Every finding on record at Seaford Center

Based on observation and interview it was determined that for two (R26 and R50) out of three residents reviewed for personal property the facility failed to provide reasonable protection of resident belongings from loss. Findings include: The facility policy on personal property last updated 8/15/23 indicated Personnel will identify and record the patients/residents' belongings upon admission to the Center. All items bought into the Center will be listed on the Inventory of Personal Effects form and kept in the patient's clinical chart. Any additional items brought into the Center after admission must be added to this list. Any loss will be documented on the property loss form and then referred to the Administrator. 1. Review of R26's clinical record revealed: 6/4/25 - A quarterly MDS assessment documented that R26 was mentally intact. 9/2/25 11:10 AM - During an interview, R26 disclosed he had several items of clothing missing. R26 stated, I have five sweatpants, one hoodie, two sweatshirts, four t-shirt's gone. R26 stated staff said they were looking into it, the lady across from desk said that but it's been a couple weeks, and I haven't heard anything. 9/3/25 - Review of an undated inventory list for R26 was absent of any record of the residents clothing. All areas for documenting clothing were blank. 9/4/25 12:44 PM - During an interview, E8 (CNA) confirmed that R26 had reported missing clothing, a few weeks ago and that a property loss form was not created. E8 stated, We just check the lost and found. The surveyor then accompanied E8 to the unit's lost and found area and located one pair of sweat paints labeled with R26's name. E8 confirmed them as belonging to R26. 9/4/2025 12:56 PM - During an interview, E9 (RN) unit manager confirmed that R26 said he had missing clothing and the staff located a gray sweater and gray pants. E9 confirmed that staff did not complete a property loss form for R26 and that the inventory belonging list should be completed on admission and updated whenever new items are provided, E9 reported R26 had several belongings including a cell [phone], clothing, clippers and maybe some sunglasses. R26's inventory list lacked documentation regarding any of those belongings. 2. Review of R50's clinical record revealed: 3/7/19 - R50 was admitted to the facility. 7/24/25 – A quarterly MDS documented a BIMS of 15, and that R50 was cognitively intact 9/2/25 12:22 PM - R50 stated shirt, pants, underwear, and a cowboy jersey are missing, 9/2/25 12:25 PM – During an observation, no underwear and no cowboy jersey were located in the resident's room. Observed one shirt, two pairs of pants, and a sweatshirt. 9/4/25 2:30 PM - E4 (Housekeeping director) confirmed that he was going to buy R50 some clothes. 9/9/25 2:00 PM – Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on interview, record review, and review of other facility documentation, it was determined that for one (R50) out of one resident reviewed for grievances, that the facility failed to ensure prompt efforts were made to resolve the resident's concerns. Findings include:Review of R50's clinical record revealed:3/7/19 - R50 was admitted to the facility. 5/4/24 2:30 PM - A grievance/concern log documented that R50 stated he was unsure where the clothing could have gone, it is possible that the laundry misplaced the clothing. On May 7, 2024, E4 (housekeeping Director) checked the laundry room and did not find any missing clothing.7/24/25 - A quarterly MDS documented a BIMS of 15, and that R50 was cognitively intact9/2/25 12:22 PM - During an interview, R50 stated, my underwear, shirts, pants, and cowboy jersey were missing. 9/4/24 2:30 PM - During an interview with E4 he stated he was going today to buy R50 some clothes.9/4/24 2:45 PM - An interview with E3 (Quality Manager) confirmed the facility lacked evidence of a prompt response/resolution for R50's missing shirt, pants, underwear, and a cowboy jersey that was reported on 5/4/24.9/5/25 12:50 PM - E6 (NPE) stated in an interview that if a resident reports a missing item, E6 will complete a grievance log, interview the resident, and obtain written statements from the involved staff. The grievance documentation will then be submitted to the NHA.9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on interview and record review, it was determined that for three (R4, R28 and R74) out of three residents reviewed for a level II PASRR, the facility failed to ensure that a referral for a level II PASRR screening was required following a new diagnosis for a mental health disorder. Findings include:1. Review of R4's clinical record revealed: 5/9/25 - A notice of PASRR level I screening outcome documented the following mental health diagnoses: major depression (recurrent, unspecified), anxiety disorder (suspected), 6/7/25 - R4 was admitted to the facility with diagnoses including but not limited to, bipolar disorder, anxiety disorder and depression. 6/8/25 - A care plan documented that R4 was at risk for complications related to the use of psychotropic drugs for depression and is at risk for distressed/fluctuating mood symptoms related to depression. 6/9/25 - An initial psychiatric evaluation documented depressed mood and listed the following medications for depression: doxepin 25 mg daily at bedtime, lurasidone 20 mg daily, sertraline 75 mg daily. 6/25/25 - In the electronic chart under active diagnoses, it was documented that R4 had the following diagnoses: bipolar disorder and depression. 7/26/25 - A re-admission five-day MDS assessment documented that R4 had a diagnoses of bipolar disorder and depression. 9/3/25 1:30 PM - During an interview E3 (Quality Manager), confirmed that R4 required a referral for a Level II PASRR due to a new onset of depression and bipolar disorder in June 2025, and acknowledged that the referral should have been completed but was not. 9/4/25 10:04 AM - During an interview, E7 (Social Worker Director) confirmed that R4 required a referral for a level II PASRR. 2. Review of R74s clinical record revealed: 1/26/10 - R74 was admitted to the facility with diagnosis including but not limited to, generalized anxiety disorder. 10/9/24 - A PASRR level I screening outcome review documented a mental health diagnosis of anxiety disorder. 5/19/25 - An admission record documented a new onset diagnosis of major depressive disorder. 6/15/25 - A care plan revision documented resident will demonstrate improved mood state .by the next review. 8/14/25 - A significant change MDS documented, active diagnoses of major depressive disorder and schizophrenia. 9/3/25 - During an interview, E3 (Quality Manager), confirmed that R74 required a referral for a Level II PASRR due to a new onset of major depressive disorder in May and acknowledged that a referral should have been completed but was not. 9/4/25 10:04 AM - During an interview, E7 (Social Worker Director) confirmed that R74 required a referral for a level II PASRR. 3. Review of R28's clinical record revealed: 10/12/19 – R28 was admitted to the facility. 2/15/25 – A facility's electronic charting system documented under active diagnosis new diagnosis of depression for R50. 6/9/25 – R28's quarterly MDS documented a new diagnosis of depression. 9/3/25 2:00 PM - An interview was conducted with E6 (SW), who confirmed that she did not have access to the facility's electronic system to place a referral for a PASRR Level II. E6 also confirmed that a PASRR Level II was not completed for the new diagnosis of depression. 9/3/25 2:44 PM - During an interview, E3 (Quality Manager) stated that an internal audit was initiated in August for all residents requiring a referral for a PASRR Level II. E3 confirmed that no PASRR Level II had been completed in response to the new diagnosis of depression. 9/9/25 2:00 PM – Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on record review and interview, it was determined that for one (R113) out of thirty residents reviewed in the investigative sample, the facility failed to develop a care plan to address an identified concern. Findings include: Review of R113's clinical record revealed:10/11/24 - R113 was admitted to the facility.3/20/25 12:00 AM - A wound note by E12 (Wound NP) documented that R113 was non-compliant with turning and repositioning and tells staff to leave her alone.3/27/25 3:59 AM - A wound note by E12 (Wound NP) documented that R113 was non-compliant with turning and repositioning and tells staff to leave her alone.9/4/25 11:08 AM - During an interview, E12 (Wound NP) stated that R113 would refuse to have her wounds touched and resisted care.9/4/25 12:09 PM - During an interview, E16 (NP) stated that R113 was resistant to care and refused to get out of bed.9/4/25 11:43 AM - During an interview, E17 (wound nurse) stated that R113 was behavioral, resistant to care and would refuse to allow staff to turn and reposition her.9/4/25 12:25 PM - A review of R113's care plan lacked evidence for refusals of care that included individualized objectives, goals, and timeframes to meet R113's needs.9/5/25 10:40 AM - During an interview, E18 (CNA) stated that R113 was very behavioral, would constantly refuse care and refuse to get out of bed.9/5/25 10:51 AM - During an interview, E6 (RN) stated that R113 refused care and treatments and confirmed that a care plan for refusals should have been completed for her.9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation and interview it was determined that for one (R79) out of ninety-one residents screened during the initial pool process the facility failed to ensure that medications were administered in accordance with professional standards. Findings include: The facility policy on medication guidelines last updated January 2025 indicated, The resident is always observed after administration to ensure that the dose was completed ingested. 9/2/25 9:16 AM - Upon entry into R79's room, the surveyor observed six pills on top of the bedside table. R79 stated I don't know what these are do you? The surveyor left the room and immediately returned with E13 (LPN) who confirmed leaving R79's medications without ensuring they were ingested. 9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R12) out of two residents reviewed for positioning, the facility failed to turn and reposition the resident and promote the healing of a pressure ulcer in accordance with professional standards of practice to prevent skin breakdown. Findings include:Review of R12's clinical record revealed:6/20/25 - R12 was admitted to the facility with diagnoses including stroke, dementia, muscle weakness, adult failure to thrive and a stage 3 sacral pressure ulcer.6/27/25 - An admission MDS documented that R12 was totally dependent for turning and repositioning. R12 had impairments on both sides for the upper and lower extremities. 7/12/25 - A nursing Braden Scale documented R12 with a score of 9.0 (9.0 or below is a very high risk for development of a pressure ulcer).8/20/25 - A care plan for R12 was documented to include turning and repositioning, as well as performing a skin check every 2 hours.On the following dates and times, R12 was observed lying in bed on his back with the head of the bed upright (approx. 45 - 60 degrees) without any positioning pillows or wedges on 9/2/25: 9:45 AM, 10:50 AM, 11:55 AM, and 12:15 PM. 12:50 PM and 2:01 PM.R12 was observed lying in bed on his back for four hours without any turning.9/4/25 11:08 AM - During an interview, E12 (Wound NP) stated that turning and repositioning is expected every 2 hours even with an air mattress. E12 stated that for R12 the facility has wedges or pillows to reposition him, but he has wiggled to angle himself in bed.9/9/25 12:20 PM - During an interview, E14 (CNA) stated that for R12, they can use pillows or wedges and that it is not a problem to get him off his back.The facility failed to ensure that R24 was turned and repositioned every two hours.9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R12) out of one resident reviewed for tube feeding, the facility failed to utilize a feeding tube in accordance with current professional standards of practice. Findings include:Review of the facility's policy and procedure titled Enteral Feeding: Administration by Pump, last revised 2/24/25, documented, . 15.3.2 Fill in the information on the container's label (patient's name, room number, date, start time, and flow rate) . 15.3.3 Label the administration set with start date and time .Review of R12's clinical record revealed:6/20/25 - R12 was admitted to the facility with diagnoses including but not limited to stroke, dementia, dysphagia, adult failure to thrive and severe protein-calorie malnutrition.6/27/25 - An admission MDS documented that R12 was on a mechanically altered diet with a feeding tube. 8/20/25 - A care plan for R12 documented that he has an enteral feeding tube to meet nutritional needs.9/2/25 10:57 AM - A direct observation revealed that Jevity 1.2 cal (a type of tube feeding) was infusing for R12 using a feeding pump. The Jevity 1.2 cal bottle was not labeled with the date, time or initials of the staff who began the infusion.9/2/25 12:54 PM - During an interview, E10 (RN) stated that the overnight shift hangs the feeding and they are supposed to date, time and initial it. E10 confirmed that there wasn't a date, time or initials on R12's tube feeding.9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation, interview, and record review, it was determined that for one (R13) out of one residents reviewed for respiratory care, the facility failed to ensure R13's oxygen mask and nebulizer equipment were stored in a protective plastic bag. Findings include:Review of the facility's policy and procedure titled Nebulizer: Small Volume, last revised 11/1/23, documented, . 21.1 Place in treatment bag labeled with patient name and date.Review of R13's clinical record revealed:4/10/24 - R13 was admitted to the facility.4/8/25 - A physician order for R13 documented ipratropium-albuterol solution 0.5 - 2.5 mg/3mL, inhale 3mL orally every 6 hours as needed for shortness of breath or wheezing.8/20/25 - A care plan documented R13 as receiving respiratory treatments as ordered due to a history of COPD (chronic obstructive pulmonary disease).8/29/25 - A significant change MDS documented that R13 received respiratory therapy. 9/2/25 10:39 AM - An observation noted R13's oxygen mask with nebulizer unit attached sitting on top of the bedside table. There was no protective bag available for the oxygen mask and nebulizer unit to be placed into.9/2/25 10:42 AM - During an interview, E10 (RN) confirmed that the oxygen mask with nebulizer unit was sitting on the bedside table and not in a protective bag. E10 stated the respiratory therapist usually puts them in a bag with the resident's name and date on it.9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation, interview and record review it was determined that for one (R10) out of two residents reviewed for dental services the facility failed to provide assistance with dental services. Findings include: The facility policy on Dental Services last updated 9/1/22 indicated, Centers will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each patient. Review of R10's clinical record revealed: 5/8/25 - R10 was admitted to the facility with Medicaid as a source of coverage. 5/15/25 - An admission MDS assessment documented that R10 was cognitively intact and broken natural teeth. 5/31/25 - A care plan was created for R10's dental problems related to broken, loose and carious teeth. Dental referrals as needed was listed as an intervention. 9/2/25 9:30 AM - During an interview, R10 stated, Supposedly they have a dentist, I talked to the unit manager [E9 (RNUM)] and I haven't heard anything it's been a couple of weeks. 9/4/25 10:12 AM - During an interview, E7 (SSD) reported being unaware of a request for dental services from R10. E7 then provided a list of residents who'd requested to be seen by the facility's contracted dentist at the next scheduled visit. Review of the list dated, 8/25/25 revealed R10 was not scheduled to be seen by the dental provider. 9/4/25 11:45 AM - During an interview, E9 (RNUM) unit manager for R10 confirmed knowledge of R10's need for assistance to see a dentist. E9 stated, I reached out to [E7 (SSD)] yesterday and asked that [R10] be put on the list. 9/4/25 11:52 AM - During an interview, with both E9 (RNUM) and E7 (SSD) it was confirmed that E7 was not aware of R10's need for assistance with dental services. E7 stated she would email the facilities dental provider that day to attempt to add R10 to the list of residents to be seen. 9/4/25 1:44 PM - E7 (SSD) provided an updated dental provider schedule that documented R10 was now added to the list of residents to be seen by the dentist next visit. 9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on observation and interview it was determined that for one (R47) out of three residents reviewed for wound care the facility failed to ensure adherence to practices that prevent the spread infection. Findings include: The CDC's webpage entitled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to prevent the spread of Multidrug-resistant Organisms (MDRO's) indicated Enhanced Barrier Precautions: Examples of high-contact resident care activities requiring gown and glove use for EBP include wound care: any skin opening requiring a dressing. (Face protection may also be needed if performing activity with risk of splash or spray). https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.htmlReview of R47's clinical record revealed: 8/21/25 - R47 was admitted to the facility with multiple conditions including Hidradenitis Suppruativa (HS - a chronic inflammatory skin condition characterized by painful lumps, abscesses [pus filled areas] and scarring) and was being treated for wound infections related to the diagnosis. 8/22/25 - A physician's order was written for R47 to be placed on Enhanced Barrier Precautions. 8/22/25 - A physician's order was written for R47 to receive Clindamycin gel, an antibiotic for three months, apply to groin topically twice a day to the infected wounds. 9/2/25 10:03 AM - During initial pool screening, R47's sheets were observed with moderately sized circular pale pink stains. R47 explained having open wounds that sometimes drained. 9/4/25 - 10:26 AM - E17 (IP) was made aware that a dressing change observation would occur. 9/4/25 10:39 AM - During a dressing change observation, E17 (IP) and E6 (NPE) entered R47's room to complete a dressing change. E17 was observed without a face covering. E17 placed a clean drape on R47's bedside table and placed the dressing change supplies, a medicine cup of the wound cleaning agent ordered, a tube of the antibiotic ointment, several packs of gauze and a cell phone. The cell phone glass was in a case, the face of the cell phone had an opaque, appearance, with fingerprints and smears visible on its face. 9/4/25 10:49 AM - During the same dressing change E6 (NPE) removed R47's soiled dressings, E17 (IP) then poured the cleaning agent from a medicine cup onto gauze held by E6. The open mouth of the cup created a potential for splashing. E6 cleaned R47's wounds removed her gloves and changed to another pair of gloves. E17 then opened a pack of gauze, pulled the gauze from the pack touching it directly with her gloved hand and handed it to E6 to pat R47's wounds dry. E17 then grabbed the cell phone and took pictures of the wounds, leaning in very closely to R47's wounds that were prone to drainage and abscess. E17 again opened a pack of gauze, pulled the gauze from the pack touching it directly with her gloved hand squeezed antibiotic ointment on the gauze and applied it to R47's wounds. E17 then covered R47's wound. 9/4/25 11:10 AM - During an interview, E17 (IP) confirmed that she did not wear a face covering and touched a cell phone during the dressing change. E17 disputed the use of a face covering because [R47's] wound was not being irrigated, and the phone was cleaned before. At no point prior to the dressing change did the surveyor observe the phone being cleaned. When the surveyor attempted to indicate the smears on the phone E17 began cleaning and wiping the phone. 9/9/25 2:00 PM - Findings were reviewed with E1 (NHA) and E3 (Quality Manager) during the exit conference.

