 3/6/2020 at 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON). 2. Review of R74's clinical record revealed the following: 11/26/2019 - R74 was admitted to the facility without a PU. 1/20/2020 11:58 PM - A progress note documented that R74 was transferred to the hospital due to a mental status change. 1/28/2020 5:37 PM -A progress note by E16 (RN) documented that R74 was readmitted to the facility from the hospital and E16 did not document the presence of a PU. 1/29/2020 12:22 AM - A plan of care note by E16 (RN) documented that R74 had a stage II skin breakdown of the coccyx measuring 1.5 cm length (L) X 1 cm width (W) X 0.1 cm depth (D) present upon admission. 1/29/2020 8:36 AM - A skin evaluation, completed by E21 (RN, UM). documented that R74 had a new stage II PU of the coccyx with partial thickness loss with the following descriptions: - Measurement: 0.6 cm L, 0.4 cm W and 0.1 cm D. - Wound bed: Granulation. - Wound Exudate: None. - Peri Wound Condition: Normal. - Dressing Saturation: None. - Odor: none. - Tunneling and/or Undermining: None. 1/29/2020 - A care plan was initiated for a stage II PU of the coccyx and included the following interventions: - Apply lotion to skin to prevent dryness everyday with AM/PM care and PRN. - CNA to assist with turn and re-position every 2 hours and PRN. - Moisture barrier cream to coccyx and peri area every shift and PRN, CNA may apply. - Weekly skin assessments done by nurse. - Pressure relief cushion to chair while out of bed. 1/28/2020 through 2/3/2020 - A review of the Treatment Administration Record revealed that the following interventions were completed: - Apply lotion to skin to prevent dryness everyday with AM/PM care and PRN. - Moisture barrier cream to coccyx and peri area every shift and PRN. 2/4/2020 - The initial Wound Care Nurse Practitioner consultation by E22 (WCNP) documented the PU as stage III with full thickness ulceration of the coccyx measuring 3.0 cm L x (times) 3.2 cm W x 0.1cm D with 100 % granulation of the wound base. The plan included to initiate a new treatment to the PU with [MEDICATION NAME] daily and as needed, continue repositioning in accordance to assessed needs, and out of bed 5 hours maximum per day. The wound size increased from the initial measurement completed by E16 (UM, RN) on 1/29/2020. The facility assessed the presence of granulation tissue in the wound bed on 1/29/2020 and incorrectly staged the PU as a stage II, rather than a stage III, according to the NPUAP staging system. 3/3/2020 10:00 AM - An interview with E9 (SD) revealed that the current process, upon identification of a new PU was for the nursing staff to document the description of the PU, however, staging of the PU would be completed by the Wound Care Nurse Practitioner (WCNP) during weekly rounds which occur every Tuesday. Subsequent to this interview, E9 provided the surveyor a copy of the policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol. Since the current facility process was for the WCNP to stage the PU, E9 confirmed there was no written guidance to accurately stage a PU. 3/4/2020 2:42 PM - An interview with E21 (RN, UM) was conducted. E21 verbalized that the usual process was for nursing staff to document the assessment of the PU without the staging since the facility's WCNP would determine the stage of the PU. E21 verbalized that the reason she staged the PU was that the hospital reported, prior to transfer that R74 had a stage I PU. E21 related that upon her assessment, E21 observed a PU on the coccyx which was not a stage I, but rather a PU with granulation of the wound bed and she staged it as a II. E21 reported that the WCNP conducted weekly consults every Tuesday and staging was to be completed by the WCNP, however, E21 assessed the PU as a stage II based on her knowledge. E21 vaguely remembered contacting E22 (WCNP) when R74 was admitted PU, however, she was not able to provide evidence to the surveyor. Lastly, E21 confirmed there was no new treatment to the PU and the interventions in place prior to the readmission from the hospital were being completed. These included moisture barrier and application of lotion. 3/5/2020 11:15 AM - An interview with E22 (WCNP) was conducted and E22 verbalized that she does not recall that she was consulted about the PU on readmission. E22 verbalized that R74 was readmitted to the facility on [DATE] from the hospital with a stage III PU of the coccyx, despite the fact that it was staged by E21 (RN, UM) as a stage II. E22 confirmed that granulation of the wound bed would not be a stage II; it would be as a stage III. The surveyor inquired if moisture barrier and applying lotion were appropriate for a stage III PU and E22 verbalized that these interventions would not be appropriate for a stage III PU, but would be appropriate for a stage II PU. The facility failed to have a system which ensured timely and accurate assessments of new PU's and new treatment orders for the PU. Due to these failures, the facility failed to provide the necessary treatment and services to promote healing and the PU subsequently increased in size. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 3/6/2020 at 2:25 PM.

Based on closed record review, interviews, review of facility and hospital documents as indicated, it was determined that the facility failed to provide consistent 2 person/staff physical assistance for one (R1) out of two (2) sampled residents, during the entire time the hoyer lift was being manipulated in the shower room. R1 was totally dependent on 2 person/staff physical assistance for bed mobility, transfers to or from: bed, chair, wheelchair and standing position. E4 (CNA) and E5 (CNA/orientee) transported R1 to the shower room via Hoyer lift. While in the shower room, E4 went out of the shower room to get something from the room while R1 was sitting on the shower chair with the hoyer pad underneath the resident. E5, alone, attempted to reposition and remove the Hoyer pad underneath R1. Without the assistance of E4 or another staff member, E5 lifted R1 forward, pulled the pad out from underneath him/her, grabbed it from the side of the shower chair and R1 fell to the floor onto his/her side. R1 was noted to have a bruise/hematoma on the left shoulder related to a fall, that began to bleed and despite the application of pressure and a compressive dressing the area continued to bleed. R1 became hypotensive and was sent to the ER and found to have a hemoglobin count of 6.8 g/dl (previously 8.5 g/dl on 1/16/19), normal range per hospital laboratory is 10.7-15.1 g/dl. R1 was admitted to the hospital and was transfused with 2 units of packed red blood cells (prbc's). The facility failed to ensure that R1 was provided 2 person/staff physical assistance in bathing and in accordance with the resident's assessments and plan of care to prevent accidents/falls. This deficient practice resulted in harm to R1. Findings include: Review of R1's clinical record revealed the following: 1/10/19- R1 was originally admitted to the facility for a rehabilitation stay from the hospital s/p altered mental status and acute kidney injury. R1 was alert, but confused, demonstrated left sided weakness on grip assessment, was severely limited in movement for the BLE (can only wiggle toes), but, cannot move the BLE spontaneously off the bed and had 2 open red wounds (right and left buttocks). 1/10/19 9:00 PM- physician's orders [REDACTED]. This medication was initiated on this same day at 9:00 PM. 1/10/19- A Nursing Fall Risk Evaluation revealed that R1 scored 10, indicating that R1 was a high risk for falls (per 0-10 scoring). 1/11/19 -The facility initiated a Care Plan entitled, Potential for falls r/t decreased mobility and included the following interventions: bed in lowest position when care is not being provided; call bell within reach at all times; non-skid footwear to be worn except during hygiene; PT/OT evaluations as needed. 1/11/19- Another Care plan was initiated entitled, Unable to do own ADLS (activities of daily living, such as bathing and toileting) without assistance R/T generalized weakness. Interventions included: Bed mobility: 2 person; transfers: 2 person hoyer (lift); ambulation: NA (not applicable, R1 does not walk); PT/OT evaluate and treat as indicated. Additionally, a daily Kardex Report (care plan for CNAs) included the following: Transferring: bed mobility - 2 person; transfers: 2 person hoyer (lift); ambulation: NA. 1/24/19- R1's 14 day MDS Admission Assessment stated that R1's daily decision- making skills were severely impaired (BIMS 4). Functional Status: bed mobility-extensive assist/2 person physical assist; transfer-total dependence/2 person physical assist; personal hygiene - extensive assist/2 person physical assist; bathing-total dependence/2 person physical assist. 1/26/19 9:00 AM- An Incident Report (revision date of 3/27/19 -2:33 PM) revealed, Resident had a witnessed fall in shower room when nurse was notified. Resident seen lying on (his/her) back on the shower room floor, resident states (he/she) hit (his/her) head. Report also revealed: Injuries Report Post Incident: injury type: bruise, left shoulder. 1/26/19 (untimed) - The Incident Report revealed that E5 (CNA Orientee) witnessed the fall that occurred in the shower room about 9:00 AM. E5 stated that she/he was in the shower room with resident giving care. I proceeded to lift resident forward to slide, lift pad from under (R1), when the resident slid on the floor and laid on his/her side. 1/26/19 12:11 PM- A Nursing Progress Note revealed, About 0900 (9:00 AM) CNA (E5) called for a nurse to the shower room. R1 had a witness (sic) fall in the shower room, CNA (E5) witnessed fall that occurred in shower room about 0900. CNA (E5) states (he/she) was in the shower room with resident giving care and proceeded to lift resident forward to slide lift pad from under (R1), when resident slid on the floor. Nurse assessed patient, Resident states (he/she) hit the head, no injury noted, no hematoma noted, awake and oriented, denies pain. Resident taking blood thinners. MD notified and ordered to send to ER for further evaluation . Review of the Medication Administration Record [REDACTED]. 1/26/19 1:56 PM- A Nursing Progress Note stated that R1 was sent out to the ER for further evaluation. Additionally, education was provided to the staff involved to ensure resident is a 2 person assist at all times with the hoyer lift used, as well as a shower bed (instead of a shower chair). Hospital Records revealed that R1 was admitted on [DATE] at 9:49 AM and CT scans were determined to have negative findings. R1 was discharged from the hospital at 2:51 PM on the same day. 1/26/19- Educational Documents for E4 (CNA) and (CNA) E5 revealed the following: E5- CNA/Orientee should not be left alone with residents that are 2 person assist or at anytime during the first week of orientation without supervision. E4- When resident is a 2 person assist- do not attempt to transfer or adjust resident alone. 1/26/19- Revised 1/11/19 Care plan for Potential for falls r/t decreased mobility included the interventions: 2 persons for all transfers and repositioning in the wheelchair (after the fall); use shower bed for showers. Nursing Progress Notes upon return from the hospital revealed the following: 1/26/19 3:46 PM- Resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Requires assistance with care. Denies pain and discomfort. Calm and cooperative with staff. Remains alert and oriented to person, place and time and requires total care from staff. 1/27/19 7:47 AM- A Nursing Progress note revealed, .Resident reported sharp BLE pain and dull gluteal pain relieved with rest, repositioning and [MEDICATION NAME] (pain medication) . 1/28/19 2:30 PM- A Nursing Progress Note revealed, .Left shoulder bruise. Pressure applied to bleeding. 1/28/19 3:11 PM- A Nursing Progress Note revealed, Resident noted during AM (morning) care with bleeding on bed sheet. This nurse observed a small bruise to left shoulder. Resident denies pain to site. Resident stated 'it may have gotten there from fall while lying on R side'. 1/28/19 3:12 PM- A Nursing Progress Note revealed, .received new orders for- Cleanse Left shoulder with NSS and apply CDD and pressure if bleeding occurs twice a day .after the dressing was applied the bleeding subsided . 1/29/19 1:15 AM- A Nursing Progress Note revealed, Resident noted with bleeding, pressure and dressing applied with no improvement. Called MD and received new orders. 1/29/19 1:40 AM - A Nursing Progress Note revealed, Received new orders for stat labs for a PTT/INR, CBC, and BMP and a stat ultrasound of the left shoulder .Called mobilex for a soft tissue ultrasound of left shoulder and left upper limb; . 1/29/19 2:36 AM (late entry)- A Nursing Progress Note revealed, During 2330 (11:30 PM) rounds, resident noted with blood soaked through gown and sheets on Left shoulder .bruise noted with pin point open area actively bleeding with bright red blood. Bruise about golf ball size in diameter; resident reports L (left) side is affected side from fall .mild swelling noted .called MD. 1/29/19 2:44 AM (late entry)- A Nursing Progress Note revealed, During 1:00 AM follow up, dressing 100% saturated. No improvement noted. Called MD again about active bleed. New orders STAT labs (CBC, BMP, PTT, PT/INR) and ultra sound with application of ice and pressure. Hold Aspirin and [MEDICATION NAME]. 1/29/19 2:47- A Nursing Progress Note revealed, 2:30 AM .active bleed continues with 1:00 AM dressings 100% saturated . Dressing changed .sharp pain in toes r/t [MEDICAL CONDITION] (nerve pain) . 1/29/19 3:48 AM- A Nursing Progress Note revealed, Dressing changed. Old dressing 75% saturated with bright red blood, Active bleed continues . 1/29/19- 5:02 AM- A Nursing Progress Note revealed, Dressing changed 100% saturated w/ (with) bright red blood . 1/29/19 5:55 AM- A Nursing Progress Note revealed, Dressing changed. Previous dressing 100% saturated . 1/29/19 7:30 AM - A Nursing Progress Note revealed, Dressing changed. 100% saturated. Active bleed continues with no change in rate . 1/29/19 7:39 AM - A Nursing Progress Note revealed, Awaiting call back from M.D. due to bleeding slowing down and then starting to bleed excessively again . 1/29/19 9:00 AM - A Nursing Progress Note revealed, (Name of Physician) in house informed of bleeding over night. N.O. (new order) Send to ER . 1/29/19 5:20 PM - A Nursing Progress Note revealed that R1 was admitted to the hospital with [REDACTED]. 1/30/19 10:16 PM - A Nursing Progress Note revealed that R1 was readmitted to the facility, AAOx2 (alert and oriented to name and place) with intermittent confusion noted DX (diagnosis) LUE (left upper extremity) hematoma and [MEDICAL CONDITIONS] . 1/31/19 5:08 PM- The primary physician's History and Physical revealed, Patient was progressing in rehab and then sustained a fall with ER visit and return back to the facility and was noted to have a hematoma of the left shoulder. Patient with . secondary to history of [MEDICAL CONDITION] and there AD dressing continued to bleed and patient became hypotensive and my concern was that patient was perhaps requiring a transfusion and was sent to the ER. In the ER patient hemoglobin was found to be 6.8 (gm/dl) and patient was transfused 2 units of packed red blood cells and the left shoulder hematoma eventually stop bleeding with continued compressive dressing and patient now returns to facility for PT/OT services . The facility failed to provide continuous 2 person/staff assistance during the entire bath, transfers and repositioning according to the facility's plan of care, to ensure the safety of R1 from a fall. This deficient practice resulted in harm to R1, when he/she sustained a shoulder hematoma which continued to bleed resulting in a transfer to the hospital to receive blood. R1 became hypotensive, hemoglobin dropped to 6.8 gm/dl (low) requiring hospitalization and R1 required blood [MEDICAL CONDITION] with 2 units of packed red blood cells. Findings were reviewed and confirmed with E1 (NHA), E2 (DON) and E3, (ADON) at approximately 12:00 PM on 3/28/19.