Based on interview and record review it was determined that for one (R1) out of three residents reviewed for abuse the facility failed to report an allegation of sexual abuse within the required time constraints. Based on the facility's evidence to correct the noncompliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 6/6/25. Findings include: Review of R1's clinical record revealed: 6/27/23 - R1 was admitted to the facility with diagnoses including but not limited to hypertension, low back pain and nervous system disorders. 5/27/25 2:38 PM - An incident summary documented On 5/24/25 [R4 (Spouse)] reported being in the bathroom and R1 and E4 (Activity Aide) were together in the activity room and E4 (Activity Aid) asked R1 to see his private parts R4 also reported R1 was very upset and asked R4 to report this 6/3/25 E1 (NHA) documented An employee passed me in the hallway and said R4 and R1 wants to see you 6/3/25 - A facility provided statement written by E1 (NHA) documented T.C. (sic) with E5 (Activities Director) I heard on Sunday (5/25/25) from [R5] in the activity room that [R4] told her that E4 (Activity Aide) was trying to look at R1's private parts. I didn't think anything of it because [R1] and [R4] come into activities and talk about their personal business. It's mainly [R4], [R1] just sits there. They do this all the time in there 6/3/25 3:30 PM - A facility report was submitted to DHCQ (Division of Healthcare & Quality) for an allegation of abuse. 6/11/25 2:57 PM - During an interview E5 confirmed and stated, I heard on Sunday (5/25/25) from another resident [R5] that [E4] was asking [R1] to see his private parts. [R4] is always in the activities room talking about their business I don't pay her no attention, when it happened, I wasn't there, that's all I know what that resident said to me, and I don't know nothing about it. 6/12/25 2:00 PM - An interview with E1 (NHA) confirmed that E6 passed E1 in the hallway and said [R4] and [R1] want to see you [E1] said [E6] did not tell me why they wanted to see me for E1 also confirmed she was not aware of the alleged abuse until 6/3/25. Based on the review of the facility's thorough investigation, documented response, completion of in-service training, power point presentations and abuse prohibition quizzes (inclusive of resident scenario/situation) audits, staff interviews and further incidents related to abuse it was determined to be past non-compliance. The plan of correction was initiated on 6/3/25 and completed on 6/6/25. 6/12/25 2:10 PM- Findings were reviewed with E1 (NHA), E2 (DON) and E3 (QA, Nurse) at the exit conference.

Based on record review and interview, it was determined that for one (R2) out of two residents reviewed for respiratory therapy, the facility failed to have R2's BiPAP settings orders in R2's EMR at admission. Findings include: Facility's Bi-Level Positive Airway Pressure (BiPAP)/ Continuous Positive Airway Pressure (CPAP) procedure policy- . 1. Verify order . 9. Initial set-up: 9.1 Apply ordered settings to the unit per manufacturer's instructions . 11/30/24 - C1 (MD) documented in R2's [Hospital] discharge summary, .Plan: . OSA (Obstructive sleep apnea) BiPAP nightly . 11/30/24 - R2 was admitted to the facility with diagnoses, including but were not limited to, obstructive sleep apnea (OSA), emphysema and chronic respiratory failure with hypoxia (low oxygen concentration in the blood). 11/30/24 - E9 (Admissions) uploaded into R2's EMR a copy of R2's [hospital] BiPAP orders stating .Uses BiPAP HS at night. RT to titrate based home settings .IPAP (cmH2O) 21, PEEP/CPAP (cmH2O) 17, FiO2 40%. 11/30/24 9:44 PM - E8 (RN) documented in R2's EMR, . Admission details: arrived by ambulance .Respiratory: Positive Air Pressure: BiPAP/CPAP .Oxygen via nasal cannula . 11/30/24 - R2 was care planned for CPAP/BiPAP therapy with interventions including; encourage resident's use of CPAP/BiPAP. Review of R2's EMR orders lacked evidence of BiPAP settings orders from 11/30/24 to 12/2/24. The facility failed to obtain BiPAP respiratory settings necessary for R2's immediate care as R2 required BiPAP nightly. 12/2/24 - E7 (MD) ordered in R2's EMR, .BiPAP (pressure settings) IPAP 21, EPAP 17 as needed and at bedtime. 12/19/24 4:02 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 Corporate clinical advisor) at the exit conference.

Based on record review and interviews, it was determined that for three (R1, R5, R6) out of three residents reviewed for dialysis, the facility failed to establish a process to obtain complete lab reports from the dialysis provider. Findings include: Cross refer F711, F775 and F842. Facility NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation Policy- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at a certified dialysis facility. Purpose: To ensure ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis patient care and services . 1 .Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis (an invasive treatment for advanced kidney disease that uses a machine to filter wastes, salts and fluids from the patient's blood). 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . Review of R5's lab results tab in the EMR reveal no laboratory blood work since 7/26/24. R5 did have COVID screening lab results as recent as 11/6/24 in the lab results profile. 12/19/24 2:15 PM - During an interview, E2 (DON) stated, . [R5's] last set of labs (CBC) are from 7/26/24, I know he [R5] has more recent labs as he is on hemodialysis 12/19/24 2:40 PM - During a telephone interview, C4 (hemodialysis center 2 RN/ facility administrator) stated, [R5] gets lab work drawn every month. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed. Redraws are done for abnormal labs results. It is our dietician who communicates with the facility the lab results on the patient's report card, which is a communication sheet that goes back to the facility usually in the patient's binder. We do not send the official lab reports to the facility. R5's reports for lab work obtained by (hemodialysis center 2) for five months (August, September, October, November and December) were not filed in R5's EMR by the facility to allow review by the facility providers. The facility failed to have a process for obtaining the (hemodialysis center 2's) lab results and communicating those results to the facility providers in order to coordinate R5's care. 2. Review of R1's clinical record revealed: 11/15/24 - R1 was admitted to the facility with diagnoses including but not limited to, hyperlipidemia, end stage renal disease and stroke. 11/15/24 - E7 (MD) ordered in R1's EMR, .Dialysis days: Mondays, Wednesdays and Fridays . 12/19/24 1:45 PM - During a telephone interview, C3 (hemodialysis center 1 RN) stated that R1 had weekly labs drawn because he was an acute kidney injury patient. Typically his (R1) labs were drawn on Monday (weekly) during his treatment and usually the results did not come back until Tuesday due to [R1] having an afternoon dialysis start time. If the labs were abnormal, we would call the results to the facility .No, we don't fax the lab sheets over to the facility. It is just a phone call if abnormal or a handwritten report of some of the labs on the dialysis communication sheet . For most hemodialysis patients, they get weekly hemoglobin checks done. Review of R1's lab results tab in the EMR reveal no documented laboratory blood work since his admission on 11/15/24. C3 stated that R1 had weekly lab work on Mondays during his hemodialysis treatments. R1's lab results from Monday 11/8/24, 11/25/24, 12/6/24 and 12/13/24 were not available in R1's EMR. The facility failed to have a process for obtaining the [hemodialysis center 1's] lab results and communicating those results to the facility providers in order to coordinate R1's care. 3. Review of R6's clinical record revealed: 12/4/24 - R6 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, hyperlipidemia, hypomagnesemia and end stage renal disease with dependence on hemodialysis. Review of R6's lab results tab in the EMR reveal no laboratory blood work since R6's CBC (complete blood count) and CMP (comprehensive metabolic profile) on 12/5/24. 12/4/24 - E7 (MD) ordered in R6's electronic medical record (EMR), .Dialysis days: Mondays, Wednesdays and Fridays, Time for pick up: 12:30 . Review of R6's Hemo Quarterly Report Card dated December 6, 2024 revealed R6's albumin, potassium, calcium, phosphorus, PTH, intact and hemoglobin levels. It did not include R6's full CBC and CMP results, just a select set of labs. 12/19/24 12:24 PM - During an interview, E10 (LPN) stated, The dialysis residents have a binder that goes with them to their treatment appointments. Both [R5 & R6's] binders are with the residents right now at their dialysis centers . Their labs are written in on the communication sheet by the staff at the dialysis center. It is not the official lab report. The dialysis staff write down any recommendations and how they treated the labs. If the labs are off (abnormal), they often call us. Typically the nurses are the only ones who look at the binders. If the labs are really off, they send the resident to the hospital and then call us to say that they sent them to the hospital. 12/19/24 1:39 PM - During an interview, E11 (NP) stated, The labs are obtained at the dialysis unit and they send a handwritten communications report in the patient's dialysis binder with written abnormal labs. We don't get copies of the official lab reports. For long-term care residents that are on hemodialysis, we order the annual labs to be drawn by our lab and then the results are uploaded directly into the EMR. When the labs are done at dialysis if a lab is really abnormal, the dialysis unit calls the facility nurses station and the nurse tells us the problematic labs. 12/19/24 2:15 PM - During an interview, E2 (DON) stated, .R6 had labs on 12/5/24 here in the facility but no other lab results are documented in [R6's] chart . We need to figure out a process to get the results from the dialysis units into the residents' EMR. 12/19/24 3:33 PM - During a telephone interview, C5 ([hemodialysis center 3] administrator/RN) stated, At our hemodialysis center, we get standing labs on admission. R6 had lab work on 12/6/24 . Then we get a hemoglobin every 2 weeks to once a month depending on how low the hemoglobin is . Honestly, if there are no discrepancies (abnormal labs), we may not even report or send the labs to the facility . Sometimes, we send the official lab report to the facility in their communication book but that is not the standard of practice. We typically write down certain lab results on a report sheet and put that in the patient's communication book quarterly . I was not aware that the facility does not order their own labs. We cannot obtain any labs that are not related to renal due to our regulations. The facility failed to have a process for obtaining the (hemodialysis center 3's) lab results and communicating those results to the facility providers in order to coordinate R6's care. 12/19/24 4:02 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 Corporate clinical advisor) at the exit conference.

Based on record review and interviews, it was determined that for three (R1, R5, R6) out of six residents reviewed for Physician Services, the facility failed to have the physician review the resident's total program of care. For R1, the physician failed to review R1's lab work (resident had labs obtained at hemodialysis) and regarding R1's supplemental oxygen usage. For R5 and R6, the physician failed to review lab work obtained at hemodialysis. R6 had a known hospitalization for hyperkalemia in November 2024. Findings include: Cross refer F698, F775 and F842 1. Review of R1's clinical record revealed: 11/15/24 - R1 was admitted to the facility with diagnoses including but not limited to, hyperlipidemia, end stage renal disease and stroke. 11/15/24 - E7 (MD) ordered in R1's EMR, .Dialysis days: Mondays, Wednesdays and Fridays . 11/18/24 - E7 (MD) ordered in R1's EMR, . Oxygen 2 L (liters) every shift . Review of R1's vital signs for pulse oximetry monitoring from 11/18/24 to 12/11/24 (the date of transfer to the hospital) revealed thirty-six documented occasions of pulse ox monitoring with eleven incidents where R1 was not utilizing his supplemental oxygen as ordered and on several occasions, R1's pulse ox was lower than the 92% acceptable range. Review of E7's progress notes dated 11/18/24, 11/25/24, 12/2/24 and 12/10/24 revealed no evidence of documentation or a plan to address R1's non-compliance with his supplemental oxygen therapy. 11/18/24 - E7 (MD) documented in R1's admission history and physical, .61 yo (year old) male with CAD (coronary artery disease), CVA (cerebral vascular accident) with left hemiplegia admitted with weakness .pt (patient) underwent exploratory laproscopic procedure on 10/21/ Severe AKI (acute kidney injury) after surgery lead to hemodialysis. Patient experienced cardiac arrest but quickly achieved ROSC (return of spontaneous circulation). Likely aspirated . Physical Exam: . Respiratory: CTAB (clear to auscultation bilaterally), diminished bibasilarly .Assessment and Plan: Dependence on renal dialysis .OSA (obstructive sleep apnea) - CPAP . This physician note lacked evidence of documentation of and a plan of care regarding R1's new supplemental oxygen usage. It also lacked a plan of care regarding frequency of lab draws for R1, who was initiated on hemodialysis due to an acute kidney injury. 11/18/24 - R1's weekly lab draw obtained at (hemodialysis center 1). Review of R1's EMR revealed no evidence of (hemodialysis center 1's) 11/18/24 weekly lab results. 11/25/24 6:54 PM - E7 (MD) documented in R1's EMR progress note, .Vital Signs: O2 (oxygen) sat (saturation): 95 RA ( room air) 11/24/24 9:12 PM History of present Illness: 61 yo male with CAD, CHF (congestive heart failure) .ESRD (end stage renal disease) on HD (hemodialysis) .Physical Exam: . Respiratory: CTAB, diminished bilaterally .Labs- All labs, images, reports and previous notes reviewed. For full lab/imaging results, see EHR (electronic health record) . Assessment and Plan: . End stage renal disease - HD MWF (Monday, Wednesday, Friday) OSA - CPAP . This physician note lacked evidence of documentation of R1's supplemental oxygen usage and a plan of care regarding R1's compliance and usage of supplemental oxygen. It also lacked a plan of care regarding frequency of lab draws and review of recent labs drawn on 11/18/24 for R1, who was initiated on hemodialysis due to an acute kidney injury. The facility lacked evidence of how E7, as stated in E7's 11/25/24 note, was able to review R1's 11/18/24 lab results as the results were not uploaded into R1's EMR. 11/25/24 - R1's weekly lab draw obtained at (hemodialysis center 1). Review of R1's EMR revealed no evidence of (hemodialysis center 1's) 11/25/24 weekly lab results. 12/2/24 6:36 PM - E7 (MD) documented in R1's EMR progress note, .Vital Signs: O2 sat: 94 RA 12/1/24 2:41 PM . History of present Illness: 61 yo male with CAD, CHF .ESRD on HD .Physical Exam: . Respiratory: CTAB, diminished bilaterally .Labs- All labs, images, reports and previous notes reviewed. For full lab/imaging results, see HER . Assessment and Plan: . End stage renal disease - HD MWF, Nephrology follow up OSA - CPAP . This physician note lacked evidence of documentation of R1's supplemental oxygen usage and a plan of care regarding R1's compliance and usage of supplemental oxygen. It also lacked a plan of care regarding frequency of lab draws and review of recent labs drawn on 11/25/24 for R1, who was initiated on hemodialysis due to an acute kidney injury. The facility lacked evidence of how E7, as stated in E7's 12/2/24 note, was able to review R1's 11/25/24 lab results as the results were not uploaded into R1's EMR. 12/6/24 - R1's weekly lab draw obtained at [hemodialysis center 1]. Review of R1's EMR revealed no evidence of (hemodialysis center 1's) 12/6/24 weekly lab results. 12/10/24 9:01 AM - E7 (MD) documented in R1's EMR progress note, .Vital Signs: O2 sat: 92 RA 12/10/24 12:49 PM . History of present Illness: 61 yo male with CAD, CHF .ESRD on HD .Physical Exam: . Respiratory: CTAB, diminished bilaterally .Labs- All labs, images, reports and previous notes reviewed. For full lab/imaging results, see HER . Assessment and Plan: . End stage renal disease - HD MWF, Nephrology follow up OSA - CPAP . This physician note lacked evidence of documentation of R1's supplemental oxygen usage and a plan of care regarding R1's compliance and usage of supplemental oxygen. It also lacked a plan of care regarding frequency of lab draws and review of recent labs drawn on 12/6/24 for R1, who was initiated on hemodialysis due to an acute kidney injury. The facility lacked evidence of how E7, as stated in E7's 12/10/24 note, was able to review R1's 12/6/24 lab results as the results were not uploaded into R1's EMR. 12/19/24 1:45 PM - During a telephone interview, C3 (hemodialysis center 1 RN) stated that R1 had weekly labs drawn because he was an acute kidney injury patient. Typically his (R1) labs were drawn on Monday (weekly) during his treatment and usually the results did not come back until Tuesday due to [R1] having an afternoon dialysis start time. If the labs were abnormal, we would call the results to the facility .No, we don't fax the lab sheets over to the facility. It is just a phone call if abnormal or a handwritten report of some of the labs on the dialysis communication sheet . For most hemodialysis patients, they get weekly hemoglobin checks done. 2. Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis. 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . R5 had lab work obtained at the hemodialysis center in August, September, October, November and December 2024. Review of R5's EMR lacked evidence of official [laboratory] reports of R5's monthly hemodialysis labs. R5's dialysis binder had communication sheets, which mentioned various labs from some of these dates but these results were not uploaded into R5's EMR. Since 11/5/24, R5 had three documented encounters with providers, E7 (MD) and E11 (NP). The progress notes from E11 for the 12/5/24 and 12/12 24 encounters lacked evidence of any review of R5's lab results. 11/13/24 - E7 (MD) documented in R5's EMR progress note, .History of present illness: 48 yo (year old) male with ESRD on HD, TThS (Tuesday, Thursday, Saturday), DM2 (diabetes), CHF (congestive heart failure) .Labs: All labs, images, reports and previous notes reviewed. For full lab/imaging results, see Facility EHR (electronic health record) . The facility lacked evidence of how E7, as stated in E7's 11/13/24 note, was able to review R5's lab results as the results were not uploaded into R5's EMR. 12/19/24 2:40 PM - During a telephone interview, C4 ([outside hemodialysis center 2] RN/ facility administrator) stated, [R5] gets lab work drawn every month. We use [laboratory] for our lab work. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed . We do not send the official lab reports to the facility. 3. Review of R6's clinical record revealed: 12/4/24 - R6 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, hyperlipidemia, hypomagnesemia and end stage renal disease with dependence on hemodialysis. 12/4/24 - E7 (MD) ordered in R6's electronic medical record (EMR), .Dialysis days: Mondays, Wednesdays and Fridays, Time for pick up: 12:30 . 12/5/24 - E7 (MD) documented in R6's admission history and physical, . 58 yo female with CAD, CHF, CKD (chronic kidney disease) stage V admitted with weakness .Labs showed elevated creatinine at 3.6 and elevated potassium. She underwent hemodialysis on 11/18/24 . 12/6/24 - E11 (NP) documented in R6's EMR progress note, .Assessment and Plan: .Acute kidney failure- continue HD as per Nephrology, monitor labs . 12/16/24 - E7 (MD) documented in R6's EMR progress note, .58 yo female with CAD . Labs: All labs, images, reports and previous notes reviewed. For full lab/imaging results, see Facility EHR . The facility lacked evidence of how E7, as stated in E7's 12/16/24 note, was able to review R6's lab results as the results were not uploaded into R6's EMR. 12/19/24 1:39 PM - During an interview, E11 (NP) stated, The labs are obtained at the dialysis unit and they send a handwritten communications report in the patient's dialysis binder with written abnormal labs. We don't get copies of the official lab reports. 12/19/24 3:33 PM - During a telephone interview, C5 ([outside hemodialysis center 3 administrator/RN) stated, At our hemodialysis center, we get standing labs on admission. R6 had lab work on 12/6/24. Then we get a hemoglobin every 2 weeks to once a month . Honestly, if there are no discrepancies (abnormal labs), we may not even report or send the labs to the facility. Sometimes, we send the official lab report to the facility in their communication book but that is not the standard of practice. We typically write down certain lab results on a report sheet and put that in the patient's communication book quarterly . 12/19/24 4:02 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 Corporate clinical advisor) at the exit conference.

Based on record review and interview, it was determined that for two (R5, R6) out of three residents reviewed for dialysis, the facility failed to have the clinical record laboratory report containing the name and address of the testing lab in the residents' EMR. Findings include: Cross refer F698, F711 and F842. 1. Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis. 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . 12/19/24 2:40 PM - During a telephone interview, C4 ([outside hemodialysis center 2] RN/ facility administrator) stated, [R5] gets lab work drawn every month. We use [laboratory] for our lab work. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed . We do not send the official lab reports to the facility. R5 had lab work obtained at the [hemodialysis center 2] in August, September, October, November and December 2024. Review of R5's EMR lacked evidence of official [laboratory] reports of R5's monthly hemodialysis labs with [laboratory's] name and address. R5's dialysis binder had communication sheets, which mentioned various labs from some of these dates; however, these lab results were handwritten, not on the official [laboratory] report with the [laboratory's] name and address and not uploaded into R5'e EMR. The facility failed to have R5's dated clinical laboratory reports with the testing laboratory's name and address filed in R5's EMR. 2. Review of R6's clinical record revealed: 12/4/24 - R6 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, hyperlipidemia, hypomagnesemia and end stage renal disease with dependence on hemodialysis. 12/4/24 - E7 (MD) ordered in R6's electronic medical record (EMR), .Dialysis days: Mondays, Wednesdays and Fridays, Time for pick up: 12:30 . Review of R6's dialysis binder revealed a Hemo Quarterly Report Card dated December 6, 2024 with R6's albumin, potassium, calcium, phosphorus, PTH- intact and hemoglobin results. These lab results were typed on the [hemodialysis center] generated report, did not include the name and address of the testing laboratory and were not uploaded into R6's EMR. The facility failed to have R6's dated clinical laboratory reports with the testing laboratory's name and address filed in R6's EMR. 12/19/24 12:24 PM - During an interview, E10 (LPN) stated, The dialysis residents have a binder that goes with them to their treatment appointments .Their labs are written in on the communication sheet by the staff at the dialysis center. It is not the official lab report 12/19/24 1:39 PM - During an interview, E11 (NP) stated, The labs are obtained at the dialysis unit and they send a handwritten communications report in the patient's dialysis binder with written abnormal labs. We don't get copies of the official lab reports. 12/19/24 3:33 PM - During a telephone interview, C5 (outside hemodialysis center 3 administrator/RN) stated, At our hemodialysis center, we get standing labs on admission. R6 had lab work on 12/6/24. Then we get a hemoglobin every 2 weeks to once a month . Honestly, if there are no discrepancies (abnormal labs), we may not even report or send the labs to the facility. Sometimes, we send the official lab report to the facility in their communication book but that is not the standard of practice. We typically write down certain lab results on a report sheet and put that in the patient's communication book quarterly . 12/19/24 4:02 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 Corporate clinical advisor) at the exit conference.

Based on record review and interview, it was determined that for three (R1, R5, R6) out of three residents reviewed for dialysis, the facility failed to maintain medical records that were complete and readily accessible with regards to lab results. Findings include: Cross refer F698, F711 and F775. 1. Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis. 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . Review of R5's lab results tab in the EMR reveal no laboratory blood work since 7/26/24. R5 did have COVID screening lab results as recent as 11/6/24 in the lab results profile. 12/19/24 2:40 PM - During a telephone interview, C4 ([outside hemodialysis center 2]RN/ facility administrator) stated, [R5] gets lab work drawn every month. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed . We do not send the official lab reports to the facility. R5 had lab work obtained at the hemodialysis center in August, September, October, November and December 2024. The facility failed to obtain and enter these lab results on R5's EMR. 2. Review of R1's clinical record revealed: 11/15/24 - R1 was admitted to the facility with diagnoses including but not limited to, hyperlipidemia, end stage renal disease and stroke. 11/15/24 - E7 (MD) ordered in R1's EMR, .Dialysis days: Mondays, Wednesdays and Fridays . 12/10/24 - E11 (NP) ordered in R1's EMR, .BMP (basic metabolic profile) STAT for suspected CO2 (carbon dioxide) level decrease. 12/19/24 1:45 PM - During a telephone interview, C3 ([outside hemodialysis center 1] RN) stated that R1 had weekly labs drawn because he was an acute kidney injury patient. Typically his labs were drawn on Monday (weekly) during his treatment and usually the results did not come back until Tuesday due to [R1] having an afternoon dialysis start time .No, we don't fax the lab sheets over to the facility . 12/19/24 2:15 PM - During an interview, E2 (DON) stated, I don't know why R1's 12/10/24 STAT labs did not get into the EMR because those labs were ordered and drawn here in the facility. R5's last set of labs (CBC) are from 7/26/24, I know he [R5] has more recent labs as he is on hemodialysis. R6 had labs on 12/5/24. We need to figure out a process to get the results from the dialysis unit into the residents' EMR. Review of R1's lab result tab in the EMR lacked evidence of the 12/10/24 STAT lab results in R1's medical record. Additionally, R1's lab results from the weekly Monday hemodialysis lab draws on 11/8/24, 11/25/24, 12/6/24 and 12/13/24 were not available in R1's EMR. The facility failed to obtain and enter these lab results on R1's EMR. 3. Review of R6's clinical record revealed: 12/4/24 - R6 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, hyperlipidemia, hypomagnesemia and end stage renal disease with dependence on hemodialysis. Review of R6's lab results tab in the EMR reveal no laboratory blood work since R6's CBC (complete blood count) and CMP (comprehensive metabolic profile) on 12/5/24. 12/4/24 - E7 (MD) ordered in R6's electronic medical record (EMR), .Dialysis days: Mondays, Wednesdays and Fridays, Time for pick up: 12:30 . Review of R6's Hemodialysis Quarterly Report Card dated December 6, 2024 revealed R6's albumin, potassium, calcium, phosphorus, PTH-intact and hemoglobin results. This report that was generated at [hemodialysis center 3] documented only some select lab results; it did not provide the entire lab panel of results. Additionally, these results remained in R6's dialysis binder and were not uploaded into R6's EMR. The facility failed to obtain and enter these lab results on R6's EMR. 12/19/24 4:02 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 Corporate clinical advisor) at the exit conference.