Based on record review, review of hospital records and other documents as indicated, observation, and interview, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 (R68 and R121) out of 35 stage 2 sampled residents. R121 experienced a decline in condition between [DATE] and [DATE]. During this time, there were multiple failures by the facility: -Failure to obtain u/a and c/s ordered on both [DATE] and [DATE]. -Failure on multiple occasions to notify the physician of changes in condition. -Failure to accurately and thoroughly assess the resident. -Failure to develop a care plan and identify interventions for use during this episodic period. On [DATE] a physician order [REDACTED]. The BLS report of the same date stated R121 was found unresponsive with hot, dry skin. According to BLS, R121 had fevers for 4 days in the facility. The ER [DIAGNOSES REDACTED]. For R68, the facility failed to remove the resident's icy hot patch as per physician orders. Findings include: Review of an undated facility policy entitled Transcribing Physician Orders, stated, . All physician orders [REDACTED]. Treatments will be transcribed on the TAR . Laboratory/Diagnostic Studies . will be . noted in the nursing progress notes (nurse's notes) . The facility Notification of Condition Change: Physician policy, last revised in ,[DATE], stated, . nurses are responsible to provide timely and complete communication to physician's when there is a change in condition . Types of condition that may require notification of the physician: . altered mental status . change in vital signs including temperature . pain . Document assessment data, attempted or actual correspondence with physician, and physician's response in the medical record . 1. R121, a [AGE] year old resident, was admitted to the facility in 2012. R121 received hospice services from approximately [DATE] until [DATE] when the resident broke her hip and the family wanted rehabilitative services. A quarterly MDS assessment, dated [DATE], coded R121 with severe cognitive impairment. She required extensive one staff person assistance with most ADLs, however, was able to feed herself with supervision after set up help. R121 was not on any special treatment, including hospice. Review of R121's care plan for swelling of her legs/feet, dated [DATE], listed interventions including . Monitor vital signs as ordered and record. Notify MD of significant abnormalities . Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . Review of R121's care plan, dated [DATE], for the problem SOB related to musculoskeletal impairment listed a goal for R121's pulse oximetry (PO2) to remain above 92%. The [DATE] POS included an order, dated [DATE], to titrate R121's oxygen at 2L/min (liters per minute) via nasal cannula every shift to maintain PO2 > 92% as needed. The facility developed a care plan for potential for pain R/T R121's [MEDICAL CONDITION] and surgery to repair the broken hip, dated [DATE]. Interventions included Administer [MEDICATION NAME] as per orders . Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain . Record review revealed the following: NN on [DATE] and [DATE] recorded resident's RR, PO2 and T all within normal limits. There was no documented use of O2 use in the NN's from [DATE] through [DATE]. [DATE] NN (10:43 PM)- coughing, lungs clear and [MEDICATION NAME] ordered to be given every 6 hours as needed for cough. RR 19, T 97.3 F. [DATE] NN (2:49 PM)- no cough noted. Lungs sound clear. T 96.6 F. [DATE] NN (9:44 PM)- no cough. T 98.0 F. There were no NN's for [DATE]. [DATE] NN (2:45 PM)- diet upgraded. [DATE] physician progress notes [REDACTED]. doesn't look well . Feels tired . Mild chills . (lungs) CTA . Malaise r/o UTI . (check) UA & C/S (check) CXR ? cold will F/U. [DATE] physician orders [REDACTED]. dx (diagnosis) SOB, R/O PNA, Urine for UA C/S via telephone by E20 (MD). [DATE] NN (12:57 PM)- new orders for CXR for SOB and u/a and c/s. Lung sounds diminished. C/O not feeling well. RR 16, T 97.8 F. [DATE] NN (2:33 PM)- CXR done, result pending. U/A C/S specimen to be collected. In coming staff will be made aware. [DATE] NN (11:47 PM)- alert and verbally responsive. Cold symptoms persist- medicated with [MEDICATION NAME] for cough. CXR negative for PNA. RR 22, T 98.6 F. [DATE] NN (8:12 AM)- alert and verbally responsive. Cold symptoms persist. [MEDICATION NAME] given for dry cough. RR 22, T 100.7 F- Tylenol 650 mg given for elevated T. There was no evidence in the clinical record that facility staff notified the MD of R121's elevated T. MAR review revealed that R121 received prn Tylenol at 5:45 AM on [DATE]. R121 was due for routinely given Tylenol 650 mg. at 6 AM (she also receives routine Tylenol at 9 PM daily). According to the MAR, the 5:45 AM and 6 AM doses were signed off as given. The only other prn Tylenol given in [DATE] was on ,[DATE] for a headache. [DATE] TAR (untimed)- [DATE] order for urine for UA C/S present. Note written onto back of TAR on [DATE] stating unable to collect urine on ,[DATE] and ,[DATE] shifts due to urinary incontinence. [DATE] physician progress notes [REDACTED]. sick visit . called to review chest xray results (-) . R/O infection . await UA & C/S appears to be [MEDICAL CONDITION] . (no) evidence pneumonia. R121 was seen by E9 (Medical Director). [DATE] physician orders [REDACTED]. [DATE] NN (3:05 AM)- alert and responsive. Episode of SOB with PO2 85%, prn O2 at 2L/min. with PO2 96%. No coughing. RR 20, T 98.0 F. There was no evidence in the clinical record that facility staff notified the MD of R121's abnormally low PO2 despite having ongoing supplemental O2 in place. [DATE] NN (1:55 PM)- lethargic this shift, napping throughout shift. Dry cough- [MEDICATION NAME] given and effective. PO2 99% on room air (without supplemental O2). C/O severe pain all over- medicated per order with positive (+) results. No s/s (signs/symptoms) of distress/SOB. T 96.8 F. MAR review revealed that R121 was medicated with [MEDICATION NAME] IR for generalized pain, ,[DATE] (0 being no pain and 10 being the worst) on [DATE] at 9 AM. R121's pain went down to 0 after being medicated. This was the only prn [MEDICATION NAME] IR given in [DATE]. The facility failed to notify the MD as per the [DATE] pain care plan to Administer [MEDICATION NAME] as per orders . Notify physician if . current complaint is a significant change from resident's past experience of pain . [DATE] NN (4:34 AM)- alert and responsive. No distress. RR 20, PO2 95% on O2 at 2L/min., T 99.4 F. There was no evidence in the clinical record that facility staff notified the MD of R121's elevated T or ongoing need for supplemental O2. [DATE] NN (11:56 AM)- alert and responsive. Tolerated medications and meals. No coughing. PO2 94% on 2L/min O2, T 98.6 F. [DATE] NN (12:46 AM)- alert and verbally responsive. Cold symptoms persist. RR 22, O2 at 2 L/min. T 100.5 F. Given Tylenol at 5 PM for elevated T (not documented on the MAR)- repeat T 99.0 F. There was no evidence in the clinical record that facility staff notified the MD of R121's elevated T or ongoing need for supplemental O2. [DATE] NN (4:35 AM)- alert and verbally responsive. Rested well. RR 20, O2 on at 2L/min. with PO2 96%, T 99.8 F. There was no evidence in the clinical record that facility staff notified the MD of R121's elevated T or ongoing need for supplemental O2. [DATE] NN (1:39 PM)- cold symptoms noted. RR 22, continues on O2 at 2L/min. PO2 95%, T 98.1 F. [DATE] NN (9:39 PM)- alert and resting. Fluids encouraged and continue O2 at 2L/min. No SOB noted. T 96.8 F. There was no evidence in the clinical record that facility staff notified the MD of R121's ongoing need for supplemental O2. Additionally, despite R121's decline and the facility stating they were monitoring for URI symptoms, review of NN's from [DATE] to [DATE] lacked complete lung assessments by nursing, including listening for breath sounds and any abnormal sounds. [DATE] NN (7:19 AM)- alert and verbally responsive. Cold symptoms persist. No distress noted. RR 18, PO2 91% on 2L/min, T 98.4 F. There was no evidence that the facility increased R121's O2 to maintain her PO2 at 92% or > as per physician order [REDACTED]. [DATE] NN (7:31 AM)- new order to straight cath for U/A and C/S. [DATE] NN (3:15 PM)- urine collected. Denies any pain. Fair appetite. Fluids encouraged. Lung sounds clear. PO2 94% (did not state if on O2), T 96.5 F. [DATE] NN (10:21 PM)- U/A and C/S pending, no c/o discomfort while urinating, urine clear yellow without foul