Based on observation, interview and record review it was determined that for two (R20 and R45) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to prevent pressure ulcers and promote healing. For R45 the facility failed to prevent an avoidable deep tissue injury from developing to the bilateral heels causing harm. For R20 the facility failed to ensure that the resident was turned and repositioned to prevent pressure ulcers resulting in an avoidable Stage 3 pressure ulcer to the right heel and an avoidable stage 4 pressure ulcer to the left heel, resulting in harm. Findings include: A policy titled Skin Integrity and Wound Management updated 5/1/24 documented a comprehensive initial and ongoing nursing assessment of intrinsic and extrinisic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of case as needed. 1. Review of R20's clincial record revealed: 5/12/22 - R20 was admitted to the facility. 5/12/22 - A careplan for R20 was intiated for dependence of care related to limited mobility. Interventions included to monitor for complications of limited mobility such as pressure ulcers and monitor for decline in ADL function. 7/16/22 - A careplan for R20 was initiated for being at risk for skin breakdown related to limited mobility, incontinence, and fragile skin. Interventions included turn and reposition every two hours, monitor for skin breakdown, and weekly skin check by licensed nurse. The care plan lacked an approach to off load pressure to the heels. 4/2024 - The CNA task flow sheet documented that R20 was to be turned and repositioned and a skin check every two hours. Ten out of ninety-three opportunities were not documented. Twelve out of ninety-three opportunities indicated R20 had reddened areas on skin that did not go away. The facility documentation lacked evidence that staff reported the reddened areas that would not go away for R20 and lacked evidence of implementing any new approaches related to skin breakdown/prevention. 5/2024 - The CNA task flow sheet documented that R20 was to be turned and repositioned and a skin check every two hours. Nine out of ninety-three opportunities were not documented. Fifteen out of ninety-three opportunities indicated R20 had reddened areas on skin that did not go away. The facility documentation lacked evidence that staff reported the reddened areas that would not go away for R20 and lacked evidence of implementing any new approaches related to skin breakdown/prevention. 5/5/24 - The Annual MDS documented that R20 was dependent for turning, bed mobility, and repositioning with two person physical assist. R20 had range of motion impairments bilaterally of the lower extremities and one side for upper extremities. The MDS assessment also identified R20 was at risk for pressure ulcers/injuries. Despite R20's dependence on staff for bed mobility and impaired range of motion the facility did not update the care plan to include off loading pressure for the heels. 5/19/24 - A nursing Braden scale documented R20 with a score of 17 indicating R20 was at mild risk for skin breakdown. 5/30/24 - An SBAR identified a skin wound or ulcer to R20's left heel which was unstageable. The SBAR lacked evidence of interventions related to care of a pressure ulcer. 5/30/24 - A skin evaluation documented a pressure ulcer was present to R20's left heel and was a in house acquired wound. The pressure ulcer was unstageable related to eschar or slough present. Descripton was noted as 5.9 cm L x 5.0 cm W, no depth, bleeding, serosanguinous exudate, and no odor. The recommendations for treatment were cover with MediHoney, heel suspension/protection device, turn and reposition. The evaluation stated provider was notified and heel cushion provided. The heel suspension/off loading was not initiated until after the pressure ulcer had developed. 5/31/24 - R20's care plan documented updated interventions to float bilateral heels using a heel up pillow and wound treatments as ordered. 6/11/24 - The SBAR identified a skin wound or ulcer on R20's right heel. The writer E21(RN) documented, wound bed was moist, malodorous, slough present, and periwound reddened and warm to touch. 6/11/24 - The skin evaluation documented a pressure ulcer was present to R20's right heel and was an in house acquired wound. The pressure ulcer was unstageable related to eschar. Desciption was noted as 3.9 cm L x 4.5 cm W, 12.5 cm A, no depth, moderate exudate, seropurulent drainage, and strong odor. The recommendations for treatment were cover with calcium alginate, foam dressing, and to offload heels. This pressure ulcer occurred after the initial offloading/floating of heels was implemented. 6/13/24 00:00 AM - A wound rounds progress note documented R20 had bilateral heel wounds with necrosis, moist tan slough, no foul wound odor noted , and periwound healthy in appearance. The progress note also documented R20 was educated on wound assessment and plan to continue Medi-Honey covered by dry dressing daily as needed. R20 was also educated on importance of floating heels when in bed to promote healing and reduce further breakdown. 7/18/24 - A wound evaluation documented for R20's left heel wound measurements as 8.63 cm L x 4.38 cm W and 28.85 cm A. The left heel remains unstageable related to slough and eschar. The left heel was noted to have seropurulent exudate and intact wound edges. The treament recommended was cleanse with dakins solution, cover with Medi-Honey, and a clean dry dressing. Continue with heel suspension/protection device and turn/repositioning programm. A review of wound evaluation documented for R20's right heel wound measurements as 3.78 cm L x 3.24 cm W and 9.16 cm A. The right heel remains unstageable related to eschar. The treatment recommended was cleanse with dakins solution, cover with calcium alginate, and a clean dry dressing. Continue with heel suspension/protection device and turning/repositioning schedule. 8/8/24 - A wound evaluation documented for R20's right heel wound measurements as 2.68 cm L x 2.17 cm W and 4.38 cm A. The right heel is now documented as a stage 3 pressure ulcer having serosainguineous exudate with attached edges. The treatment recommended was wet gauze with dakins solution and covered with clean dry dressing. Continue with heel suspension / protection device and turn/repositioning program. 8/15/24 - A wound evaluation documented for R20's left heel wound measurements as 5.56 cm L x 3.85 cm W and 17.26 cm A. The left heel remains unstageable related to eschar and was noted to have bleeding, serosainguineous exudate, and attached edges. The treatment recommended was wet gauze with dakins solution and covered with clean dry dressing. Continue with heel suspension/protection device and turn/repositioning program. 9/17/24 10:35 AM - An observation of R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/18/24 10:32 AM - An observation of R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/19/24 9:10 AM - An observation or R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/19/24 10:31 AM - An observation or R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/19/24 11:26 AM - An interview with E22 (RN) revealed the purpose of floating heels is to prevent skin breakdown and the nurse on duty will verify every shift that the CNA is floating resident's heels while they are in bed. The CNA is expected to check and reposition at least every two hours. 9/20/24 9:24 AM - An observation of R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/20/24 10:33 AM - An observation of R20's bilateral heels resting on mattress with pillow noted under calves. The pillow was not positioned correctly for R20's bilateral heels to be suspended off the mattress. 9/20/24 2:09 PM - An interview with E23 (LPN, WCN) revealed the expectation of floating heels is to prevent skin breakdown and/or keep current skin breakdown from worsening. E23 stated that staff should be adjusting pillows for floating heels every two hours or sooner when they go to reposition. E23 confirmed that R20 does not currently have a low air loss mattress at this time and R20's pressure ulcers were in house acquired. 9/24/24 9:48 AM - An interview with E24 (WC, NP) revealed the expectation of floating heels is to prevent skin breakdown and/or keep current skin breakdown from worsening. E24 confirmed that staff should turn and reposition residents at least every two hours and that heels should be floated while residents are in bed. E24 stated R20's bilateral heel wounds were caused by pressure. 2. Review of R45's clinical record revealed: 7/31/19 - R45 was admitted to the facility. 8/18/19 - A care plan for R45 was intiated for dependence of care related to decline in functional ability. Interventions included to monitor for complications of limited mobility such as pressure ulcers and monitor for decline in ADL function. 8/18/19 - A care plan for R45 was initiated for risk of skin breakdown related to decreased physical mobility and occasional incontinence. Interventions included pat skin when drying and a weekly skin check by a liscensed nurse. The careplan lacked an approach to off load pressure to the heels. 11/10/23 - A nursing Braden scale documented R45 with a score of 19 indicating R45 was at no risk for skin breakdown. 11/10/23 - The quarterly MDS assessment documented that R45 was completely dependent with two physical person assist for bed mobility and turning. R45 had range of motion impairments bilaterally for upper and lower extremities. The MDS assessment also identified R45 was at risk for pressure ulcers/injuries. The MDS indicated that R45 had pressure reducing devices to the bed and chair and did not need a turn/reposition program. The careplan continued to lack approaches to off load pressure from the heels. 12/2023 - The CNA task flow sheet documented that R45 was to be turned and repositioned and a skin check every two hours. Ten out of ninety-three opportunities were not documented. Five out of ninety-three opportunities indicated R45 had reddened areas on skin that did not go away. The facility documentation lacked evidence that staff reported the reddened areas that would not go away for R45 and lacked evidence of implementing any new approaches related to skin breakdown/prevention. 12/20/23 - An SBAR documented that R45 had a DTI (deep tissue injury) to the right heel, unstageable due to sloth or eschar. The SBAR documented the DTI as in house acquired with the following measurements 5.8 cm L x 5.6cm W and 25.7 cm A. The wound was described as a scab, with no exudate, no odor, attached edges, and with dry/flaky calloused surrounding tissue. The treatment recommendations were sure prep, foam mattress, repositioning device(s), and turn/repositioning program. There were no approaches added to off load pressure from the heels. 12/27/23 - A physician's order was completed for a venous doppler study. The study revealed doppler blood flow detected and no indication of thrombus. 12/28/23 - A skin and wound evaluation documented a DTI to the right heel measuring 7.81 cm L x 7.42 cm W, 43.86 cm A, black in color with eschar, attached edges, and dry flaking peri wound. The following interventions were suggested: heel suspension/protection device, low air loss mattress, positioning wedge, and turn/repositioning program. 1/3/24 - An SBAR documented that R45 had four areas noted for DTI. Treatment recommendations were low air loss mattress and to discontinue heel boot to right foot. The record lacked evidence of another form of offloading/floating of heels. 1/13/24 2:15 AM - A skilled evaluation progress note documented a DTI to the right heel with no exudate, odor, tunneling, and fragile periwound. 4/15/24 - A physician's order for a bilateral duplex study was completed. The results recommended a CT study for further evaluation. The results also revealed a positive note for stenosis in multiple arteries. A diagnosis of PVD (peripheral vascular disease) was added to R45's diagnosis list. The facility lacked evidence that a CT study for further evaluation was completed. 4/25/24 - A wound care evaluation documented R45's right heel with an unstageable pressure ulcer, dry black eschar, with tan moist slough along parameter, mod amount of foul smelling drainage, peri wound is healthy in appearance. Pt consented to debridement of eschar cap, 7mm x 7mm escar cap debrided with scapel down to granulated tissue with tan moist slough, no bleeding noted, no s/s of pain during procedure. Educated patient on wound assessment and of plan to continue dakins moist gauze covered by ABD pad and wrap with Kerlix BID and PRN as well as of importance of at least every two hour turn/repositioning, and of floating his heels when in bed. Patient verbalizes understanding, denies pain with wound assessment. 9/18/24 9:22 AM - An observation of R45 in bed and heels resting directly on the mattress. No pillow noted to float heels. 9/18/24 10:35 AM - An observation of R45 in bed and heels resting directly on the mattress. No pillow noted to float heels. 9/19/24 9:13 AM - An observation of R45 in bed and heels resting directly on mattress and pillow on side of mattress away from feet. 9/19/24 10:30 AM - An observation of R45 laying on back and heels resting directly on mattress. 9/19/24 11:16 AM - An observation of R45 in bed with heels resting directly on mattress. 9/19/24 11:26 AM - An interview with E22 (RN) revealed the purpose of floating heels is to prevent skin breakdown and the nurse on duty will verify every shift that the CNA is floating resident's heels while they are in bed. The CNA is expected to check and reposition at least every two hours. 9/20/24 9:24 AM - An observation of R45's heels laying directly on the mattress. A pillow was placed under legs improperly and the heels are not elevated. 9/20/24 10:36 AM - An observation of R45's heels laying directly on the mattress. A pillow was placed under legs improperly and the heels are not elevated. 9/20/24 2:09 PM - An interview with E23 (LPN WCN) revealed the expectation of floading heels is to prevent skin breakdown and/or keep current skin breakdown from worsening. E23 state that staff should be adjusting pillows for floating heels every two hours or sooner when to go to reposition. E23 confirmed that R45's pressure ulcers were in house acquired 9/24/24 9:48 AM - An interview with E24 (WC NP) confirmed she was working with R45 since April 2024. R45 was sent to wound care and no wound care surgeon would take his case. E24 confirmed she debrided wound to right heel and that R45 was educated on positioning and floating heels. E24 confirmed that staff was educated on how to use the float devices. E24 stated the expectation for any resident with wounds should be turned and repositioned every two hours, will not wear shoes, and should maintain no pressure from bed. E24 stated that R45's wound reopened this past week and stated lack of floating heels was very likely why the wound reopened. E24 stated any area that has a wound will be weakened and have greater risk to reopen and import to alleviate pressure especially to those areas. 9/24/24 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate 1) at the exit conference.

Based on record review and interview, it was determined that for four (R7, R22, R43 and R66) out of twenty (20) sampled residents, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings and that meetings occurred every three months. In addition, R66's care plan had not been reviewed and revised to reflect a behavior of frequently removing his nebulizer equipment from the protective plastic bag. Findings include: 1. Review of R7's clinical record revealed: 4/10/24 - R7 was admitted to the facility. 9/19/24 - A review of the notes for the initial care plan meeting on 4/25/24 lacked evidence of input from the Physician. Additionally, there was no evidence that a quarterly care plan meeting occurred in July, 2024. 2. Review of R22's clinical record revealed: 4/10/14 - R22 was admitted to the facility. 9/19/24 - A review of the notes for the care plan meeting on 10/11/23 lacked evidence of input from R22's nurse. A review of the notes for the care plan meeting on 8/14/24 lacked evidence of input from the Physician. Additionally, there was no evidence that there was a care plan meeting from 11/29/23 to 8/14/24 although an OBRA significant change in status assessment was conducted on 2/15/24. 3. Review of R43's clinical record revealed: 7/25/19 - R43 was admitted to the facility. 9/19/24 - A review of the notes for the care plan meeting on 11/22/23 lacked evidence of input from the certified nursing assistant. There was no evidence that there was a care plan meeting from 2/21/24 to 9/11/24, although a quarterly MDS was conducted on 3/16/24 and 6/16/24. Finally, a review of the care plan meeting notes dated 9/11/24 lacked evidence of input from the Physician. 9/24/24 9:59 AM - In an interview, the Surveyor shared the above information with E1 (NHA), who acknowledged that the missing IDT members and gaps in care plan meetings were likely due to staffing issues and turnover. 47114 4. Cross Refer F695. Review of R66's clinical record revealed: 5/24/23 - R66 was admitted to the facility with the following diagnoses, including, but not limited to, chronic obstructive pulmonary disease (lung disease that blocks air flow and makes it difficult to breathe) and stroke. 8/30/24 - A quarterly MDS (Minimum Data Set) assessment revealed R66 was severely cognitively impaired. 9/18/24 10:31 AM - During an interview, E15 (LPN) stated, [R66's] nebulizer treatments are ordered to be given every 6 hours as needed. In addition, E15 revealed R66 turns the nebulizer machine on and off himself and R66 takes the nebulizer tubing and mask out of the protective bag himself all the time. Additionally, E15 reviewed R66's care plan for this behavior and stated, I can't find a care plan for the behavior. 9/18/24 10:54 AM - During an interview, E2 (DON) confirmed she was not aware of E66's behavior of turning the nebulizer machine on and off and removing the nebulizer equipment from the protective plastic bag. E2 confirmed that R66 was not care planned for those behaviors. E2 updated R66's care plan to reflect the behavior. 9/24/24 2:00 PM - Findings were reviewed with E1, E2 and E3 (Corporate 1) at the exit conference.

Based on interview and record review it was determined that for three (R20, R38 and R45) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to maintain or restore bladder continence. Findings include: A policy revised on 6/15/22 titled Continence Management documented continence status will be reviewed quarterly as part of the care planning process to provide appropriate treatment and services for patients with urinary incontinence to restore continence to the extent possible. 1. Review of R20's clinical record revealed: 5/12/22 - R20 was admitted to the facility. 5/5/24 - The Annual MDS assessment documented that R20 was dependent for toileting hygiene and not on a toileting program. The MDS also documented that R20 was frequently incontinent of bowel and bladder. 5/2024 - The CNA task sheet documented that R20 was incontinent of urine seventy-three out of eighty-five opportunities. 6/2024 - The CNA task sheet documented that R20 was incontinent of urine seventy-eight out of eighty-four opportunities. 6/12/24 - A skilled evaluation progress note documented that R20 was incontinent of urine. Resident uses adult briefs. New onset incontinence: No. Resident is frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). 7/2024 - The CNA task sheet documented that R20 was incontinent of urine eighty-six out of eighty-six opportunities. 8/2024 - The CNA task sheet documented that R20 was incontinent of urine seventy-seven out of eighty opportunities. 8/5/24 - The quarterly MDS assessment documented that R20 was dependent for toileting hygiene and not on a toileting program. The MDS also revealed that R20 was always incontinent of bladder and frequently incontinent of bowel. 9/20/24 10:45 AM - An interview with E7 (CNA) confirmed that R20 is dependent for care and was not on a toileting program. E7 states that R20 does not use a bed pain and is not offered one. 9/20/24 11:30 AM - An interview with E19 (UM) confirmed that the residents bowel and bladder are assessed upon admission and then quarterly thereafter. E19 confirmed that nurses can intiate a toileting program if they notice a change or decline during the quarterly assessments. E19 confirmed that R20 is not currently on a toileting program. The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R20. The facility lacked evidence of a quarterly bowel and bladder assessment for R20. 2. Review of R38's clinical record revealed: 5/10/23 - R38 was admitted to the facility. 9/29/23 - The significant change MDS documented that R38 required extensive two person assist for toileting and hygiene care. R38 was frequently incontinent of urine and always incontinent of bowel. R38 was not on a toileting program. 10/2023 - The CNA task sheet documented that R38 was incontinent of urine fifty-four out of seventy-three opportunities. 11/2023 - The CNA task sheet documented that R38 was incontinent of urine fifty-seven out of eighty-three opportunities. 12/2023 - The CNA task sheet documented that R38 was incontinent of urine seventy-seven out of eighty-nine opportunities. 12/30/23 - The quarterly MDS documented that R38 was dependent for toileting and hygiene care. R38 was always incontinent of bowel and bladder and not on a toileting plan. 9/16/24 10:49 AM - An interview with R38 confirmed that she used to use a bed pan but has not been using one due to the facility not having a small enough one for her. 9/20/24 11:15 AM - An interview with E20 (CNA) confirmed that R38 is dependent for toileting and hygiene care. E20 also confirmed that R38 did not use a bed pan and was not on a toileting program. 9/20/24 11:30 AM - An interview with E19 (UM) confirmed that R38 was not on a toileting program. The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R38. The facility lacked evidence of a quarterly bowel and bladder assessment for R38. 3. Review of R45's clinical record revealed: 7/13/19 - R45 was admitted to the facility. 11/10/23 - The quarterly MDS assessment documented that R45 was dependent for toileting and hygiene care. R45 was frequently incontient of bowel and bladder, and not on a toileting program. 11/2023 - The CNA task sheet documented that R45 was incontinent of urine fifty-two out of eighty opportunities. 12/2023 - The CNA task sheet documented that R45 was incontinent of urine seventy-two out of eighty-five opportunities. 1/2024 - The CNA task sheet documented that R45 was incontinent of urine eighty-nine out of eighty-nine opportunities. 1/11/24 - The quarterly MDS assessment documented that R45 was dependent for toileting and hygiene care. R45 was always incontient of bowel and bladder and not on a toileting program. 9/20/24 11:15 AM - An interview with E20 (CNA) confirmed that R45 is dependent for care and is currently not on a toileting program. E20 states that R45 does not use a bed pain and is not offered one. 9/20/24 11:30 AM - An interview with E19 (UM) confirmed that R45 was not on a toileting program. The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R45. The facility lacked evidence of a quarterly bowel and bladder assessment for R45. 9/24/24 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate 1) at the exit conference.