odor. T 96.3 F. [DATE] U/A result (untimed)- urine amber and cloudy (as opposed to previous NN in which urine was noted to be clear yellow) with many bacteria. Note on UA result that E9 (Medical Director) aware and he will wait for c/s results- dated [DATE] at 2:30 PM. [DATE] NN (3:08 AM)- alert and responsive. No pain, SOB, or distress. No cough. RR 18, remains on O2 at 2L/min with PO2 94%, T 98.0 F. There was no evidence in the clinical record that facility staff notified the MD of R121's ongoing need for supplemental O2. [DATE] NN (2:01 PM)- alert and verbally responsive. Assisted with feeding. Fluids encouraged. Total care by staff. Out of bed to wheel chair sitting by nurse's station. U/A and C/S pending. RR 20, O2 at 2 L/min with PO2 96%. There was no evidence in the clinical record that facility staff notified the MD of R121's ongoing need for supplemental O2 and that R121 has declined in ADLs now needing total care and having to be assisted with feeding. [DATE] NN (2:17 PM)- High Risk Meeting held with E9 (Medical Director), E2 (DON), E1 (NHA) and E19 (RN). E9 wants to wait for urine c/s results as U/A results inconclusive. Although a high risk meeting was held in which R121 was discussed, there was no evidence that R121 was physically seen or examined by an MD on this date. There were no progress notes written since [DATE], although R121 continued to decline. [DATE] NN (8:27 PM)- cold symptoms persist. RR 18, PO2 94%, T 98.6 F. [DATE] NN (5:15 AM)- alert and verbally responsive. Cold symptoms persist. Urine c/s results pending. RR 20, T 99.3. There was no evidence in the clinical record that facility staff notified the MD of R121's ongoing need for supplemental O2 or elevated T. [DATE] NN (1:50 PM)- urine C/S pending. Urine yellow, no pain or foul odor. Lethargic with poor appetite- refused lunch. No respiratory distress. T 97.2. [DATE] NN (10:53 PM)- Urine C/S results pending. Will contact lab. No concerns this shift. [DATE] NN (11:20 PM)- No cough, SOB, cold symptoms, or distress noted. [DATE] NN (8:05 AM)- Cold symptoms persist. + general malaise. RR 18, O2 at 2 L/min with PO2 93%, T 99.1 F. [DATE] physician progress notes [REDACTED]. In no distress. Lungs clear. Urine c/s + for E. coli > 100,000+ colonies (of bacteria). UTI, [MEDICATION NAME] (ABT) ordered twice a day for 7 days, may thicken (to make it easier to swallow). R121 was seen by E22 (MD). [DATE] physician orders [REDACTED]. [DATE] physician orders [REDACTED]. Obtained telephone order from E22 at 1:46 PM. [DATE] NN (5:52 PM)- monitoring for cold symptoms- has runny nose. No C/O pain. No SOB. Poor intake today. Fluids encouraged and tolerated. Started [MEDICATION NAME] for UTI. Nasal O2 on at ,[DATE] L/min. with PO2 94%. T 97.7 F. [DATE] NN (9:41 PM)- Started new ABT for UTI. Poor appetite this shift, fluids encouraged. PO2 93%, T 97.9 F. [DATE] NN (6:23 AM)- Cold symptoms persist, but remains stable resting in bed. Poor oral intake. Started on [MEDICATION NAME] for UTI. RR 16, PO2 94 %, T 97.6 F. [DATE] NN (4:20 PM)- RR 22, PO2 ,[DATE]% on O2 at 3 L/min. T 100.7 F. Obtained telephone orders for STAT CBC, BMP (laboratory tests) and CXR from E23 (NP) at approximately 12:00 PM. Review of the [DATE] lab results revealed a critical sodium of 155 (,[DATE]), chloride high at 110 (,[DATE]), BUN high at 44 (,[DATE]), creatinine high at 1.8 ((0.6- 1.5), and glucose high at 196 (,[DATE]). WBC count high at 24,000 (3,500- 11,000) indicative of an infection. [DATE] NN (11:37 PM)- CXR shows pneumonia in both lower lobes- new telephone order obtained by E20 (MD) at approximately 5:50 PM for [MEDICATION NAME] (ABT) twice a day for 7 days. CBC and BMP abnormal with no new orders. Fluids provided and tolerated well. RR 20, T 99.8 F. [DATE] NN (3:15 AM)- alert and verbally responsive. T 100.6 F- prn Tylenol given for elevated T. [DATE] NN (7:58 AM)- T 101.3 F (still febrile despite being on ABT's)- prn Tylenol given for elevated T at 5:30 AM. PO2 ,[DATE]% on O2 at 3 L/min. via nasal cannula. Oral fluids encouraged, but not taken well. [DATE] physician orders [REDACTED]. [DATE] NN (12:32 PM)- sent to ER due to PO2 81% on O2 at 2 L/min. + labored breathing with use of abdominal muscles. RR 22, T 100.2 F. Review of NN's from [DATE] to [DATE] lacked complete lung assessments by nursing, including listening for breath sounds and any abnormal sounds. The BLS report, dated [DATE], stated the ambulance crew was notified at 10:59 AM and they reached R121 at 11:05 AM. R121 was found unresponsive with hot, dry skin. BLS immediately applied oxygen at 15 L/min. via a non-rebreather mask (NRB) and after 5 minutes, R121's PO2 increased to 88% and her RR was 36. According to BLS, R121 had fevers for 4 days in the facility. Review of the ALS- medics report, dated [DATE], revealed that ALS met the BLS ambulance at 11:13 AM. BLS reported that R121 found in facility with increased respiratory rate with a PO2 of 79% and change in mental status. Family reported to BLS they noticed changes in resident condition this morning and asked staff to summon 911 (R121 was a DNR). ALS started an IV to administer fluids and monitored R121's heart rhythm and vital signs until they released the resident to the ER at 11:30 AM. During ALS care, R121 opened her eyes and withdrew in response to painful stimuli and she continued to have labored breathing with abnormal breath sounds and a PO2 ,[DATE]% on oxygen via NRB as above. R121's RR ranged from ,[DATE] on a NRB mask at 15 L/min. during the time ALS provided care. Review of hospital ER records, dated [DATE] and timed 11:49 AM, stated that R121 presented to the ER with severe SOB, not worsened or alleviated by anything. R121 had URI with cough for about 2 weeks and few days ago was diagnosed with [REDACTED]. Was diagnosed with [REDACTED]. Has had steady decline in health for past few weeks, acutely worse today. PO2 89% on 15 L/min. NRB + severe respiratory distress, transitioned to [MEDICAL CONDITION] and PO2 improved to ,[DATE]%. Family does not want resident to be intubated or CPR, they want her to be comfortable and are okay with antibiotics and fluids at this time and to see how she does on a trial of [MEDICAL CONDITION]. Laboratory reports upon admission to the ER revealed severe dehydration, AKI, and [MEDICAL CONDITION]. R121's WBC count in the ER was very high at 26,500 (3,500- 11,000), indicating infection. R121's sodium was critically high 163 (,[DATE]), BUN high at 58 (,[DATE]) and Creatinine 1.90 (0.50- 1.00) indicative of dehydration and ARF. The facility developed a care plan . is on Antibiotic Therapy for PNA and UTI on [DATE], the day R121 was sent to the ER and admitted to the hospital. Interventions included, . Report pertinent lab results to MD (dated [DATE], although care plan developed on [DATE]). Although R121 showed a decline with URI symptoms for 2 weeks, the facility failed to develop a care plan with interventions for it. The hospital Discharge Summary, dated [DATE], listed [DIAGNOSES REDACTED]. A Doctor's Order Sheet Certification Of Medical Necessity For Transport By Ambulance, dated [DATE], stated that R121 was being transferred to a hospice unit in another hospital d/t . nonresponsive/catatonic . end stage dementia . R121's death certificate listed the immediate cause of death [MEDICAL CONDITION] followed by aspiration pneumonia. date of death was [DATE]. An interview was done with E9 (Medical Director) on [DATE] at 3:04 PM. E9 stated he recalled this case somewhat. Reviewed u/a and c/s ordered on [DATE] and on [DATE] a physician order [REDACTED]. R121 with elevated temperatures, decreased appetite and lethargic. Another physician order [REDACTED]. E9 stated he was not the primary care physician for R121, but he would expect if he orders something for it to be done. Findings were reviewed with E1 and E2 during an interview on [DATE] at approximately 3 PM. 2. R68 was ordered to have an Icy Hot Patch applied to her back for pain relief every day at 8 AM and removed every night at 8 PM. Review of R68's [DATE] MAR revealed that the 8 PM removal of the icy hot patch for R68 was signed off as completed on [DATE]. An observation during medication administration on [DATE] at 8:59 AM revealed that E10 (RN) removed the previous day's icy hot patch prior to applying the new patch. In an interview on [DATE] at approximately 2:30 PM, E10 confirmed that the icy hot patch she removed should have been removed on [DATE] at 8 PM. The facility failed to follow physician orders [REDACTED].

Based on record review, staff interview and review of other facility documents, it was determined that the facility failed to provide adequate monitoring for one (R15) resident's drug regimen out of 40 Stage 2 sampled residents. For R15, her [MEDICATION NAME] ([MEDICAL CONDITION] (abnormal electrical activity in the brain causing repetitive muscle jerking) medication) dose was increased on 4/17/14 after her blood level was found to be below therapeutic level at 7.8 (low - normal range is 10-20 ug/ml (micrograms per milliliter)). The facility failed to monitor the [MEDICATION NAME] blood level to determine if R15 was in the therapeutic range after the dosage was increased on 4/17/14. R15 was subsequently hosptalized on [DATE] for a change in mental status and her [MEDICATION NAME] level was 37.8 ug/ml (critically high value) on 5/12/14 and went as high as 38.8 ug/ml (critically high value) on 5/13/14. R15's hospital discharge [DIAGNOSES REDACTED]. Findings include: Pfizer is the manufacturer of [MEDICATION NAME] and the following information was obtained from their website; https://www1.pfizerpro.com/hcp/[MEDICATION NAME] stated, " ...When changing the dosage form or brand, you should carefully monitor patient's [MEDICATION NAME] serum (clear fluid obtained from whole blood) levels ... There are many drugs that may increase or decrease [MEDICATION NAME] levels or may be affected by [MEDICATION NAME]." According to the website http://labelng.pfizer.com/ShowLabeling.aspx?id=546, "... Steady-state therapeutic levels are achieved at least 7 to 10 days (5-7 half-lives) after initiation of therapy with recommended doses of 300 mg/day. When serum level determinations are necessary, they should be obtained at least 5-7 half-lives after treatment initiation, dosage change, or addition or subtraction of another drug to the regimen so that [MEDICATION NAME] or steady-state will have been achieved...Peak (highest concentration) levels indicate an individual's threshold for ... dose-related side effects and are obtained at the time of expected peak concentration. For [MEDICATION NAME] capsules, peak serum levels occur 4 to 12 hours after administration. Optimum control without clinical signs of toxicity occurs more often with serum levels between 10 and 20 mcg/ml... Warnings ... Patients treated with any AED (antiepileptic/[MEDICAL CONDITION] drug) for any indication should be monitored... for any unusual changes in mood or behavior ... Adverse Reactions ... Nervous System ... most common adverse reactions encountered with [MEDICATION NAME] therapy are nervous system reactions and are usually dose-related. Reactions include...slurred speech...and mental confusion... Overdosage ... The initial symptoms are... dysarthria (speech that is characteristically slurred, slow, and difficult to understand). Other signs are...lethargy (lack of energy/abnormal drowsiness), slurred speech, nausea, vomiting. The patient may become comatose (unconscious) and hypotensive (low blood pressure)... Dosage and Administration Serum concentrations should be monitored ... Allergic reactions or serious problems ... Symptoms can include ... severe fatigue or weakness; nausea or vomiting... Most common side effects of [MEDICATION NAME] include: slurred speech, confusion, dizziness, nausea, vomiting ...". R15 had [DIAGNOSES REDACTED]. The following documentation was contained in R15's clinical record: R15's care plan, dated 8/31/12 and entitled, "... [MEDICAL CONDITION] Disorder r/t (related to) Stroke" included the following interventions: "... Give medications as ordered. Monitor/document for effectiveness and side effects; Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness; Monitor labs and report any subtherapeutic or toxic results to MD (medical doctor); Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated ..."; 3/27/13 - Quarterly MDS - R15 was alert and oriented with independent decision making. [DIAGNOSES REDACTED]. 4/17/13 - Lab result for "Therapeutic Drug Monitoring - [MEDICATION NAME]/[MEDICATION NAME] (generic for [MEDICATION NAME]) - 9.4 L (low)". The therapeutic range was listed as 10-20 ug/ml; 4/18/13 - A physician's orders [REDACTED]. 4/29/13 - A physician's orders [REDACTED]. 5/30/13 - Annual H & P (History and Physical) stated, "... Plan: ... [MEDICAL CONDITION] D/O (disorder) - [MEDICAL CONDITION] free, [MEDICATION NAME] 100 mg TID (three times a day)... "; October 2013 - No evidence of a [MEDICATION NAME] level done in October 2013 as previously ordered; 12/26/13 - Quarterly MDS- R15 was alert and oriented with independent decision making; 2/17/14 - physician's orders [REDACTED]. According to the web site, http://labeling.pfizer.com/ShowLabeling.aspx?id=546, "... Drugs that may increase [MEDICATION NAME] serum levels, include: ... [MEDICATION NAME]"; 2/18/14 - Readmission H & P stated, "... Plan: ... [MEDICAL CONDITION] D/O - Stable Lo/[MEDICATION NAME] (below therapeutic level) ..." despite no evidence of labwork for a [MEDICATION NAME] level since 4/17/13. 3/23/14 - Quarterly MDS - was unchanged for R15 in the area of decision making; The 4/2014 Physician order [REDACTED]. 4/12/14 - Lab result for "Therapeutic Drug Monitoring - [MEDICATION NAME]/[MEDICATION NAME] - 7.8 L (low). " R15's [MEDICATION NAME] level remained low; more so, than when it was checked in the facility, a year ago on 4/17/13 (decreased from 9.4 to 7.8); 4/15/14 - Doctor's progress note stated as part of the plan, "...sz ([MEDICAL CONDITION]) free on [MEDICATION NAME] ..."; 4/17/14 - An untimed telephone verbal doctor's order stated, "(increase) [MEDICATION NAME] 150 mg PO (by mouth) TID for [MEDICAL CONDITION]" This increased R15's [MEDICATION NAME] from 300 mg to 450 mg per day; April 2014 Medication Administration Record [REDACTED]. an order for [REDACTED]. 4/18/14 at 10:32 AM - A nurse's note stated, "New order to increase [MEDICATION NAME] from 100 mg to 150 mg TID ..."; May 2014 MAR - Revealed that R15 received [MEDICATION NAME] 150 mg TID from 5/1/14 through 5/12/14 at 9 AM more than 24 days for a total of 74 doses, yet, there was no evidence that monitoring for a therapeutic level was implemented; 5/11/14 at 11:09 PM - A nurse's note stated, "... Noted with moderate amount emesis (vomit) at dinner or (sic) undigested food. Stable at this time with no further emesis noted"; 5/12/14 at 4:21 AM - A nurse's note stated, " ... No N/V (nausea/vomiting), no emesis Resident is on ABT(antibiotic) for treatment of [REDACTED]. No c/o (complaints of) pain or discomfort"; 5/12/14 at 11:45 AM - A nurse's note stated, "resident vomit x (times) 1, [MEDICAL TREATMENT] rescheduled ..."; 5/12/14 at 12:35 PM - A nurse's note stated, "resident screaming out, grasping for staff, usually A&OX3 (alert and oriented times three to person, place and time) A&OX1 now B/P (blood pressure) high this am (morning) rechecked at 1130 (11:30 AM) 148/96 (normal = 90/60 to 120/80), 102 (pulse/normal =60-100 beats per minute), 24 (respirations/normal = 12-18 breaths per minute) ... Dr. (name) informed N.O. (new order) send to (hospital), RP (responsible party) (name) informed"; 5/12/14 at 4:23 PM - A nurse's note stated, "Pt (patient) B/P was 150/154 (sic), 154 (pulse). Pt c/o feeling nausea (sic), but no ememes (sic) at that time. Night shift reported that pt vomited x 1. Rechecked B/P 129/114, 90 (pulse). Dr. (name) ordered [MEDICATION NAME] (medication used to treat nausea and vomiting) 4 mg x 1 dose stat (now). No order for B/P meds at this time, Pt was on her way to [MEDICAL TREATMENT] when she vomited x 1. Pt seemed confused and agitated. Dr. called new order to sent (sic) pt. out to evaluated (sic)"; The following documentation was contained in R15's hospital record: 5/12/14 at 12:31 PM - The "Prehospital Care Report" completed by first responder on the seen (ambulance personnel) stated, "... patient, sitting in a wheelchair, alert to verbal stimuli... displays no obvious visual signs of immediate life threatening conditions... Facility staff relays that patient has an acute mental status change... advised that she is normally alert, oriented, and verbal, however, today she is aphasic (loss of ability to understand or express speech), alert to verbal and painful stimuli, and somewhat combative... flails her arms at personnel unless told what is going on, and then is cooperative ... communicates to the negative when asked if she feels ok ... is incontinent to urine, and has postictal (altered state of consciousness after an epileptic [MEDICAL CONDITION] type stare when aroused... has contractions of her right side with a right sided facial droop. Staff relays that the contractions are from a [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke), however, the facial droop was a new onset... transported to the closest facility (name of hospital) due to stroke like and [MEDICAL CONDITION] signs ..."; 5/12/14 at 1:03 PM - (Hospital) emergency room record - describes R15 as "...lethargic... eyes open and mumbles with stimuli ... speech unintelligible ... confused/combative ... weakness ... decrease psychomotor ... non-communicative ... Clinical Impression Altered Mental State ... [MEDICATION NAME] Toxic ... Disposition - admitted ..."; 5/12/14 at 2:07 PM - [MEDICATION NAME] Level = 37.8 - with the notation "result (s) checked and called to and read back to (name) on 5/12/14 at 2:59 PM; 5/12/14 at 6:06 PM - Hospital "Admission History and Physical" stated chief complaint was change in mental status; Labs: elevated phyenytoin (sic); Assessment/Plan ... Toxic [MEDICAL CONDITION] secondary to [MEDICATION NAME] toxicity. Discussed with poison control, who recommend monitoring [MEDICATION NAME] level until it is metabolized (processed and used by the body). Admit ..."; 5/12/14 at 10:55 PM - Interdisciplinary Admission Assessment stated R15's admitting [DIAGNOSES REDACTED]."; 5/13/14 at 09:59 AM - Doctor's consult stated, "... Impressions: 1. [MEDICATION NAME] toxicity 2. Chronic stroke ... 3. [MEDICAL CONDITION] disorder ... Recommendations: 1. Discontinue [MEDICATION NAME] 2. [MEDICATION NAME] ([MEDICAL CONDITION] drug) 500 mg bid (twice daily) plus an additional 500 mg following each [MEDICAL TREATMENT]..."; 5/13/14 at 11:10 AM - A doctor's note stated, "F/U (follow up) toxic [MEDICAL CONDITION]/ (change) MS (mental status)... A/P (assessment/plan): (1) Toxic [MEDICAL CONDITION] - likely secondary to (increased) [MEDICATION NAME] level..."; 5/13/14 at 1:15 PM - A doctor's note listed, "... Assessment/plan: (1) Acute toxic [MEDICAL CONDITION] - improving. Monitor. (2) [MEDICATION NAME] toxicity - monitor [MEDICATION NAME] level ...; (4) [MEDICAL CONDITION] - now on [MEDICATION NAME] ...; 5/13/14 at 4:20 PM - Critical lab value - [MEDICATION NAME] 38.8; 5/13/14 - Untimed nephrology (kidney specialist) consult stated, "... [MEDICATION NAME] level 37 ... (Change) mental status ... [MEDICATION NAME] overdose... monitor [MEDICATION NAME] level ..."; 5/14/14 at 10:30 AM - A doctor's note stated, "... [MEDICATION NAME] (lab value) 24.7 ... confusion - improving ... [MEDICATION NAME] Overdose ...; 5/15/14 at 10:55 AM - A doctor's note listed, "... [MEDICATION NAME] level at 23.3 ... Acute toxic [MEDICAL CONDITION] - likely secondary to [MEDICATION NAME] toxicity - improving. Will monitor [MEDICATION NAME] level ... "; 5/17/14 at 4 AM - Lab value for [MEDICATION NAME] - 13.4; 5/18/14 9:35 AM - A doctor's note stated, " ... [MEDICATION NAME] toxicity - resolved ..."; 5/19/14 at 2:30 PM - Renal doctor note stated, " ... awake ... confused ... [MEDICATION NAME] overdose ..."; 5/21/14 at 5:39 PM - Interagency discharge orders listed, "Reason for admission: Toxic [MEDICAL CONDITION] - change mental status - [MEDICATION NAME] toxicity... Discharge diagnosis (es): [MEDICATION NAME] toxicity - [MEDICAL CONDITION] (low blood pressure) (possible [MEDICAL CONDITION] (glands, located on top of each kidney, that do not produce adequate amounts of steroid hormones))...". Upon R15's readmission to the long term care facility, E17 (doctor) completed a H & P, dated 5/22/14, which stated, "... s/p (status [REDACTED]. Dr. (name)...Assessment & Plan: ... (1) TME (Toxic metabolic [MEDICAL CONDITION]) causing (change) MS; (2) [MEDICATION NAME] toxicity - (Changed) to [MEDICATION NAME]. F/U (Follow up) c (with) Dr. (name); (3) Possible [MEDICAL CONDITION] ...". On 8/7/14 at 1:36 PM, during a telephone interview, E18 (Medical Director) stated that he could not speak for another clinician, but he would have rechecked the [MEDICATION NAME] level to see if the change in dose led to the desired result. The facility failed to monitor R15 for the progression to the therapeutic goal and/or evaluation of adverse consequences of medication administration. On 5/13/14, R15 was found to have a toxic [MEDICATION NAME] blood level of 38.8 ug/ml (critical level), which resulted in a ten day hospitalization for toxic [MEDICAL CONDITION] and [MEDICATION NAME] toxicity. On 8/7/14 at 4:10 PM, findings were discussed with E1 (NHA), E2 (DON) and E19 (CCS).