Based on record review and interview, it was determined that for five (E7, E8, E9, E10 and E11) out of five certified nursing assistants reviewed, the facility failed to complete an annual evaluation. Findings include: 9/23/24 approximately 8:50 AM - E1 (NHA) provided documentation regarding CNA evaluations for the following employees: E7 (CNA) with a date of hire of 12/6/22; E8 (CNA) with a date of hire of 5/24/22; E9 (CNA) with a date of hire of 11/20/17; E10 (CNA) with a date of hire of 10/14/19; E11 (CNA) with a date of hire of 3/7/23; 9/23/24 11:59 AM - In an interview, E1 stated that there had been a system failure due to turnover with facility staff. The facility was in the process of completing the overdue performance evaluations at the time of the survey. 9/24/24 2:00 PM - Findings were reviewed with E1, E2 (DON) and E3 (Corporate 1) at the exit conference.

Based on observation, interview and record review, it was determined that for one (R21) out of fourteen residents reviewed for abuse, the facility failed to ensure that R21 was free of sexual abuse by R6, a resident with a history of sexually inappropriate behavior. The facility's failure to monitor R6 allowed the sexual abuse of R21 on 5/22/22. An Immediate Jeopardy (IJ) was identified and due to the facility's corrective measures following the incident, this is being cited as an immediate jeopardy, past non-compliance with and abatement date of 5/24/22, which was verified by interviews and review of facility records. Findings include: OPS300 Abuse Prohibition Policy (Genesis) stated, .The Center will implement an abuse prohibition program through the following: .prevention of occurrences .Federal Definitions: Sexual Abuse is a non-consensual sexual contact of any type with a resident . 5. Actions to prevent abuse, neglect . 5.2 identifying, correcting and intervening in situations in which abuse, neglect . is more likely to occur; . If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 6.3.1 The center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. 6.3.2 The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation . 5/23/19 - R21 was admitted to the facility with diagnoses including schizophrenia and dementia. 5/24/19 - R6 was admitted to the facility with diagnoses including vascular dementia. 7/27/19 - Per an Incident report filed with the Department of Health Care Quality (DHCQ), E28 (former DON) documented that R6 initiated a sexually inappropriate interaction with R3, who was R6's cognitively impaired roommate at the time. This incident was documented to acknowledge that R6 (the perpetrator) had a known history of a sexually inappropriate interaction with another resident in the facility. 7/27/19 - R6 was moved to a double room without a roommate until a private room was available. 7/27/19 - E28 (former DON) updated R6's care plan with focus that R6 . exhibits sexually inappropriate behaviors as evidenced by touching roommate's genitals .Interventions included: explore [R6]'s history and available medical records for sexual abuse, sexual dysfunction, inappropriate sexual behavior, deviant sexual practice or vulnerability to sexual victimization, monitor conditions that may contribute to inappropriate behaviors including psychiatric disorders, dementia, evaluate [R6]'s understanding of sexually inappropriate behaviors (triggers, coping mechanisms), evaluate for Psych/Behavior health consult, social services visits to provide support, as needed, divert [R6] by giving alternate objects or activities, familiarize [R6] with own belongings and surroundings, listen to [R6] and try to calm, remove [R6] from environment. 7/30/19 - R6 was evaluated by C1 (Psychiatrist) who recommended, If possible, patient should be in a single room and monitored when out of his room. 8/1/19 - R6's care plan was updated with an intervention, motion sensor to R6's doorway. 9/19/19 - E30 (MD) ordered door alarm in place and functioning correctly, check every shift. 1/6/20 - A Psychiatry Consultant recommended fluoxetine (anti-depressant) 10 mg by mouth daily for sexually disinhibited behaviors. 10/28/20 - R6 was moved to a private room. 11/1/21 - R6's fluoxetine dosage increased by Psych NP from 10 mg (milligrams) to 20 mg daily. Fluoxetine was being utilized for depression but was increased to treat R6's Compulsive Sexual Behaviors (CSB). This drug was known to cause drug-induced sexual dysfunction with a decrease in sexual desire and function. 3/4/22 - R6's quarterly MDS assessment documented a BIMS score of 12, which is in the range of moderate cognitive impairment. In the Behavior section, R6 was documented as having no hallucinations/delusions, no aggressive or sexually abusive behaviors, no wandering and no refusals of care. In the Functional Status section, R6 was documented as independent for bed mobility and locomotion and required supervision for transfer, walk in room, dressing, toileting and personal hygiene. 4/22/22 - R21's quarterly Minimum Data Set (MDS) assessment documented a BIMS score of three, which indicated a severe cognitive impairment. 5/22/22 - Per a facility-reported Incident report to Department of Health Care Quality (DHCQ), R21 was involved in sexually inappropriate interaction with R6. R6 was deemed by police authorities to be the aggressor/perpetrator and R21 was the victim. 5/22/22 4:15 PM - E31's (LPN) Witness Statement documented, . I was coming out of room (number) and I observed R6 standing in the doorway of his room. R21 was leaning against the wall holding the handrail facing the nurses' station. I observed R6 with his hand in R21's pants. R21's pants were moving. I said Get out of there! I told both parties to Go to your room. R6 backed up into his room. R21 was led to his room. 5/22/22 5:58 PM - E32 (on-call MD) ordered 1:1 observation of R6 for sexual behaviors. 5/22/22 11:00 PM - Documentation of 1:1 observation of R6 was initiated. 5/24/22 4:44 PM - E33's (MD) Progress note of R6 documented . seen for inappropriate behavior. Reportedly had unwanted physical contact with another resident. Will discontinue fluoxetine and start sertraline (anti-depressant) to decrease libido . 5/24/22 2:52 PM - For R6, E33 (MD) ordered sertraline 50 mg by mouth daily for depression and discontinued fluoxetine 20 mg daily. 5/25/22 - R6's care plan was updated with the following interventions: private room and 1:1 for inappropriate touching of other residents. 5/27/22 - E33 (MD) discontinued R6's sertraline 50 mg daily and reordered fluoxetine 20 mg by mouth daily. 9/15/22 - R6's Significant Change MDS assessment documented a BIMS score of 11, which is in the range of moderate cognitive impairment. In the Behavior section, R6 was documented as having no hallucinations/delusions, no aggressive or sexually abusive behaviors, no wandering and no refusals of care. In the Functional Status section, R6 was documented as requiring extensive assist with 2 staff for transfers; extensive assist with 1 staff for bed mobility, dressing, toilet use and personal hygiene, and supervision with physical assist of 1 staff for walking and locomotion. 11/16/22 - E33 (MD) discontinued 1:1 observation for R6 due to the decrease in functional status. 6/29/23 2:55 PM - E25 (NP) discontinued door alarm for R6 as it was no longer needed. 8/15/23 through 8/21/23 - Observations by the Surveyor revealed that R6 remained in his room after being placed in his wheelchair by staff and the Surveyor never witnessed R6 self propelling his wheelchair inside or outside his room. 8/21/23 11:32 AM - During a combined interview, E19 (CNA) stated, When the door alarm bongs, staff is suppose to visualize whether a staff member went in the room or if R6 is coming out. If R6 is coming out, R6 needs to be kept in someone's (staff) eyesight. No one person is assigned this. This statement was confirmed by E36 (LPN). 8/21/23 12:41 PM - Interview with E33 (MD) revealed that sertraline was started on 5/24/22 and discontinued on 5/27/22 because it was deemed that fluoxetine was a better drug for Compulsive Sexual Behaviors (CSB). E33 also stated that there was no order for direct sight visualization with the door alarm. E33 stated, Staff were aware that they needed to do this. There was no evidence of any other sexual resident-to-resident incidents involving R6 after 5/22/22. 8/23/23 9 AM - Based on interviews and record reviews of facility documentation, an Immediate Jeopardy (IJ) was called and reviewed with the facility leadership, including E1 (NHA) and E2 (DON). During this conference, both E1 and E2 confirmed that to their knowledge, there had been no other incidents of sexually inappropriate contact by R6 with other residents. Both acknowledged that they did not work in the building at the time of the previous assault in 2019 and were unaware of the 2019 incident prior to the Surveyor bringing it to their attention. 8/23/23 3:30 PM - E1 (NHA) submitted an acceptable documentation of corrective action plan that was fully abated on 5/24/22 signed, dated and timed. The facility's corrective actions at the time of the incident included: - notifying the responsible party for both residents; - initiating 1:1 observation of R6; - notifying the police; - filing an incident report and follow up investigation with the State Agency; - consulting with the Medical Director; - obtaining labs on R21 to rule out medical issues; and - engaging Social Services to interview each resident. R6 remained care planned for this behavior. Due to the corrective actions taken by the facility after the 5/22/22 incident and no further sexual resident-to-resident incidents involving R6, this occurrence was deemed to be past non-compliance. 8/23/23 3:41 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for four (R5, R15, R91 and R102) out of four residents reviewed for Insulin, the facility failed to ensure that the physician reviewed the residents' total program of care as presented in the interfacility transfer documentation. For R91, the physician's failure to ensure that the resident's total program of care was accurately evaluated upon his admission and throughout his stay in the facility placed R91 in Immediate Jeopardy (IJ) of a serious, adverse outcome. The Physician's failure to order an insulin sliding scale, finger stick blood sugar checks, Trojeo (concentrated insulin) medication daily, and the correct frequency of Synjardy (combination anti-diabetic medication containing empagliflozin and metfomin) resulted in R91's metabolic derangement and resultant diabetic ketoacidosis (DKA). R91 was admitted to a hospital critical care unit with the diagnosis of diabetic ketoacidosis (DKA) requiring a continuous insulin drip five days after his admission to the facility. The IJ was identified on 8/31/23 at 3:15 PM and was abated on 9/7/23 at 3:20 PM. In addition, for R5, several notes (12/13/22, 3/22/23, 5/7/23, 7/16/23) documented that R5 was no longer on insulin when, in fact, the physician had restarted insulin in February 2022. For R15, several notes documenting R15's decreased appetite and remaining on remeron (anti-depressant used for appetite stimulation) for appetite enhancement when, in fact, R15 had gained 28 pounds in the past year and was not and has never been on remeron. For R102, fingerstick blood sugar monitoring and management of diabetes were omitted from the plan of care/treatment orders. Findings include: 1. Cross refer F773 and F760. According to the U.S. Food and Drug Administration (FDA) for Synjardy medication - Drug Safety Communications- FDA warns that Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors for diabetes may result in a serious condition of too much acid in the blood issued on May 15, 2015. Safety Announcement .Medicines in the SGLT2 inhibitor class include canagliflozin, dapagliflozin and empagliflozin .In patients taking an SGLT2 inhibitor, ketoacidosis can occur even if the blood sugar is less than 250 mg (milligrams)/ dL (deciLiter) .In many cases, ketoacidosis was not immediately recognized because the blood glucose levels were below those typically expected for diabetic ketoacidosis .In some cases, predisposing factors for ketoacidosis were identified. These included: reduction of insulin dosage, acute febrile illness, reduced caloric intake due to illness or surgery, pancreatic disorders suggesting insulin deficiency and alcohol abuse. According to the Journal of Investigative Medicine - HIGH IMPACT CASE REPORTS . Since the approval of SGLT2 inhibitors by the U.S.FDA for type 2 diabetes, there have been several reports of euglycemic diabetic ketoacidosis in patients using this class of medication . DKA (diabetic ketoacidosis) is defined by the triad of hyperglycemia (high blood sugar) (greater than 250 mg/dL), anion-gap acidosis and increased plasma ketones. Euglycemic DKA is defined as DKA without hyperglycemia (high blood sugar). J Investig Med High Impact Case Rep. 2017 Apr-Jun; 5(2): 2324709617710040 1. R91's clinical record and hospital records revealed: 6/1/23 - Hospital A record documented that R91 was discharged to home with home health referral after a right total knee replacement on 5/31/23. Hospital A discharge summary documented, Discharge Medication Reconciliation-Home Medications Active: . Synjardy (combination anti-diabetic medication containing empagliflozin and metformin) 12.5mg - 1000mg by mouth twice a day, . Toujeo (concentrated insulin) Solostar 300 units/ml (milliliter) 24 units SQ (subcutaneously - under the skin) once a day (at bedtime), . Ozempic (semaglutide - anti-diabetic medication) 1 mg (milligram) SQ Q (every) Tuesday, . Humalog insulin Kwikpen- SSI (sliding scale insulin) TID ( three times a day) AC (before meals) . 6/5/23 - R91 was admitted to an acute rehabilitation center from home. 6/16/23 - R91 was admitted to the facility from acute rehabilitation center B with diagnoses including diabetes and aftercare following joint replacement therapy. Of note, 6/16/23 was a Friday. 6/16/23 - R91's Discharge Reconciliation Report from acute rehabilitation center B listed these medications to be continued upon transfer to the facility, . Synjardy (Patient OWN medication) 12.5 - 1000 mg by mouth twice a day - last given 6/16/23 at 8:57 AM, . Ozempic (Patient OWN Medication) inject 1 mg under the skin once a week on Tuesday - last given 6/14/23 at 12:15 PM . Additionally, acute rehabilitation center B's Discharge Summary stated, . Recommendations/Plan: . DM2; Diabetes: monitor accuchecks. Continue DM meds - Synjardy and insulin reg for sliding scale PRN . Of note, review of the records from acute rehabilitation center B noted that the Toujeo (concentrated insulin) was not listed or administered during his confinement there. Upon admission to the facility, R91 had already missed eleven doses (6/5/23 to 6/15/23) of his nightly Toujeo (concentrated Insulin) medication. 6/16/23 8:36 PM - E46 (LPN) entered a telephone order from E33 (MD), Synjardy 12.5 - 1000 mg by mouth one time a day for diabetes. 6/16/23 - E33 gave a verbal order for R91 to have a complete metabolic panel (CMP) and complete blood count (CBC) drawn. This blood work includes a fasting blood sugar level. 6/17/23 8:56 AM - E33 signed the Synjardy 12.5 - 1000 mg by mouth one time a day order in R91's medical record. This was not consistent with the acute rehabilitation center discharge paperwork listing this medication's frequency as BID (twice daily) and not daily. 6/17/23 11:17 AM - R91's lab work was reported to the facility. The lab work revealed an elevated Anion gap of 19 (normal range for this lab was 8 to 16). An anion gap measures the difference or gap between the negatively charged and positively charged electrolytes in a patient's blood. If the anion gap becomes too high, the person's blood is more acidic than normal. There was no documentation that the staff called the physician to report the labs or that the physician reviewed the labs. 6/17/23 to 6/19/23 8:00 AM - R91's Medication Administration Record (MAR) reflected R91 receiving a dose of Synjardy 12.5 - 1000 mg by mouth each day. 6/19/23 - E33 documented in R91's History & Physical (H&P), External Records and/or discussions: Today I reviewed external hospital notes/ discharge summary from: [Hospital A] health note/ discharge date ,d+[DATE], {Acute rehab center B] D/C 6/16, Summary: see HPI . E33 signed this note on 6/20/23 at 7:46 AM. Despite reviewing R91's 6/1/23 hospitalization (Hospital A) and 6/16/23 acute rehab center B's records, the Physician failed to recognize the following: - R91's Synjardy was ordered twice a day at acute rehab center B and was listed on the transfer/discharge medication list as BID or twice a day but was ordered at this facility as once a day; and - R91 was on Toujeo (concentrated insulin) 24 units SQ (subcutaneously) once daily at Hospital A. E33 documented that he reviewed this document in his H&P note but did not recognize that R91 had not been ordered this medication to manage his diabetes while in the facility or at acute rehab center B. 6/19/23 1:35 PM - Four days after admission, E25 (NP) entered an order in R91's medical record for sliding scale insulin coverage and STAT lab work for another CMP and CBC. 6/19/23 4:52 PM - Records indicate the blood work was collected at the facility. 