Based on record review, observation, interview and review of hospital records and other facility documents, it was determined that the facility failed to ensure that two (R49 and R79) out of 37 Stage 2 sampled residents' environment remained as free from accident hazards as is possible. The facility failed to ensure the environment was free of accident hazards to prevent an avoidable accident that resulted in an injury to R79. The facility was aware that the closet that stored the motorized wheelchairs, battery chargers and coated electric wires cluttered on the floor was kept closed but unlocked and could be accessed by anyone. The facility was also aware that R79 put his motorized wheelchair away in this storage room by himself before bedtime and continued to allow him to do so. R79 was found on his buttocks on the floor, reportedly tripped on a wire , hit his head on the wall as he was putting away his motorized wheelchair. R79 sustained bleeding skin tears on his left hand, a hematoma on the base of his neck and complained of pain. R79 was sent to the emergency room for evaluation and was subsequently admitted to the hospital with [REDACTED]. For R49 the facility failed to ensure that staff properly used transfer equipment and followed procedures thereby creating an accident hazard for R49 during a Hoyer lift transfer. The Hoyer lift tipped over, R49 fell and sustained a right hip fracture requiring surgical repair. Additionally, based on repeated observations and interview, it was determined that the facility failed to provide handrail access in the area joining the West end of hallways A and B on the second floor. Findings include: Cross refer F280, example #1 1. R79 had [DIAGNOSES REDACTED]. According to R79's Admission Minimum Data Set (MDS) assessment dated [DATE] , his cognitive skills for daily decision-making were "moderately impaired:decisions poor; cues/supervision required". R79 was independent in all of his Activities of Daily Living (ADLS) but had physical performance limitations in balance, gait, strength and muscle endurance. R79 had impaired balance during transfers, and gait problems, such as unsteady gait, even with a mobility aid or personal assistance. R79 used a cane and/or motorized wheelchair as a mobility device. R79 received an antianxiety psychotropic drug Clonazepam 0.5 mg tablet 1 tablet twice a day. R79 was assessed as a high risk for falls and had a history of [REDACTED]. The facility initiated a care plan for R79, dated 4/26/12 entitled, "Dementia: Resident demonstrates short and long term care memory; demonstrates impaired decision-making ability". The care plan intervention included: "Observe and document behavior carefully; Keep MD informed and Ensure resident safety". Another care plan was initiated on 4/26/12 entitled "Resident is at High Risk for falls secondary to self reported fall" [DIAGNOSES REDACTED]. The approaches included "increased supervision after room change and Follow Protocol for Prevention of Falls." According to R79's 3-11 PM shift nurse's note dated 7/20/12, "Resident was in the room that housed the motorized wheel chairs shouting for help. CNA went to the room to find him on the floor with blood oozing from (L) hand where he had sustained a skin tear. Resident stated "I (sic) putting away my w.c (wheelchair) and when I got up my feet got tangled in the wire (lost his balance per incident report) and I fell back and hit the wall. Resident complained of pain in his neck area,..rated pain as "6" ( rated "8"/incident report) unable to lift head upward due to pain...Hematoma at nape of neck Call made to on call physician...order obtained to send to Hospital for evaluation. Resident was found in wheelchair room at 2050 (8:50 PM). Was transported via 911 (hospital ER) at approximately 2115 (9:15 PM)". According to the incident report dated 7/20/12, a neck collar was applied by Paramedic before he was transported to the hospital. According to the hospital MRI (Magnetic Resonance Imaging) findings, R79 sustained fractures of C1 (cervical vertebral body 1), acute fracture of the T3 (thoracic vertebral body) with slight compression, epidural hematoma in the ventral aspect of the spinal canal at the level of C1 and thin hematoma of the posterior aspect of the spinal canal through much of the cervical region. According to the hospital physician's clinical summary and decision making, R79 had "C1 burst fracture, C1-C2 instability and Epidural hematoma. Surgical stabilization would likely be necessary, and would likely involve an occiput to C2 fusion which would likely result in 50% reduction in the patient's range of motion including flexion, extension and lateral rotation...the patient's family may elect to treat it simply in a collar. However, the injury is unlikely to heal fully. Nevertheless, surgery may become necessary. The patient is currently on Coumadin (blood thinner). Coumadin will need to be normalized and reversed". R79 was discharged back to the facility with a Miami-J collar that was to remain on at all times for 8-10 weeks. In an interview with E19 (CNA) on 8/10/12 at 3:45 PM, she stated that the resident was non-compliant and abusive. He would do what he wanted to do. He always put his motorized wheelchair in the storage room at night without supervision and would not listen to the staff that he was not allowed to go to the wheelchair storage room. (The facility failed to Care Plan for this non-compliance.) It was observed on 8/10/12 that the motorized wheelchair storage room contained approximately 4 motorized wheelchairs, electric battery chargers on the wall and black coated wires on the floor. A sign was posted on the door that stated "Staff Only" and "Please keep the door closed at all times". According to E19 (CNA), during the 8/10/12 interview, the sign had been posted on the door before the accident occurred and the door had no lock on it prior to R79's fall. A lock was installed after the accident. Interview with E20 (LPN) on 8/10/12 at 4:00 PM confirmed that R79 had always been non-compliant about not entering the storage room by himself. E20 stated, "If I work that side of the unit (passing medication), I watched him. Last night, he tried to do it again but the door was locked. He waited for a while, then he did not attempt anymore to open it and went back to his room". The facility failed to ensure the resident's environment was free from accident hazards when the storage door was unlocked which housed numerous electrical wires and motorized wheelchairs accessible to R79. This finding was discussed with E1(Administrator) and E2 (DON) on 8/14/12. 2. R49 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to both the 12/28/11 admission Minimum Data Set (MDS) assessment and the 6/28/12 quarterly MDS assessment, R49 was cognitively intact and was totally dependent on 2 staff for bed mobility and transfers. These same MDS assessments stated that R49 did not ambulate in the room or in the corridor. The facility developed a care plan for ADLs (Activities of Daily Living) on 12/29/11, which was last reviewed on 7/5/12. This care plan stated that R49 required maximum assistance of 2 staff for transfers with a Hoyer lift. The facility policy entitled, "Mechanical Lift" stated, "...Guidelines: The portable lift is to be used by two nursing assistants to perform the procedure...Steps:..10. To put the resident back to bed, you should:..f. Assist the resident in guiding his or her legs..." An Incident Report, completed on 8/5/12 at 2:50 PM by E12 (nurse) stated "Heard a loud noise from residents room upon entering the room I saw resident lying on right side of bed on the floor on his back with the lift wedged between the bed and bedside table. Resident was still hooked up to hoyer lift denied hitting his head (complained of) right hip pain." Review of the Fall Investigation Form, dated 8/5/12 revealed that R49 was being transferred from a wheelchair to bed via a Hoyer lift by E10 (Certified Nurse's Aide-CNA) and E11 (CNA). The clinical record revealed that R49 was sent out to the hospital on [DATE] for evaluation of the right hip pain and was subsequently admitted for a right hip fracture that required surgical repair. R49 returned to the facility, post hospitalization , on 8/8/12. A Reportable Statement completed by E11, dated 8/5/12 stated, "(R49) asked me to put him to bed at 2:30 PM and I asked (E10) to help me get him into the bed. In the process of putting him to bed the machine till (sic) over and he fall (sic) at the right side off (sic) the bed." A Reportable Statement completed by E10, dated 8/5/12 stated, "(E11) ask me to help her put (R49) in the bed. As she trun (sic) to put him in the bed the lift tilt over...I was in the room with (E11) at the time this happing (sic)." A second Reportable Statement completed by E10, dated 8/6/12 stated, "I (E10) was ask (sic) by (E11) to spot her with (R49) I did so First we wt (weighed) him then (E11) start to turn the lift toward the bed the next thing i new (sic) the lift was on it side and (R49) was on the floor." On 8/13/12 at approximately 2:00 PM, E10 was interviewed in R49's room. E10 was asked to describe and demonstrate what had occurred on 8/5/12 when R49 had the fall while being transferred with the Hoyer lift. E10 stated that she was asked to "spot" the Hoyer transfer from wheelchair to bed. She stated that the resident's wheelchair was positioned at the foot of the bed, facing the doorway and that R49 was assisting E11 in hooking up the sling straps to the Hoyer lift. E10 stated that E11 said she had to weigh the resident so she (E10) stepped over to the resident's right side to zero out the scale on the Hoyer, and then they lifted and weighed R49. E10 stated she then had to step back, off to E11's left, as she had to back the Hoyer out in order to then get it into position under the bed. When asked, E10 stated that the legs of the Hoyer were opened appropriately because of the resident's oversized wheelchair and that the bed was in mid position and not in the low position. She stated that the wheels on the Hoyer were not locked (according to the facility's "Safe Transfer: Mechanical Lifts-Hoyer...The wheels of the lift are never to be locked unless lift is being stored. Locking of the wheels during transfer may cause the lift to tilt."). She said that E11 had to back up and turn the lift and then it tilted and the resident fell to the floor. E10 stated that the lift fell on to the edge of the over bed table which was off to the side of the bed headboard. E10 stated that she did not see anything done incorrectly. According to her statement, E10 was standing behind and to the right of E11 when she was maneuvering the Hoyer back and towards the bed. E10 did not guide the resident's legs or have a hold on the sling. On 8/13/12 at 2:20 PM, R49 was attempted to be questioned about the fall. He became very angry and said that he was "sick and tired of everyone asking him about this repeatedly." He did state that the hoyer tipped and that he has felt it tipping in the past during various transfers, so he doesn't understand why everyone is saying that they shouldn't tip over. R49 did state that the machine was working correctly and that the aides "did nothing incorrectly." On 8/13/12 at 3:10 PM, E11 was interviewed by two (2) surveyors. A Hoyer lift (not the lift involved) was taken into R49's room and E11 demonstrated how she transferred R49 on 8/5/12. E11 demonstrated that she backed up the hoyer then proceeded to direct the Hoyer legs under the bed. Prior to directing the legs under the bed she slightly closed the legs of the Hoyer (this particular Hoyer only had 2 locking positions for the legs; wide open or closed/parallel). She stated that when she started pushing the legs under the bed, the lift tilted and the resident landed on the floor near the head of the bed. On 8/14/12 at 10:15 AM, E1 (Administrator) was interviewed. E1 stated there was no identified problem with the Hoyer, and that the CNAs did not say there was an operational problem with the hoyer. Despite this whenever there is a problem with equipment, it is removed from the floor and checked by Maintenance, who did not find any problems with the lift. Additionally, the lift supplier was called in to check the lift. An adjustment was done to a spring inside the mechanism to tighten the locking of the base legs when in closed or open position, but that this adjustment was routine and not the cause of the fall. Although R49's Hoyer transfer was completed with two (2) staff in the room, there is no evidence that staff were holding onto the sling/resident while the lift legs were being positioned under the bed. The staff failed to follow the facility policy which states "Assist the resident in guiding his or her legs." In an interview with E9 (CNA) on 8/14/12 at 11:00 AM, E9 stated that during a Hoyer transfer two CNAs are in the room. One CNA operates the Hoyer controls and the other guides the resident with the strap on the back of the sling. She stated that at times due to the size of the room and equipment it is hard to maneuver in the room, as they are small and sometimes crowded. In an interview with E8 on 8/14/12 at 11:20 AM, E8 stated 2 CNAs are present during a Hoyer transfer, one controls the Hoyer, the other guides the resident with the strap on sling. Stated she always makes sure that she has space to work and clears clutter out of the way. 3. Repeated observations and interviews revealed that the facility failed to provide handrail access in the area joining the West end of hallways A and B on the second floor. Observations are as follows: On the second floor on 8/2/12 at 8:10 AM revealed that the handrails on one side of the back hall were obstructed by an empty portable trash cart, Diapulse machine, hoyer lift and one (1) Geri-chair outside of room 218. On the back hall, the handrails on one side were obstructed by a motorized chair and one (1) Geri-chair and on the opposite side there were two (2) wheelchairs. Hall B had equipment stored on both sides of the hall. Observations were confirmed by E14 (RNAC). E14 instructed staff to move equipment to one side of the hall. On the second floor on 8/2/12 at 8:15 AM revealed that at the corner of Hall B and the back hall by room 226, there was a floor "caution" cone in the hallway which opened to a very small area to walk through on the back hall between rooms 226 - 201. The handrails on both sides of the back hallway between rooms 226 and the locked storage room were obstructed by two (2) wheelchairs and a hoyer lift and from the locked storage room to room 201, there was one (1) foam chair and a flat bed maintenance cart. On the opposite side of the hall, there were three (3) wheelchairs and a Geri-chair. At 8:25 AM, observations were confirmed by E6 (nurse manager) who stated, "Well, it should be on one side of the hallway and not all jammed up like this... the cart was probably left by maintenance and should be in the basement as well." E6 proceeded to move equipment to one side of the hall. On the second floor on 8/8/12 at 11:15 AM revealed that the handrails on one side were obstructed by two (2) Geri-chairs and a Geri-chair and wheelchair on the opposite side. Observations were confirmed by E10 (CNA). On the second floor on 8/9/12 at 12:00 PM revealed that the handrails on one side of the hallway were obstructed by two (2) wheelchairs and two (2) Geri-chairs, an oxygen cylinder, linen cart and a walker on the opposite side.