6/19/23 6:56 PM - R91's STAT labs were reported to the facility with a serum glucose of 258 and an anion gap of 29 (normal lab range 8-16). Both labs were abnormally elevated. There was no evidence that the facility contacted the provider with the laboratory results or that these labs were reviewed by the Physician on 6/19/23. 6/19/23 5:58 PM - E47 (nurse) documented finger blood sugar (BS) as 309 and administered 8 units of insulin. 6/19/23 11:21 PM - E47 documented BS as 309 and administered 8 units of insulin. 6/20/23 5:37 AM - E47 documented BS as 317 and administered 8 units of insulin. 6/20/23 7:30 AM - Emergency Medical Services (EMS) was called due to R91's altered mental status. 6/20/23 8:20 AM - C4 (emergency room MD) documented in the hospital emergency room note, . Nursing home noted that he (R91) was tachycardia today, encephalopathy (altered mental status) and called EMS. On paramedic's arrival (sic), they noted the patient's blood sugar was in the 400's. They gave 10 units of insulin and sugars (sic) improved to 60 . 6/20/23 2:21 PM - C5 (Critical Care MD) documented in the Critical Care Medicine Admission note, . Per record, patient has been in rehab, family is unaware whether he has been receiving his anti-glycemic medication . Assessment and Plan: Acute encephalopathy likely secondary to metabolic derangement/DKA (diabetic ketoacidosis) . PCO2 in VBG (Venous blood gas) is not elevated. UA (urine analysis) shows no evidence of infection . Leukocytosis (elevated white blood cell count) without any focus of infection. The elevated white cell count could be reactive .High anion gap metabolic acidosis secondary to DKA. The inciting factor for DKA is unknown at this time but suspect may have been secondary to medications, stress . No signs of infections the leukocytosis is likely reactive .On insulin drip per protocol . latest anion gap 7 however chloride is significantly elevated at 120 and bicarb is still below 20 . Plan to continue insulin drip until bicarb level is above 20 .Disposition: ICU (intensive care unit) level of care. Prognosis is guarded . 8/31/22 12:39 PM - During an interview, E33 stated that he did not recall getting a call about R91's admission orders. He could not remember if the Synjardy frequency was reduced intentionally. The only reason it would be reduced was to get the patient back on their home dose. The hospital pre-op (pre-operation) History & Physical (dated 5/23/23) documented that R91 was on Synjardy but does not give the dosage or frequency. When asked about reviewing the Hospital records as documented in his Admission Note (dated 6/19/23), E33 did not recall reading that R1 was on Toujeo 24 units Q (every) evening. E33 stated that he was not on call or in the building on the weekend of 6/17/23 to 6/18/23. 8/31/23 3:15 PM - Based on interviews and record reviews of facility documentation, an Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA) and E2 (DON). 9/1/23 - E1 (NHA) submitted an acceptable Abatement Plan signed, dated and timed which included: providing education to all on-call and inhouse providers regarding admitting residents to the facility and E33 (MD) taking on-call daily until all other providers received education regarding admissions to the facility. 9/7/23 3:20 PM - The Surveyors confirmed that the on-call schedule for the facility only scheduled providers who had been trained and affirmed their understanding of the training. Currently, E33 (MD) and E25 (NP) were the only providers taking on-call coverage in the building. The surveyors confirmed that education was disseminated to all the market on-call providers at the facility and the building was in the process of collecting the affirmation of understanding from these providers prior to listing them on the facility on-call schedule. The facility was deemed to have fully abated this IJ. 2. Review of R5's clinical record revealed: 8/19/20 - R5 was admitted to the facility with diagnoses including stroke and diabetes. 3/23/22 - E27 (MD) ordered Insulin Glargine 100 units/ml inject 50 units subcutaneously one time a day for diabetes. 3/23/22- E27 (MD) ordered HumaLOG solution (Insulin Lispro) inject as per sliding scale: if 0-149 = 0 (units); 150-200 = 6 (units); 20-1-250 = 10 (units); 251-300 = 14 (units); 301-350 = 16 (units); 351+ = 18 (units); subcutaneously before meals for Diabetes AND inject 10 units subcutaneously before meals for diabetes. 4/30/22 12:47 PM- E27 (MD) documented in R5's Progress Note, .Chief Complaint & History: [R5} was seen on 4/28/2022 .blood sugars are better controlled .Lantus 50 units + High dose sliding scale coverage AC. HgA1c (hemogloblin A1 c- lab test for diabetes management) Q (every) 3 months for now. 4/27/2022 sugars 212 am/ 138 with lunch/ 148 at dinner .Assessment/Plan & Other Information: .NIDDM (non-insulin dependent diabetes mellitus) 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 4/30/22 Progress note. 5/23/22 2:30 PM- E27 (MD) discontinued the Insulin Glargine 50 units order. 5/23/22- E27 ordered Lantus (Insulin Glargine) solostar pen 100 unit/ 1 ml (milliliter) insulin pen- inject 50 units subcutaneously one time a day for DM (diabetes). 7/28/22 4:06 PM- E27 (MD) documented in R5's Progress Note, .Assessment/Plan & Other Information: .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 7/28/22 Progress note. 8/18/22- E27 ordered HumaLOG solution 100 unit/ml (Insulin Lispro (Human))- inject as per sliding scale: if 0-149= 0 (units); 150-200= 6(units); 201-250= 10 (units); 251-300 = 14 (units); 301-350 = 16 (units); 351+ = 18 (units); subcutaneously before meals for diabetes AND inject 10 units subcutaneously before meals for diabetes. 8/23/22 4:13 PM- E27 (MD) documented in R5's Progress Note, . Chief Complaint & History: Do (sic) well with better glucose control . insulin coverage 10 units with meals + ss (sliding scale) coverage + 50 units of insulin glargine .Assessment/Plan & Other Information: .NIDDM 2005, started insulin 2013, now stopped 8/2020 . 10/7/22 6:57 PM- E27 (MD) documented in R5's Progress Note, .Review of Systems: . Blood sugars reviewed with the nursing staff >100<200 mg/ dl (deciliter) all .Assessment/Plan & Other Information: .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 10/7/22 Progress note. 12/13/22 9:11 PM- E27 (MD) documented in R5's Progress Note, .Assessment/Plan & Other Information: .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 12/13/22 Progress note. 2/3/23 4:42 PM- E27 (MD) documented in R5's Progress Note, .Chief Complaints & History: . Multiple sweets in the room though HgA1c are appropriate . NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 2/3/23 Progress note. 3/22/23 4:41 PM- E27 (MD) documented in R5's Progress Note, .Assessment/Plan & Other Information: .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 3/22/23 Progress note. 5/7/23 4:24 PM- E27 (MD) documented in R5's Progress Note, .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 5/7/23 Progress note. 7/16/23 1:10 PM- E27 (MD) documented in R5's Progress Note, .NIDDM 2005, started insulin 2013, now stopped 8/2020 . R5 was on a daily dose of insulin and insulin sliding scale at the time of the 7/16/23 Progress note. During the time period of 4/30/22 to 7/16/23, E27 (MD) wrote nine Progress Notes on R5 stating that R5, who was a diabetic, was no longer being managed with with insulin when in fact, R5 was on a daily dose of insulin and was being additionally monitored with finger stick blood glucose with an insulin sliding scale. 3. Review of R15's clinical record revealed: 5/3/21- R15 admitted to the facility with diagnoses including end-stage renal disease and diabetes. 9/15/21- E30 (MD) ordered R15's diet as a regular diet, dysphagia advanced texture- ground meat only- no salt packet, sugar free condiments, 1500 ml (milliliter) fluid restriction. 8/3/22- R15 documented as weighing 168.4 pounds. 6/22/23- E33's (MD) R15 Progress Note documented, .Diagnosis, Assessment & Plan: . R63.0 (the International Classification of Diseases {ICD} 10 code for Anorexia)- decreased appetite, encourage supplements, Remeron and follow weights. Also the Medication List in this Progress note does not include Remeron. 6/25/23- R15 documented as weighing 206 pounds. 7/7/23- R15 documented as weighing 204.6 pounds. 7/19/23- E33's (MD) R15 Progress Note documented, .Diagnosis, Assessment & Plan: . R63.0 (the ICD 10 code for Anorexia)- decreased appetite, encourage supplements, Remeron and follow weights. In the History section, the Medication List does not include Remeron. 8/3/23- R15 documented as weighing 196.9 pounds, which reflected a gain of 28.5 pounds in one year. 8/3/23- E33's (MD) R15 Progress Note documented, .Diagnosis, Assessment & Plan: . R63.0 (the ICD 10 code for Anorexia)- decreased appetite, encourage supplements, Remeron and follow weights. In the History section, the Medication List does not include Remeron. R15's Order recap printout, which showed all orders for a resident since time of Admission, revealed that R15 has never been on Remeron (mirtazapine). 8/16/23 11:44 AM- During an interview, E38 (RN) confirmed that R15 was not ordered Remeron on electronic medical record. 8/17/23 8:34 AM- During an interview with E37 (Nutritionist), E37 stated that R15 was on a regular diet for preference and that this order was approved by the C2 (Dialysis NP). E37 stated that R15's Body Mass Index (BMI) when adjusted for amputations was 35.6. E37 acknowledged the 28 pound weight gain over a year during this interview. During the time period of 6/22/23 to 8/3/23, E33 failed to provide an accurate account of R15's care in the three Progress notes ( 6/22/23. 7/19/23, 8/3/23) that he wrote. 4. Review of R102's clinical record revealed: 8/14/23 - Hospital discharge summary documented that R102's fingerstick blood sugar was being checked four times a day: before breakfast, lunch, dinner and at bedtime. R102's orders included insulin lispro (Humalog Medium scale). 8/18/23 - R102 was admitted to the facility from acute care hospital where R102 was treated for cellulitis (inflammation of the tissues indicating a local infection) and multiple venous stasis ulcers (wound on the leg or ankle caused by abnormal or damaged veins) to the right and left lower legs. 8/18/23 - An admission record documented Type 2 Diabetes Mellitus with Diabetic Neuropathy. 8/19/12 - A care plan was initiated, Problem: The resident has a diagnosis of diabetes, the resident will be free of all symptoms of hypo/hyperglycemia such as: sweating Interventions included: - Administer hypoglycemic medications as ordered. - Educate resident on the signs and symptoms of hypo/hyperglycemia. - Monitor for signs and symptoms of hyper/hypoglycemia. 8/22/23 - A nurse practitioner's progress note documented .male with a past medical history significant for diabetes .worsening wounds to bilateral lower extremities 8/22/23 - An order recap report included one order related to diabetes: Consistent carbohydrate diet r/t diagnosis with no current meds. 8/31/23 approximately 2:00 PM - During an interview, E7 confirmed that R102 was not getting fingerstick blood sugar checks and no insulin was ordered. 8/31/23 2:12 PM - During an interview, E2 confirmed that R102 was not getting fingerstick blood sugar checks and no insulin was ordered. 8/21/23 2:50 PM- Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review and staff interview, it was determined that the facility failed to ensure that residents were free from significant medication errors for one (R1) out of three sampled residents for medication investigation. The facility failed to follow R1's physician's orders [REDACTED]. blood sugar at 4:30 PM to determine if sliding scale Insulin [MEDICATION NAME] was needed on the day of admission. After these significant medication errors, R1 experienced harm with extremely elevated blood sugars and was emergently readmitted to the hospital in Diabetic Ketoacidosis. These failures put the residents at risk for significant medication errors. An immediate jeopardy (IJ) was called on 1/15/2021 at 12:45 PM and was removed on 1/16/2021 at 4:00 PM. Findings include: Cross refer F755 1/1/2013 (last revised) - The Long Term Care Facility's Pharmacy Services and Procedure Manual policy for Facility Formulary Therapeutic Interchange of medications included: The facility should - Discontinue the original medication in the physician's orders [REDACTED]. [REDACTED]. medication inventory. 11/12/2016 (last revised) - The Long Term Care Facility's Pharmacy Services and Procedure Manual policy for Receipt of Interim/Stat/Emergency Deliveries included: The facility should immediately notify Pharmacy when Facility receives from a Physician/Prescriber a medication order that may require an interim/stat/emergency delivery. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions (an earlier or special delivery, delivery by a contract courier or dispense and delivery by a third party pharmacy). The following was reviewed in R1's clinical record: 12/11/2020 - The Hospital's Medication List upon Discharge for R1 included physician orders [REDACTED].>- Insulin [MEDICATION NAME] inject 5 units subcutaneously (sq) two times a day with meals. - [MEDICATION NAME] Insulin (generic name is Insulin [MEDICATION NAME]) inject 8 - 12 units as per sliding scale sq three times a day before meals. - Insulin [MEDICATION NAME] inject 8 units sq take with dinner. 12/12/2020 12:30 AM - Nursing Note: R1 arrived from the hospital and was admitted to the facility for rehabilitation. The .reason for stay .Management of Diabetes .Resident came in @ 0030 (12:30 AM) via stretcher. Resident AAOx4 .(Resident) will be going to [MEDICAL TREATMENT] today. 12/12/2020 4:00 AM - Review of R1's physician orders [REDACTED]. - Insulin [MEDICATION NAME] inject 5 units subcutaneously (sq) two times a day with the first dose to be given on 12/12/2020 at 6:00 AM. - Insulin [MEDICATION NAME] inject as per sliding scale sq three times a day (at 6:30 AM, 11:30 AM and 4:30 PM) starting on 12/12/2020 at 6:30 AM. - Insulin [MEDICATION NAME] inject 8 units sq one time a day starting on 12/12/2020 at 4:30 PM. 12/12/20 2:20 PM - Nursing Note: Resident left for (name of [MEDICAL TREATMENT] center) [MEDICAL TREATMENT] about 0930 am. 12/12/2020 10:40 PM - Nursing Note: Called by primary nurse for 'high sugar', unable to read on machine, greater than 600 mg/dL, and patient is symptomatic with increased lethargy and tiredness. (Physician) contacted and decision was made to send to ED (Emergency Department) for evaluation . 12/12/2020 - Review of the eMAR revealed that R1 did not receive any of the Insulin ordered on the day of her admission (on 12/12/2020). 12/13/2020 12:23 AM - The hospital admission record documented that R1 presented to the emergency room with a complaint of a high blood sugar that started today. R1 reported that she had not received Insulin for over 24 hours since 12/11/2020 at 11:00 PM. R1 reported that she began to feel different and reported that her blood sugar was high and she was transported to the ed (Emergency Department) for further evaluation. R1 further reported that during the ambulance drive to the ED she developed chest pain which she described as chest tightness. A blood sugar greater than 600 was documented in the record. The physician statement in the ED record documented that critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Cardiac failure and metabolic crisis. 12/15/2020 - The Physician's Hospital Discharge Summary documented that R1 was in DKA (Diabetic Ketoacidosis) with a blood sugar of 666 mg/dl (high), anion gap of 23 (high), and a [MEDICATION NAME] of 18 (low). R1 received an Insulin drip with IV (intravenous) fluids and was eventually converted back to Insulin via injection once her anion gap closed. It is suspected that the reason for the DKA was based on the fact she hadn't had any Insulin. R1 was discharged to home with home care therapy. 12/16/2020 - Review of the State Agency's Incident Reporting Center revealed that the facility self-identified these significant medication errors and planned to implement nursing staff education regarding off hour admissions, STAT medication requests, house stock Insulin review and confirmation of orders by the primary care nurse for corrective measures. 12/19/2020 - During the incident investigation, E4 (LPN) provided a written statement that included: Insulin showed (in eMAR) as dced with no new orders. Resident stated in the evening around (8:00 PM) that she didn't get her Insulin. As I was looking into the orders, I noticed new Insulin orders sitting out (electronically not signed) there not complete. As I was correcting them, the resident called with the bell and stated she did not feel well so I checked her FS (fingerstick blood sugar). It was higher than the machine would go so MD (medical doctor) notified and we sent her out. 12/20/2020 - During the incident investigation, E2 (LPN) provided a written statement that included: Resident came in @ 0030 (12:30 AM), was unable to ADT (admit into the electronic medical record) her until around 0200 (2:00 AM), after getting off the phone with IT (information technology help desk) I was able to put meds (medications) in, once the meds were in I printed the face sheet and list of meds and faxed it to the pharmacy. I waited 20 minutes and called pharmacy to get meds stat'd out, they stated they were just admitting the resident into the system and to call back, because she would have to talk to the pharmacist. I called back around 0430 (4:30 AM), and they stated that all her meds should be available in the ( facility stock medications) and they had reviewed the med list, therefore her meds would be in (delivered to the facility) by the 1100 am (11:00 AM) run. I did check her BS (blood sugar) and it was 134 (normal before meals: 80-131 mg/dl), I looked in the fridge/med room and did not find any house stock Insulin. When I left that morning all the orders were put in and paperwork faxed to pharmacy. 