Based on observation, record review and interview, it was determined that the facility failed to maintain acceptable parameters of nutritional status, such as body weight for one (R6) out of eight (8) sampled residents. R6 experienced a severe weight loss of 12 lbs. or 9.5% over a three (3) and 1/2 month time period. Findings include: Facility policies state the following: Policy entitled "Nutrition" states "...In evaluating weight loss, the dietitian will consider the resident's usual weight through adult life; the assessment of potential for weight loss; and care plan for weight management..." Policy entitled "Nutritional Care Planning Process" states "...7. Criteria to be considered in determining those whose weights need weekly monitoring are as follows: d. Significant (unplanned) weight loss until weight loss has stabilized...8. Those who fall within significant weight loss range are reported to physician, dietary, RNAC (Registered Nurse Assessment Coordinator), responsible party, nursing administration and Administrator for interventions within 24 to 48 hours...11. Care plan will be updated significant weight loss and updated at weekly weight meetings..." Policy entitled "Weighing and Measuring the Resident" states "...14. Assess for significant weight loss/gain. 15. Reweigh if weight loss/gain is 5 pounds or 5% of previous weight within 24 hours." Policy entitled "Supervision of Resident Nutrition" states "...7. Food and fluid intake must be observed by nursing personnel at each meal. The amount eaten (e.g., 25%, 75%, etc.) must be recorded and/or reported to the charge nurse. Deviations from the normal patterns must be recorded in the resident's medical record. This information must be provided to the attending physician and dietitian and/or dietary manager..." Policy entitled "Snacks (Between Meal and Bedtime), Serving" states "...8. Remove the snack tray when the resident has finished his or her snack. (Note: Allow the resident plenty of time to eat his or her snack and note the percentage consumed.)..." R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. Review of the diet requisition slip, dated 10/13/11 revealed R6 was to receive a regular diet, small portions and a bedtime snack. R6's admission weight was 135 lbs on 10/13/11. A Comprehensive Nutritional Assessment, completed on 10/17/11 by E4 (Registered Dietitian-RD), noted R6 with a total score of "3." A total score greater than 12 indicated high risk for [MEDICAL CONDITION]. E4 wrote that R6's ideal body weight (IBW) was 115 lbs. The UBW (usual body weight) was blank. The assessment did not identify [MEDICAL CONDITION] (swelling of soft tissues as a result of excess water) as a [DIAGNOSES REDACTED]. On 10/17/11 a care plan was developed for the problem "Resident has: therapeutic diet." The nutrition care plan failed to identify the goals of this care plan and failed to include measurable objectives and timetables. The care plan's only listed approaches were "diet as ordered:" A revision dated 10/27/11, stated "give hot coffee 3 times a day, takes it black (with) 2 sugars..." On 10/19/11, R6's weekly weight was 125 lbs., a weight loss of 10 pounds or 7.4% in one week. There was no evidence that a re weigh was completed within 24 hours as per facility policy. Additionally, there was no evidence that the physician was consulted and POA notified. A nutrition note, dated 10/19/11 stated that the height had been obtained and the assessment completed. A second nutrition note, dated 10/26/11 stated R6's weekly weight on 10/26/11 was 127 lbs. and on 10/19/11, 125 lbs. and that the weights were stable. Neither the 10/19/11 or 10/26/11 nutrition notes mentioned the weight loss. According to the admission Minimum Data Set (MDS) assessment, dated 10/20/11, R6 was independent for eating with setup help only. Review of the clinical record revealed that R6's weekly weights remained stable at 127 lbs. on 11/2/11 and 11/9/11. Despite the stability of weights from 10/19/11 through 11/9/11, R6 had already lost 5.9% of her weight (wt) since admission (one month). A nutrition note, dated 11/16/11, stated "New admit (follow up). Admit 135 lbs., 10/19 125 lbs., 10/26 127 lbs., (positive) diuretic use. Likely cause of initial weight (loss) current wt WNL (within normal limits) of IBW (ideal body weight). No other changes noted reassess as needed." This note again referenced IBW instead of UBW, as per facility policy. Review of physician's progress notes and nurse's notes from 10/13/11 through 11/16/11 did not state that R6 had any problems with [MEDICAL CONDITION]. A physician's progress note, dated 11/17/11 stated that R6's responsible party (POA) had requested that the resident receive one can of boost or ensure (dietary supplements) daily. An order was written on 11/17/11 for R6 to receive one can a day of regular Resource (supplement) 240 mls. Review of meal intake records from 10/13/11 through 11/30/11 revealed R6 was consuming 25-100% of her meals, with the majority being over 50%. On 12/1/11, R6's monthly weight was 126 lbs. A physician's progress note, dated 12/13/11 stated "...states she has decreased PO (oral) intake and (decreased) appetite. States gets full quickly after meals. Feels depressed at times...complained of non productive cough x 2 days...encourage (increased) PO intake, no limitations in diet..." On 12/13/11 the physician wrote an order for [REDACTED]. Review of meal intake records for 12/11 revealed that for 66 out of 90 meals (73%), R6 consumed 50% or less. There was no evidence in the clinical record that this decline in intakes was identified or addressed by facility staff or that R6 was being encouraged to eat. Additionally, the clinical record lacked evidence that the bedtime snack, listed on the diet requisition slip dated 10/13/11, was being provided and or consumed by the resident. The MAR indicated [REDACTED]. On 1/6/12, R6's monthly weight was 122 lbs., an additional 4 lb weight loss since 12/1/11. A quarterly nutrition assessment was completed on 1/9/12, which now stated that R6's UBW was in the 120's. The assessment stated that R6's intakes remain 25-75% for meals and the Resource was accepted 100% per nursing records. Review of meal intake records from 1/1/12 through 1/30/12 revealed that for 65 out of 90 meals (72%), R6 consumed 50% or less. The MAR indicated [REDACTED]. Although, from 1/14/12 through 1/30/12, the Resource was signed off as being given, the staff failed to document the percentage consumed by the resident. The clinical record continued to lack evidence that the bedtime snack was being provided and or consumed or that R6 was being encouraged to eat. On 1/17/12 the care plan noted that it was reviewed and to "continue care plan." There were no changes made to the plan of care. On 2/1/12, R6's monthly weight was 115 lbs., an additional 7 lbs. weight loss since 1/6/12. This was a total weight loss of 12 lbs. weight or 9.5% since 10/13/11 (time frame of 3 and 1/2 months). The record revealed that a re weigh was not completed until 5 days later on 2/6/12, instead of within 24 hours. A nutrition note, dated 2/8/12 stated "Wt note: 115 lbs Re wt 115 lbs. Suggest sig (significant) loss 5.7% in 1 month, 9.4% in 3 months. Meal intakes remain variable. Supplement in place to ensure adequate intakes. Wt @ IBW. (No) further loss desired. Monitor weekly wt x 4 and (increase) Resource 2.0 to 240 ml BID (twice daily)." This note again addressed IBW instead of UBW, as per facility policy and incorrectly identified the weight loss as significant when it was a severe weight loss. Review of the nutrition care plan revealed that there were no changes made when a severe weight loss was identified. The clinical record lacked evidence that R6's physician had been consulted and that the POA had been notified. R6 was observed on 2/10/12 eating her midday meal of which she consumed 25%. While speaking with the resident, she stated that she did not want anything else and that she has never been a big eater. In an interview on 2/10/12 with R6's POA, the POA stated that the resident was never a big eater and that she mainly likes her snacks and coffee. R6 was observed on 2/13/12 at 8:40 AM with her breakfast tray in front of her. The resident had consumed a waffle, a 6 ounce (oz) cup of orange juice and an 8 oz cup of coffee and stated that she did not want anything else. During lunch on 2/14/12, R6 was observed to have eaten 50% of her meal. When asked if she would eat more she stated, "I'm only going to eat what I want to eat!" During an interview with E8 (nurse) and E9 (nurse) on 2/10/12 at 2:30 PM, both stated that bedtime snacks are charted on the medication administration record. During an interview with E3 (nurse) on 2/14/12 at 3 PM, E3 was not able to confirm that R6's physician had been consulted or that the POA had been notified regarding the weight loss. E3 acknowledged the lack of evidence of the bedtime snack being provided and or consumed. E3 acknowledged that the care plan was never revised. On 2/15/12, during an interview with E4, she stated that she believed that R6's admission weight was inaccurate, but failed to document this in her notes. E4 stated she believed this because the subsequent weekly weights remained stable between 125-127 lbs. (Even when the 127 weight was used to the weight loss of 115 it was a 9.4% loss=severe.) Additionally, she stated that the bedtime snack had been discontinued on 11/30/11 when staff told her the resident was not accepting it and the resident herself told her that she didn't want anything. This failed to be noted in the clinical record. E4 acknowledged that the nutrition care plan was not revised when a severe weight loss was noted. On 2/15/12, E2 (Director of Nursing) stated that when the dietary slip was written for R6 to receive a bed time snack, they failed to transcribe it onto a physician's orders [REDACTED]. Consequently the facility failed to ensure R6 received the snack.

Based on record review, interviews, observations and review of facility investigation documents, it was determined that for one (1) of ten (10) residents reviewed (R10) the facility failed to provide adequate supervision to prevent the resident from eloping from the facility at an unknown time on 7/2/11 and being gone from the facility for an unknown amount of time. Prior to this elopement, R10 was not considered by facility staff to be at risk for elopement. R10, however, had cognitive impairment and was able to exit the building unobserved by facility staff and walk away. He was found hours later by the police a mile and a half from the facility and was returned unharmed. Observations and interviews revealed that stairwell / elevator access and issues with the facility ' s door alarm system function were accident hazards. Findings include: 1. R10 resided on the 3rd floor of the facility and had multiple medical [DIAGNOSES REDACTED]. The care plan addressing R10 ' s " change in mental status " included the approach " ensure resident safety " . An addition to this care plan dated 2/18/11 indicated that R10 was " spending more time in common areas " of the facility. According to an incident report dated 7/2/11, R10 was " noted at 5:10 PM not at dinner- Missing Person ' s Policy activated at 5:20 PM due to building searched (and) resident not located " . According to the " Missing Resident " policy / procedure dated March, 2011, if a resident is not found within 15 minutes of doing a preliminary and then complete check of the building, " the police must be summoned " . The police were called by facility staff at approximately 5:32 PM. Statements obtained by the facility while investigating R10 ' s 7/2/10 elopement indicated that R10 had last been seen by a facility staff member at 2:55 PM. The facility staff did not consider R10 " missing " , however, until 5:10 PM according to the incident report. The 3rd floor nursing staff incorrectly believed that R10 was on the first floor attending an activity but no staff member verified this. Consequently it remains unknown where R10 was between 2:55 PM and approximately 6:43 PM (nearly 4 hours later) when he was located by the police a mile and a half from the facility. The time frame obtained during the facility ' s staff interviews conflicted with the time frame provided on the incident report. Interviews indicated that facility staff looked for but could not find R10 at approximately 4:30 PM, nearly an hour before the police were contacted. The incident report indicated that 5:10 PM was the point at which the facility considered R10 to be " missing " . Staff statements included the following information: -E3, the CNA assigned to R10 for the 3 PM to 11 PM shift, had also worked the 7 AM to 3 PM shift on 7/2/11 although R10 was not one of the residents he cared for on that shift. E3 reported that the last time he saw R10 was " during lunch time " (undated statement obtained by the facility and confirmed to the surveyor on 7/9/11 at 6:08 PM). -According to a written statement dated 7/2/11, E4, the day shift CNA assigned to R10 last saw R10 at 2:55 PM as he (R10) was going to use the bathroom. E4 ' s shift ended at 3 PM and she left the facility. -In an undated statement obtained during the facility ' s investigation, E5, the LPN nurse assigned to give medications to R10, " after report at 3:30 PM noticed (R10) not on unit, questioned CNA who states resident went down with activity staff. Noted resident not in room around 4 PM med pass, directed CNA (E6) to escort resident back to unit. CNA returned stating resident not downstairs " . E5 confirmed that it was between 4 PM and 4:30 PM that she was unable to locate R10 to give him his medications and she had asked a CNA (E6) to bring R10 back to the 3rd floor (interview with E5 on 7/9/11 at 5:40 PM). -E6, a 3 PM to 11 PM shift CNA, wrote that it was 4:30 PM when E5 asked her to bring R10 back to the unit because R10 ' s assigned CNA (E3) was busy (undated statement obtained by the facility). -In a written update provided to the surveyor on 7/11/11 by the E1 (Administrator), it was revealed that the facility staff had searched the building beginning between 4:40 - 4:45 PM and expanded the search between 5:00 - 5:10 PM. According to a police report (also provided to the surveyor by the facility), the initial call to police regarding R10 was made at approximately 5:32 PM. This was 52 minutes after the staff began a search of the building and vicinity for R10. The facility ' s " Missing Resident " policy / procedure requires police contact to occur within 15 minutes of the building search beginning if a missing resident is not found. The facility failed to provide adequate supervision to R10 to prevent his elopement from the facility at an unknown time on 7/2/11 between 2:55 PM and approximately 4:30 PM (when E6 went to look for R10 at the nurse ' s direction and R10 was not found). It remains unknown how R10 left the building but interview with the receptionist (E7) revealed that in addition to watching the front door, she has clerical duties to perform including copying, typing, and answering phones. E7 confirmed that it is not always possible to maintain direct visual supervision of the door. Observations on 7/9/11 revealed and interview with E1 (Administrator) on 7/11/11 at 4:25 PM confirmed that no alarm would sound if a facility resident without a Wanderguard bracelet(such as R10) walked out the front door. E1 also confirmed that it was most likely that R10 left the building on 7/2/11 through the front door. Facility staff did not verify R10 ' s location at the start of a new shift on 7/2/11. As a result, there was a time frame of several hours during which R10 may have been out of the building although he was not considered " missing " by the staff. Prior to the end of this follow-up survey, the facility initiated corrective actions including increased supervision of the front door and increased supervision (at least an hourly accounting / observation) of all residents. 2. Accident hazards involving stairwell / elevator access and issues with the functioning of the facility ' s door alarm system were identified during the follow-up survey. a. The facility ' s " Elopement Prevention " policy and procedure dated May, 2011 instructed staff to " Apply Wanderguard security bracelet to wrist " . Staff interviews and record reviews, however, revealed that for 3 residents (R2, R3, and R9) identified by the facility as at risk for elopement the security bracelet was attached to the residents ' wheelchairs (R3 and R9) or walker (R2). The placement of the security bracelet anywhere but the wrist was not covered by this policy / procedure and therefore it could not be ensured that the alternative placement of the bracelet was compatible with the Wanderguard alarm system as currently installed and operating in the facility. Additionally placement on an object other than the wrist could not ensure that the bracelet was monitoring R3, R9 or R2 for elopement. Prior to the end of the follow-up visit, the facility scheduled a service visit with the alarm company for 7/15/11. b. Observations on 7/9/11 and interviews with E7 (receptionist, 12:12 PM interview) and E1 (Administrator, 12:18 PM interview) on 7/11/11 confirmed that the front door of the facility is unlocked and does not alarm between the hours of 6:30 AM and 9 PM. Both E7 and E1 acknowledged that the receptionist ' s desk is located in an office near the front door and that the receptionist also has clerical duties in addition to watching the front door. As a result, direct visual observation of the front door is not always possible. Following discussion with the surveyor, the facility placed a desk directly inside the front door of the facility with a designated staff member assigned to sit at the desk and monitor the front door between the hours of 6:30 AM and 9 PM when the door is unlocked. c. Observations during the survey revealed that stairwell doors on the residential floors of the facility (2nd and 3rd floors) are unlocked and equipped with an audible alarm that must be deactivated by entering a numerical code. According to an interview with E1 (Administrator) on 7/11/11 at 4:25 PM, 9 facility residents wear a Wanderguard security bracelet because they have been identified by the facility as at high risk for eloping. E1 confirmed, however, that the stairwell doors are alarmed but are not equipped with any locking mechanism to prevent residents with a Wanderguard bracelet from entering the stairwells. Consequently, the stairwells of the facility are accessible to residents at risk for elopement from the facility as well as other mobile residents. d. At approximately 11:35 PM on 7/9/11, it was observed that the surveyor was able to enter the double doors leading to the patio smoking area with a Wanderguard security bracelet attached to a shoulder bag. The alarm sounded but the doors failed to lock as the surveyor approached them allowing the surveyor to push open and pass through the doors. The facility ' s assistant maintenance director (E8) stated that this happened " once in a great while " . Shortly after this, the surveyor was able to push open the double doors near the kitchen when the bag with the Wanderguard security bracelet was at knee level. The doors did lock when the bracelet was held slightly higher than knee level. e. Observations during the survey on 7/9/11 revealed that the elevators sometimes, but not at all times throughout the day, required keypad use in order to operate. Interview with E1 (Administrator) on 7/11/11 at 12:18 PM revealed that the keypad is used after 9 PM when the front door is locked. Access to the elevators allows residents to leave their residential floor without the knowledge of the staff.

Based on record review, interview and review of other facility documents, it was determined that the facility failed to ensure that one (R3) out of five (5) sampled residents was free of significant medication errors. R3, a diabetic resident had received her own oral antidiabetic medicine and was given her own lunch time fast acting insulin. After receiving the insulin R 3 was incorrectly given another resident's medications (R6) which included another antidiabetic medication. R3 was transferred to the hospital and was treated for [REDACTED]. Findings include: R3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessments, dated 2/28/10 and 8/25/10, stated the resident's cognitive skills for daily decision making were independent-decisions consistent/reasonable and that there were no short or long term memory problems. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 6:30 AM - [MEDICATION NAME] Insulin 2 Units subcutaneously for blood glucose of 176 (lowers blood sugar). 8:00 AM - [MEDICATION NAME] HCl 4 mg tablet (skeletal muscle relaxant). - [MEDICATION NAME] 50 mg tablet (non-narcotic [MEDICATION NAME]). - Glimepiride 4 mg tablet ( antidiabetic agent). - [MEDICATION NAME] 20 mg tablet (treatment of [REDACTED]. - [MEDICATION NAME] 50 mg tablet (treatment of [REDACTED]. - [MEDICATION NAME] HCl 20 mg tablet (antidepressant). - [MEDICATION NAME] 10 mg tablet (treatment of [REDACTED]. - [MEDICATION NAME] 100 mg capsule (unlabeled use for chronic pain). 11:30 AM - [MEDICATION NAME] Insulin 4 Units subcutaneously for blood glucose of 218 (lowers blood sugar - must start eating within 5-10 minutes after the injection). Review of the meal consumption record for 5/13/10 revealed that R3 had consumed 50% of her breakfast and was "out" (not in facility) at lunch time. Although the medical record stated that R3 remained in the facility until 1:20 PM, she was not served any lunch after being given 4 Units of [MEDICATION NAME] insulin. Review of the facility's "Report of Medication Variance" dated 5/13/10 and timed 12:15 PM, stated that R3 erroneously received (R6's 12 noon medication) [MEDICATION NAME] ([MEDICATION NAME]) 100 mg tablet, [MEDICATION NAME] (narcotic [MEDICATION NAME]) 80 mg tablet, [MEDICATION NAME] (anti-anxiety) 1 mg tablet and [MEDICATION NAME] (antidiabetic) 25 mg tablet. A nurse's note, dated 5/13/10 and timed 1:00 PM, stated that the resident was administered the wrong medication and the physician, who was currently on the unit, was informed and ordered that R3 be sent to the emergency room (ER) for [MEDICAL CONDITION] lavage (process of cleaning out the contents of the stomach). A second nurse's note, dated 5/13/10 and timed 1:30 PM, stated that R3 refused to go to the ER. However, after the physician, Director of Nursing and EMS (Emergency Medical Services) spoke with her for at least 30 minutes, she then agreed to go to the ER at 1:20 PM. Review of the facility's investigation of the incident revealed that E7 (Licensed Practical Nurse-LPN) was orienting E8 (LPN) to the medication pass. E7 wrote in a statement, dated 5/17/10, that she identified the resident (R6) who was to receive 12 noon medications and that the resident (R6) was seated in her wheelchair in the hallway, but that she then went back to her room. E7 wrote "...We punched out her medication, my orientee took the medications and held them while I poured water into the cup and locked the cart. While I was locking cart, I realized my orientee was gone from the area. I then left to go find her. When I did find her she stated she's now ready to go downstairs, she had already given R6's medication. However, my orientee was coming from the opposite side of where R6 was. I pointed toward were (sic) R6 was and said that was quick. 'Is that whom you gave the medications to.' She (E8) placed her hand around head (sic) and said No. She then pointed towards Room (number) and I asked her to show me to who she gave the medication she identified R3. I immediately (sic) if she had checked the name band or verified resident's name and she just said 'I am sorry'." E8 also completed a written statement, dated 5/17/10 stating "...We were trying to finish up the work on the floor and (E7) handed me a cup of meds and asked to give them to R6, me not really familiar with the resident's gave them to R3 thinking I was giving them to the right person..." E8 was subsequently terminated from employment in the facility. The facility failed to ensure that a resident was properly identified before medication was administered, resulting in R3 receiving another resident's medication. During an interview with R3 on 10/28/10 at 10:10 AM, she stated that on the morning of 5/13/10 she had already received her usual morning medications. R3 stated that the physician and Director of Nursing were in the room with her discussing the need for new medications. R3 stated that when E8 came into the room, she believed it was the new medication so she just took it without question. R3 also stated that she was wearing a wrist identification band, however, E8 never checked it nor asked her name prior to giving her the medications. Additionally, R3 confirmed that she had not had any lunch prior to being taken to the ER. Review of the hospital Emergency Nursing Record revealed that R3 was triaged (process of sorting people based on their need for immediate medical treatment) at 1:30 PM. At 2:30 PM, R3 was identified as being in "no acute distress" and "asleep/arousable." The "Emergency Provider Record" (completed by the ER physician), dated 5/13/10 and timed 2:30 PM, indicated R3 had "decreased responsiveness...somnolent but arousable...lethargic..." At 3:53 PM, an intravenous of Normal Saline Solution was started at 150ml/hour and blood work was drawn. Results of the blood work indicated that R3 had a blood glucose of 47 (reference: 74-118 mg/DL) and at 5:37 PM was given one amp of D50 (intravenous [MEDICATION NAME] of 50 percent [MEDICATION NAME] in water for a low blood sugar). At 6:38 PM a repeat accucheck indicated R3's blood glucose was 176. R3 was subsequently admitted to the hospital. The hospital History and Physical, dated 5/13/10 and completed by the attending physician stated, "...responds appropriately to commands. Alert and oriented. Appears comfortable...blood sugar of 47...Assessment and Plan: 1. Accidental ingestion of medications. The patient appears to be stable...The patient awake and alert. Was initially hypoglycemic...2. [DIAGNOSES REDACTED] probably secondary to accidental medication use..." The hospital physician's discharge summary, dated 5/17/10, stated "Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED]. 3. [MEDICAL CONDITION]. 4. Urinary Tract Infection. 5. Acute [MEDICAL CONDITION] on chronic [MEDICAL CONDITION].During the course of stay in the hospital, the patient was evaluated with blood tests. She continued to be stable throughout her hospitalization . She did have [DIAGNOSES REDACTED] (low blood sugar) initially, which was corrected with IV (intravenous) glucose..." The facility failed to ensure that standards of practice were followed during the administration of medications. Nursing staff failed to properly identify the resident resulting in R3 receiving another resident's medications. R3 was sent to the hospital and required the administration of D50 to correct her [DIAGNOSES REDACTED].