12/28/2020 4:00 PM - An interview with E2 (DON) confirmed that on 12/12/2020, R1 did not receive the 6:00 AM Insulin [MEDICATION NAME], 4:30 PM Insulin [MEDICATION NAME] or 4:30 PM fingerstick blood sugar with sliding scale coverage of Insulin [MEDICATION NAME] that were ordered by the physician. Although E3 (LPN) entered the admission Insulin orders and called the pharmacy to deliver them stat, the Insulin [MEDICATION NAME] and Insulin [MEDICATION NAME] were not on the formulary and required therapeutic exchange. She explained that the pharmacy discontinues medication orders that require a formulary therapeutic exchange and electronically submits new orders with the formulary medications that require approval by a nurse. In this case, the nurses did not electronically approve the new Insulin orders. The new orders do not appear on the eMAR until approved by a nurse, and therefore the nurse caring for R1 was not aware of the Insulin orders until the resident brought it to the nurse's attention that she had not received any Insulin the entire day. E2 confirmed that the facility does not stock the ordered Insulins; new orders for Insulin must be obtained from the pharmacy and should be ordered for stat delivery. After being sent to the emergency department, R1 was admitted to the hospital and was eventually discharged to home. 12/29/2020 at approximately 4:45 PM - The above information was reviewed with E1 (NHA) during a teleconference. Despite being discharged from the hospital with a history of DKA, R1 went approximately 24 hours without receiving any of her three (3) ordered Insulin medications. The facility's failure placed R1 in a situation that resulted in a severe adverse outcome and required an acute care hospital stay for another episode of DKA. 1/15/2021 12:45 PM - During a meeting at the facility with E1 (NHA), an immediate jeopardy (IJ) was called. 1/15/2021 10:29 PM - The facility's immediate jeopardy (IJ) removal plan was accepted. 1/19/2021 4:30 PM - After another visit to the facility, which included staff interviews and record reviews, it was confirmed that the immediate jeopardy was removed at 4:00 PM on 1/16/2021. The following was completed by the facility: - Insulins were added to the house stock on both units, - Nursing staff was educated on procedures for how to address pharmacy directed medication changes, notifying the pharmacy of new admissions, procedure for the stat delivery of medications, pharmacy escalation process, and confirmation of orders throughout the shift. - A quality assurance system was implemented to ensure the above procedures are followed. 1/19/2021 4:40 PM - The above information was reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on record review, interview and review of other facility documentation it was determined that the facility failed to maintain fluid and electrolyte balance in one (R70) out of three sampled residents receiving enteral feeding.(Total of 6 residents with enteral feeding in the facility.) The facility failed to provide the calculated minimal amount of fluid in the presence of diarrhea, excessive oral secretions and sweating. This failure resulted in harm when R70 required treatment in the hospital for fluid and electrolyte imbalance on 12/4/18 and 1/23/19. After the second hospitalization for dehydration, the facility conducted a root cause analysis, provided education for dietitians and nursing leadership, implemented laboratory blood testing to monitor hydration status for residents receiving nutrition by tube feeding and conducted audits. The failure to readjust fluid intake is past non-compliance. Findings include: Facility policy entitled Fluid Balance (last revised 7/24/18) included the facility will provide patients with sufficient amounts of fluids based on individual needs .Patient's hydration status will be determined through routine nursing evaluation. Patients identified as being at risk for dehydration or needing acute rehydration will be monitored to identify appropriate care plan interventions for promoting adequate hydration. Review of R70's clinical record revealed: 3/22/18 - Admission to the facility with multiple [DIAGNOSES REDACTED]. 3/23/18 - A care plan for enteral feeding tube to meet nutritional needs included the goal that R70 would display no signs of aspiration (fluids from mouth entering the lungs). Interventions included: Aspiration precautions; Check patency and placement of tube daily and before administering feedings and meds; Dietary evaluation and monitoring; Free water; Monitor for nausea, vomiting, diarrhea, cramping, fatigue, weakness and vital sign changes and report; and Mouth care every shift and PRN. 3/27/18 - A care plan for nutritional risk included interventions: Glucerna 1.5 (tube feeding formula) with flush (water) as ordered; and Monitor for signs of aspiration. Manufacturer (Abbott Laboratories) nutritional information revealed that each 1,000 mL of Glucerna 1.5 contained 759 mL of free water. 4/4/18 - A care plan for being at risk for dehydration had the goal that R70 will not exhibit signs of dehydration as evidence by moist mucous membranes. Interventions included: Monitor for signs of dehydration (increased temperature, decrease output, mental status changes, dry mucous membranes, orthostatic [MEDICAL CONDITIONS]; and Obtain dietitian consult as needed/ordered. 6/29/18 - A Significant Change MDS Assessment included that R70 had received nutrition by tube feeding. 11/7/18 (3:23 AM) - Nursing progress note documented Increased secretions noted around mouth. Tick, white sputum which was difficult to suction. Feeding held for one hour as a nursing measure and patient sitting up with HOB (head of bed) elevated. Staff has noted an increase in secretions and the need to be suctioned. Not written in NP's book to make aware of problem. 11/13/18 - NP note acknowledged the increased oral secretions. 11/21/18 (2:20 AM) - Nursing progress note documented R70 had a coughing spell and had a large amount of flatulence (gas). Abdomen was very distended. Feeding held from 1:15 AM - 2:45 AM. 11/24/18 (8:17 AM) - Nutrition note included spoke with nursing regarding explosive bowel movements with reports of 3 movements daily. Reviewed MAR and noted orders for (name of stool softener) .if holding stool softener does not correct loose stools will review adding fiber to firm stools . 11/24/18 - A Nutritional Assessment showed the fluid factor used by E12 (RD) was 30 mL per kilogram (kg) of weight. E12 (RD) used 114 pounds (from 11/12/18) to calculate calorie and fluid needs. E12 documented that R70 was having some diarrhea (noted today) and that RD unsure of diarrheal frequency. Nutrition plan included if R70's diarrhea continues, (R70) may need a formula which contains less dietary fiber. - Fluid needs determined to be 1,554 mLs daily. - Nutrition plan for Glucerna 1.5 at 85 mL per hour for 14 hours (provided 903 mL water); -150 mL water flush every 6 hours (provided 600 mL water); - Totaled 1,503 mL water daily which did not meet R70's calculated fluid needs of 1,554 mL. November, (YEAR) - eMAR review discovered that R70 received one dose of PRN medication for increased oral secretions ([MEDICATION NAME]). November, (YEAR) - Review of CNA documentation showed that R70 had frequent diarrhea: - 39 medium / large loose bowel movements (BMs); and - 5 medium / large watery BMs. 12/3/18 - A change of condition note revealed E8 (NP) was notified of shortness of breath and ordered nebulizer (breathing) treatments, blood tests and chest x-ray. 12/3/18 (10:06 PM) - A nursing progress note documented crackles (abnormal sounds indicating fluid, mucus, secretions) over trachea (upper breathing tube in neck area) and suctioned thick, bloody mucus secretions. Chest x-ray was negative for pneumonia. 12/4/18 (6:30 AM) - A late entry nursing progress note documented resident's pulse was 130 and respirations were reading at 40 physician was notified at 6:30 AM .911 was notified . Resident had secretions coming from mouth while ambulance were preparing (R70) for transport. 12/4/18 - Emergency Department physician documentation included that R70 was unresponsive, had a fever (102.2 F), low blood pressure (82 / 40) and high heart rate (150s). Elevated blood tests revealed fluid and electrolyte imbalance and acute [MEDICAL CONDITION] (kidney injury) (sodium 155, BUN 91, creatinine 1.73, potassium 5.6, hematocrit 46.2, urine specific gravity 1.026). R70's condition improved with IV fluids. 12/4/18 - Hospital History and Physical included the following Diagnoses: [REDACTED].Acute [MEDICAL CONDITION] (low blood pressure) and sinus [MEDICAL CONDITION](high heart rate) .sec (secondary) to dehydration .Acute [MEDICAL CONDITION] (high sodium) and [MEDICAL CONDITION] (high potassium), and (sic) due to dehydration and AKI (acute kidney injury) . [MEDICAL CONDITION] is most often the result of unreplaced water that is lost from the gastrointestinal tract (diarrhea), skin (sweat) or urine (increased urine production with high blood glucose). https://www.uptodate.com/contents/treatment-of-[MEDICAL CONDITION]-in-adults 12/11/18 - R70 returned to the facility with the continuation of hospital tube feeding orders: - Glucerna 1.5 at 55 mL per hour for 14 hours (provided 583 mL water); and - 150 mL water flush every 6 hours (provided 600 mL); - Totaled 1,183 mL water daily which was even less than prior to hospitalization . 12/12/18 - A NP progress note documented that during the hospital stay, (R70) had shown improvement in clinical status and blood pressure is now stable. (R70's) tube feed rate has advanced and R70 tolerated it well. R70 finished a seven-day course of antibiotics for a urinary tract infection [MEDICAL CONDITION]. R70's mental status is at baseline. 12/12/18 (1:39 PM) - A nursing progress note documented that R70 had some diaphoresis (sweating) once this morning. 12/12/18 (10:55 PM) - A nursing progress note documented that R70 was given a PRN (as needed) [MEDICATION NAME] after a coughing episode and saliva draining out the sides of R70's mouth. 12/16/18 (4:52 AM) - A nursing progress note documented R70 had moderate amount of foamy white sputum (secretions) draining from his/her mouth. Mouth suctioned and PRN [MEDICATION NAME] was effective. 12/16/18 - The Nutritional Assessment used R70's weight of 117.4 pounds (from 12/11/18) for calculating calorie and fluid needs. 117.4 pounds divided by 2.2 kg equals 53.6 kg. E25 (RD) kept the fluid factor at 30 mL per kg of resident weight to equal 1,600 mL of water even though the resident was recently readmitted to the facility after being hospitalized for [REDACTED]. Nutrition plan included: - Glucerna 1.5 increased to 65 mL per hour for 14 hours (provided 692 mL water); - 150 mL water flush every 6 hours (provided 600 mL water); - R70's weight increased by seven pounds in the past 14 days, which may be related to fluids delivered in the hospital. - E25 did not calculate R70's daily water (totaled 1,292 mL which did not meet R70's calculated minimal fluid needs of 1,600 mL). The facility failed to ensure fluids provided met the 1,600 ml minimum. 12/23/18 - A Nutritional Assessment used R70's weight of 117 pounds (from 12/19/18) for calculating calorie and fluid needs (117 pounds divided by 2.2 equals 53.18 kg). - E25 (RD) still used the fluid factor of 30 mL per kg which equaled 1,595 mL. - Nutrition plan included tube feeding at 65 mL per hour for 14 hours (provided 692 mL water). - E25 requested weekly weights and did not calculate the daily amount of water provided (including the flushes) that totaled 1,292 mL which did not meet R70's 1,600 mL calculated minimal fluid needs. December, (YEAR) - January, 2019 - Review of eMARs, nursing progress notes and CNA documentation revealed that R70 received many doses of PRN medication for increased oral secretions and had frequent diarrhea: - [MEDICATION NAME] PRN for increased secretions (20 doses in December, after 12/11/18; and 6 doses in January, until 1/23/19); - December: 33 medium / large loose BMs and 6 medium / large watery BMs; and - January: 34 medium / large loose BMs and 3 medium / large watery BMs. 1/23/19 (4:24 PM) - A nursing progress note documented that R70 was sent to the hospital for shortness of breath, facial swelling, increased oral secretions, and heart rate in 130s. 1/23/19 - The hospital History and Physical included that R70 was sent to the hospital from the nursing home with gurgling sounds from his/her throat. Lab tests showed elevated sodium 157, BUN 63 (indicating dehydration - low fluid volume) and WBC 16.4 (indicating infection). Chest x-ray did not show pneumonia. Admitting [DIAGNOSES REDACTED]. The hospital did not identify that the amount of free water in R70's nutrition plan in the nursing home was not meeting the resident's 1,600 mL minimal calculated needs. 1/26/19 - R70 was readmitted to the facility with tube feeding orders(continued from the hospital): - Glucerna 1.5 at 40 mL per hour (provided 728 mL water); and - 200 mL water every 4 hours (provided 1,200 mL water). - Daily water totaled 1,928 mL. 1/27/19 - A nutrition note by E25 (RD) documented that R70 had increased need for hydration and that R70 sweats profusely. 1/29/19 - A Nutritional Assessment revealed that E12 (RD) calculated calorie and fluid needs based on R70's weight of 117.4 (from 1/27/19). - Fluid factor was increased to 35 mL per kg (1,855 mL daily) - surveyor calculation: 117.4 divided by 2.2 equals 53.36 then times 35 equals 1,867 mL calculated fluid need; - Glucerna 1.5 at 65 mL per hour for 16 hours (provided 789 mL water); and - 200 mL water every 4 hours (provided 1,200 mL). - Daily water totaled 1,989 mL which was the first nutritional plan that met R70's calculated fluid needs. The amount of free water ordered was doubled from 150 mL four times a day (600 mL) to 200 mL every 4 hours (1,200 mL). 5/1/19 (around 1030 AM) - During an interview with E8 (NP) to discuss prior hydration needs in relation to number of loose and watery stools, E8 said I increased the free water since then. 5/1/19 (10:55 AM) - During an interview with E2 (DON) to review hydration needs in relation to R70's loose and watery stools, E2 stated, I identified the issue and involved corporate who provided education to the dietitians to ensure residents with tube feedings receive adequate hydration in consideration of insensible fluid loss (secretions, diarrhea, sweating). The hydration issue was identified after the (MONTH) 2019 hospitalization . E2 explained the results of the 1/30/19 root cause analysis including that nursing relied on dietitians for calculating the amount of feedings and water flushes. E2 conducted an audit of current residents receiving tube feeding to calculate the amount of free water ordered for administration. Education provided to the dietitians included that sensible fluid loss should be assessed when calculating free water. Education provided to nursing leadership involved the completeness of tube feeding and fluid orders as well as the completion of blood testing within two weeks after hospitalization . E2 or designee audited tube feeding, fluid needs and blood testing daily, three times a week, weekly and monthly and achieved 100% compliance. R70's nutritional assessment from 2/11/19 incorporated sensible fluid losses and documented R70 was given medication for his/her secretions. (R70) has excess secretions .saliva/drool observed around lips and on his/her chin .lips appear slightly cracked .skin appears moist, but well hydrated. 5/1/19 (12:55 PM) - During an interview with E12 (RD) to find out how the amount of free water is determined for a resident receiving tube feeding, E12 said the gold standard for normal folks is 25-35 mL per kg. When asked how insensible fluid loss gets determined, E12 said it's anecdotal, talk with nurses and aides. They don't do I & O (intake and output measuring) here which makes it hard. After the surveyor showed R70's tallies of medium and large loose / watery stools by month, E12 stated that staff mentioned that R70 had some explosive watery diarrhea. After discussion about review of the facility's root cause analysis findings, E12 added that R70 is in a better place now. The facility failed to provide R70 with the calculated minimal amount of fluid in the presence of diarrhea, excessive oral secretions and sweating. This failure resulted in harm when R70 required treatment in the hospital for fluid and electrolyte imbalance / dehydration on 12/4/18 and 1/23/19. During the survey the facility was in substantial compliance with meeting hydration needs for residents receiving nutrition and hydration by tube feeding. Findings were reviewed with E1 (NHA) and E2 (DON) on 5/3/19 during the exit conference beginning at 11:15 AM.