Based on record review, observation and interview, it was determined that the facility failed to ensure that 1 sampled resident (R63) remained free from accident hazards. R63 had [DIAGNOSES REDACTED]. It was known to the facility that R63 had a history of [REDACTED]. R63 sustained a finger fracture on or about 4/23/09 and an x-ray revealed "acute osteoporosis" of the finger, yet full side rails and bolsters remained in place. The rails, ordered for safety and as enablers had not been utilized by R63 as enablers for a long time due to deterioration of her dementia. Facility assessments on 3/3/09 and 6/2/09 confirmed that R63 did not have a medical condition that required side rails nor were they indicated or served as enablers to promote independence. The facility also failed to have PT/OT screenings/evaluations for appropriate use of the side rails/alternative devices. The facility failed to recognize that the side rails had become an accident hazard for R63, yet they remained in place. The facility also failed to have side rail care plan interventions that were current to R63's present situation. Additionally, there were electric wheelchairs being charged incorrectly in the hallways which posed an accident hazard. Findings include: Cross refer F221, example #1 1. R63 was admitted to the facility in 2004. [DIAGNOSES REDACTED]. An annual MDS (minimum data set) assessment, dated 2/28/09, and quarterly MDS, dated [DATE], stated that R63 had severe cognitive impairment with short and long-term memory impairment. R63 was totally dependent on staff for all care, bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) required 2+ persons for physical assistance, and she required a mechanical lift with 2 persons for transfers. Review of R63's care plan for side rails, dated 3/2/09 and last updated 7/16/09, stated, "1. Resident has requested to use a side rail... 2 1/2 rails... for bed mobility/an enabler to promote independence and actively participate in his/her own care...". Approaches included, "1. Patient will fill out and sign Side Rail Consent Form... 3. Continued patient education on the safe use of side rails and encouraging use of alternative devices... 6. P.T. (physical therapy)/ O.T. (occupational therapy) screen/eval (evaluation) for appropriate use of side rails/alternative devices...". On 7/16/09, the facility added "Padded SRs (side rails) for safety, resident hits the SRs when agitated." R63's high risk for falls care plan, dated 7/24/08, last updated on 7/16/09, listed the approach, "... 26. padded SRs for protection... hits SRs...". On 4/24/09, a care plan was developed for R63 for "... is experiencing/has potential for pain secondary to osteoporosis has pathologic fx (fracture) R (right) hand 5th metatarsal (pinky finger) Resident at risk for further fx's secondary to combativeness." Approaches included, "... 12. padded SRs in bed". Review of a facility incident report and investigation, dated 4/24/09, stated that the resident's daughter came to staff at 8 PM and told them R63's right pinky finger was swollen and painful to touch. An x-ray, dated 4/23/09, stated, "... fracture... 5th proximal phalangeal base with mild displacement. There is associated soft tissue swelling. Impression: Acute osteoporosis (thinning of the bone with increased risk for fx) related right 5th finger fracture as described." A physician progress notes [REDACTED]. Review of the clinical record, including the care plan, revealed no recent falls or fx's. MDS assessments from 8/30/08 through 8/28/09 revealed lack of [DIAGNOSES REDACTED]. An exception to this was a quarterly MDS assessment, dated 5/29/09, which incorrectly stated that R63 had "other fracture in last 180 days". R63's pain/osteoporosis care plan, developed on 4/24/09, stated that R63's finger fx was a pathologic fx, although subsequent quarterly MDS assessments, dated 5/29/09 and 8/28/09, failed to list a [DIAGNOSES REDACTED]. During an interview with E4 (unit manager) on 7/23/09, she stated that when she began employment in the facility in 1/09, she found sheets wrapped around R63's SRs. She believed that R63's daughter did it to protect the residents arms. E4 stated that she implemented the bolsters at this time, although the care plan reflected it was done later. E4 previously stated in an interview on 7/21/09 that R63's finger fx occurred after flailing her hand against the padded side rail. On 7/23/09, E4 clarified that it was assumed that R63 hit her finger on the bolster. On 7/23/09, E17 (Certified Nurses Aide assigned to R63) was interviewed. She confirmed that the bolsters were initiated in 1/09 and stated that prior to that, she wrapped towels around the SR's because R63 was combative and hit the rails. E17 further stated that although the bolsters are attached by 4 velcro straps each, R63 could remove them and E17 had found them on the floor. E17 stated that staff put the bolsters back and she confirmed that R63 continued to hit her hands/arms on the side rails. Multiple observations from 7/20/09 to 7/24/09 revealed R63 lying on her back in bed with full bilateral SR's up and bolsters in place. R63 was not observed attempting to reposition herself or using the side rails as enablers. She did not appear to be aware of the rails. According to R63's ADL (activities of daily living) care plan, dated 7/24/08 and last updated on 3/2/09, an intervention, dated 9/5/08, stated, "Family requests resident be back in bed by 1600 (4 PM) if up early. Up approx. 2-3 hours daily." R63 spends approximately 21-22 hours per day in bed. During a family interview on 7/23/09, R63's POA stated that the family requested the side rails a few years ago, but R63 had not been able to use them as enablers for a "long time." The POA stated she never signed a consent for the rails. Facility assessments on 3/3/09 and 6/2/09 revealed that R63 did not have a history of falls, she did not have a medical condition that required side rails, nor were they indicated or served as enablers to promote independence. Record review revealed lack of a signed consent for the side rails and lack of any PT or OT assessments or evaluations regarding the appropriate use of side rails/alternative devices as per the care plan. These findings were confirmed during interviews with E2 (Director of Nursing) on 7/22/09 and 7/23/09. R63 had a history of [REDACTED]. The facility assessed in 3/09 and 6/09 that the side rails were no longer indicated and they no longer served as enablers to promote R63's independence. The facility failed to have a signed consent for usage of the side rails and they failed to have PT/OT screenings and/or evaluations to determine the appropriateness of the rails/alternative devices. R63 sustained a finger fx on or about 4/23/09, which was thought to be caused by R63 hitting the bolster and/or side rail. The facility care planned R63 to be at risk for further fx's due to combativeness, yet they failed to recognize her side rails as an accident hazard and thus, they remained in place as of 7/24/09. 2. Resident electric wheel chairs were observed being charged in the hallways on both the second and third floors. Electric Wheel chairs must be charged in a safe area approved by the fire marshal.

Based upon observation and interview, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. The facility failed to maintain an environment free of accident hazards by having unlabeled and propped opened doors to the electric wheelchairs' battery charging rooms on the second and third floors. In addition, R43 had a specialized geri chair with a ripped arm rest which was a potential safety hazard. Findings include: 1. On 10/21/09 and 10/22/09, observations were made on the 2nd floor and on the 3rd floor of the electric wheelchairs' battery charging rooms. Both doors were propped open by a door stopper. The doors were unlabeled, failing to reflect that the rooms were for battery charging only. Rooms on both floors were used to store lifts, weighing scales, recliners, manual and electric wheelchairs and combustible materials. On the second floor a 36" X 48" bulletin board was attached to a wall in the electric wheelchairs' battery charging room. The bulletin board had a a 2 inch black plastic border and yellow sheets of paper stapled to it. On 10/21/09, the State Fire Marshall was contacted by telephone and observations were reviewed. Subsequently, the Fire Marshall visited the facility on 10/22/09 and concurred that the facility had a potential for an accident hazard on the 2nd floor and on the 3rd floor of the electric wheelchairs' battery charging rooms. The Team Coordinator and Environmentalist on the survey along with E1, the Administrator, E2, the Director of Nursing, and E9, Maintenance, accompanied the Fire Marshall during the tour of the second and third floor electric wheelchairs' battery charging rooms. The Fire Marshall stated that the facility failed to have properly labelled, self closing doors, failed to safely maintain the rooms without combustible materials, failed to have a policy and procedure for the proper use of the room and the safe charging of the electric wheelchair batteries and failed to inservice all staff on the policy and procedures. The facility failed to ensure that the resident environment remained as free of accident hazards as was possible in relation to the electric wheelchairs' battery charging rooms on the second and third floors. On 10/22/09, the findings were confirmed by E1 and E2. 2. During an observation on 10/27/09 at 1:30 PM, R43 was observed sitting in a specialty geri chair with the left arm rest separated, duct taped and foam exposed on the whole length of the arm rest. Interview with E10, the Unit Manager, confirmed that this posed a potential for injury such as skin tears. E10 telephoned and obtained permission from R43's sister to contact the specialty company that made the chair to repair it. E10 stated that R43's sister stated that her mother had seen it this way this past weekend. E10 stated that the specialty company would be out tomorrow to look at the chair. E9, maintenance, was contacted and immediately removed the chair to temporarily repair it. Review of R43's nurse's notes, dated 10/27/09 and timed 3:30 PM, revealed that "... left arm of chair has been repaired by maintenance and that staff instructed to cover L (left) arm while resident in chair due to a slight elevation in seam near hand of chair... aware that resident favors leaning L side..." Left armrest had been sewn closed leaving a small raised seam on top of armrest. During an interview on 10/28/09, E2 acknowledged the findings and stated that the specialty company was scheduled to look at the chair.