Based on record review and interview it was determined that for one (R95) out of 47 sampled residents the facility failed to ensure the resident received the services and assistance to maintain bladder continence. R95 was admitted to the facility continent of bladder. When the resident was assessed as declining to occasionally incontinent and later frequently incontinent of bladder, the facility failed to thoroughly assess and develop interventions to restore bladder function. This lack of assessment and failure to implement interventions resulted in harm to R95. Findings include: The facility's Continence Management policy dated 6/1/96 and last revised 3/1/18 documented: A urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. The following was reviewed in R95's clinical record: 9/28/17 - admitted to the facility. 10/5/17 - Admission MDS documented R95 was cognitively intact (BIMS 15), required supervision with one person physical assist for toileting, continent of bladder and no toileting plan. 11/5/18 - 11/7/17 - admitted to hospital. 11/14/17 - Medicare MDS documented a decline in cognition to a BIMS of 12, independent in toileting with supervision and continent of bladder. 1/27/18 - Urinary Incontinence Evaluation provided no conclusion or plan for R95. 2/14/18 - Quarterly MDS documented a BIMS of 14, independent in toileting, continent of bladder and no toileting plan. March (YEAR) - Review of CNA documentation in the EMR revealed that R95 was incontinent of bladder 4 out of 75 opportunities or 5% of the time. 3/23/18 - 3/29/18 - admitted to hospital. 4/5/18 - Medicare MDS documented a BIMS of 14, supervision with one person physical assist with toileting, continent of bladder and no toileting plan. 4/6/18 - Urinary Incontinence Evaluation documented resolved after treatment. There was no description of what the treatment was. 4/19/18 - Quarterly MDS documented a BIMS of 14, extensive assistance with toileting with one person physical assist (decline), occasionally incontinent of bladder (decline) and no toileting plan. 4/22/18 - 4/28/18 - admitted to hospital. April (YEAR) - Review of CNA documentation in the EMR revealed that R95 was incontinent of bladder 11 out of 73 opportunities or 15% of the time. 5/1/18 - Urinary Incontinence Evaluation provided no conclusion or plan. No evidence of a 3-Day Diary found in the record. 5/5/18 - Medicare MDS documented a BIMS of 12 (decline), extensive assistance with toileting with one person physical assist, frequently incontinent of bladder (decline) and no toileting plan. 5/6/18 - Urinary Incontinence Nursing Interventions indicated the use of individually selected absorbent products. 5/7/18 - Care plan for Resident is incontinent of urine and is unable to cognitively or physically participate in a retraining program due to his cognitive loss. Goal: Resident will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. Interventions included: -complete incontinence assessment at intervals according to policy and procedure, encourage to consume fluids, use appropriate continent product, offer/assist with urinal/commode as requested/needed. On 5/7/18 when the facility identified R95's cognitive decline the facility failed to implement individualized interventions for continence/toileting. 5/12/18 - Medicare MDS documented at BIMS of 9 (decline), extensive assistance with toileting with one person physical assist, frequently incontinent of bladder, and no toileting plan. April (YEAR) - Review of CNA documentation in the EMR revealed that R95 was incontinent of bladder 25 out of 50 opportunities or 50% of the time. 5/16/18 11:25 AM - Interview with E8 (CNA) revealed that R95 uses a urinal for urine and can be assisted to toilet for bowel movements but has been totally incontinent at times. E8 stated that he has those days he just does not know and will be incontinent. E10 (CNA) entered the conversation and confirmed the residents continence status. Both CNAs confirmed he was not on a toileting plan. 5/17/18 9:57 AM - Interview with E9 (CNA) revealed that if a resident was on a toileting plan it would be in the EMR task. E9 added that in the last year she has not had a resident on a toileting plan. 5/17/18 10:50 AM - Interview with E4 (RN, UM) revealed the resident was using a urinal and now has days when he will not let staff care for him. E4 stated that the 3-Day Diary is done on admission and how to toilet a resident is on the Task section of the EMR. 5/17/18 11:09 AM -Interview with E7 (RNAC) revealed when a decline is noticed with the MDS assessment an e mail is sent to the unit manager to do an assessment and care plan. 5/22/18 10:19 AM - Interview with E6 (RNAC) revealed that a new urinary assessment is scheduled when there is a change in coding for bladder continence. It was further revealed that toileting information should be in the care plan and the CNA task including prompted or timed voiding. E6 added that as a rule the facility does not do individualized toileting programs. The facility failed to: - Comprehensively assess the resident's continence after a noted decline on 4/5/18. - Comprehensively assess the resident's continence after a further decline was noted on 4/19/18. - Comprehensively assess the resident's continence after a hospitalization and readmission on 4/2818. - Comprehensively assess the resident's continence after a further decline was noted on 5/5/18. - Implement individualized interventions for continence. 5/22/18 around 4:30 PM - Interview with E2 (DON) while reviewing above information confirmed that there were some issues with completing the incontinence assessment / 3-Day Diary. Findings were reviewed with E1(NHA), E2 (DON) and E3 (ADON) at the exit conference on 5/23/18 at 11:45 AM.

Based on record review, interview, review of other facility documentation and review of hospital records it was determined that the facility failed to monitor the oral intake to prevent dehydration for three (R255, R72 and R74) out of 37 sampled residents. For R72 and R74 the facility failed to monitor I & O and order fluid guidelines when each resident experienced diarrhea from [MEDICAL CONDITION] (C.diff) infection. For R255, the facility failed to: - monitor intake and output and laboratory tests when the resident was experiencing diarrhea from C.diff infection. - monitor the resident's weight in the presence of C.diff diarrhea. - report continued diarrhea to the NP after treatment ended and the NP was documenting resolution. - recognize and notify the NP when R255's blood pressure dropped to an extremely low level. The failure of the facility caused harm to R255 as the resident became unresponsive and was hospitalized for [REDACTED]. Findings include: Cross Refer F684, Example 3 and F711. 1. Review of R255's clinical record revealed: 1/3/18 - Readmission to facility for rehabilitation after hospitalization and receiving antibiotics for pneumonia. Care Plan - 1/3/18: Nutritional Risk: Goal to maintain a stabilized weight of 150 pound (plus or minus 4%). Interventions included: Encourage 100% consumption of all fluids provided; Provide regular liberal diet; Offer snacks. - 1/5/18: Exhibits or is at risk for complications of infection related to history of pneumonia and (as of 1/30/18) C.diff. Interventions included: Monitor for changes in nutritional status such as change in intake, ability to feed self, unplanned weight loss or gain, abnormal labs and notify dietician / physician as indicated; Monitor vital signs and report to physician as indicated. 1/10/18 - Admission MDS Assessment recorded that R255 had dementia with moderate cognitive impairment but was one point away from severe cognitive impairment. - 1/17/18: Care plan for Risk for Dehydration as evidenced by infection, and/or nausea, diarrhea, vomiting with the goal of not exhibiting signs/symptoms of dehydration as evidenced by moist mucous membranes, no fever, vital signs and labs at baseline. Interventions included: Monitor for signs/symptoms of dehydration (increased temperature, decreased (urine) output, mental status changes, dry mucous membranes, orthostatic [MEDICAL CONDITION], and increased heart rate); Monitor lab work as ordered and report as indicated; Contact precautions (added 1/23/18) while symptomatic. 1/21/18 - Weight 146.4 pounds. 1/21/18 (10:29 PM) - Nursing note documented R255 was having loose watery stools. This is a continuous thing with the resident. 1/22/18 - NP note documented resident stool was positive for C.diff and ordered an antibiotic for 10 days for the infection. 1/23/18 - Nutrition note documented R255's weight had been relatively stable during this admission. Resident consuming 75-100% of regular diet meals. Currently positive for C.diff, will monitor for weight changes. January, (YEAR) - February, (YEAR) a. Bowel Movements per CNA Flowsheets: - loose stools: (MONTH) 9-11, 13, 15, 30; (MONTH) 1, 6, 7, 13. (10 days) - watery stools: (MONTH) 12, 14, 16-17, 20-29, 31; (MONTH) 2-5, 8-12, 14-17. (28 days) b. Intake per CNA Flowsheets and eMARs: - meal intake average - (MONTH) 81% (7 meals not recorded); (MONTH) 54.3%. This was a 26.7% decrease of meal intake. - shifts when a drink other than with meals was signed by the CNA as being accepted by R255: (MONTH) 20 days, 13 evenings, 7 nights. (MONTH) 12 days, 9 evenings, 4 nights. - nurses signed off every shift that R255 was encouraged to drink fluids. The amount of liquids consumed were not recorded so it was unclear how much R255 drank during or between meals. Abnormal Laboratory Results (normal range in parenthesis): - 1/8/18: Sodium 146 (136-145), Chloride 112 (98-107), Potassium 3.2 (3.5-5.1), Hemoglobin 8.0 (13.6-17.5); Hematocrit 24.4 (41-52). - 1/15/18: Chloride 110 (98-107), Potassium 3.3 (3.5-5.1). - Potassium level tested : (MONTH) 11, 29, 30, 31; (MONTH) 1, 2, 5, 6, 7, 8, 9, 12, 16.(Potassium levels ranged from 2.4 to 4.0 and the resident had been receiving potassium orally.) Review of physicians' orders found no other laboratory blood tests were performed to monitor the resident's hydration status. 2/6/18 - Nutrition note documented the trigger for weight loss was from an old admission weight. Weight loss likely in association with disease state. Recent [DIAGNOSES REDACTED]. Will monitor. Slight weight increase in past 1 week. Current 148.3 pounds (from 2/5/18). There were no further weights obtained. 2/6/18 - NP Progress Note documented R255 completed the course of antibiotics for C.diff, which had resolved. Monitor for reoccurrence. (C.diff was noted as resolved in the NP Progress Note despite continued loose and watery stools.) 2/7/18 - 2/9/18 - NP Progress Notes recorded the C.diff infection had resolved. (C.diff was noted as resolved in the NP Progress Note despite continued loose and watery stools.) There was no evidence in the nursing progress notes that the NP was informed of R255's continuing diarrhea. 2/8/18 - Nursing note recorded R255 fed self meals, appetite good. CNA flowsheet recorded R255 ate 100% breakfast and lunch. 2/14/18 - Facility Grievance / Concern Form documented family concerns including, but not limited to, not getting enough to drink in the water mug and losing weight and may need more staff assistance with meals due to getting tired. Facility response involved that water pitchers were to be checked and refilled at the beginning and end of the shift. Resident weight 2/5/18 was 148.3 and R255 had been observed effectively feeding self. Staff consistently set-up the meal tray and supervised with meals. Care conference scheduled for 2/15/18 was rescheduled to 2/20/18 since son unable to attend. (Despite family concern, no weights or I&O were ordered to effectively monitor this resident.) 2/15/18 (4:21 PM) CNA flowsheet - Blood pressure 93/48 which was extremely low for R255, who usually ran 120-150 systolic (top number of the blood pressure). There was no nursing progress note acknowledging the low blood pressure, that the blood pressure was repeated to verify accuracy, that the NP was made aware or that the blood pressure was obtained on the subsequent night and day shifts. 2/16/18 - NP Progress Note recorded that R255 was less alert than usual. Resident informed the NP that s/he was having diarrhea and did not feel well. An antibiotic was ordered for recurrent infection. 2/16/18 (6:57 PM) - CNA flowsheet showed R255's blood pressure even lower at 79/44 without a nursing progress note acknowledging the blood pressure, that the blood pressure was repeated to verify accuracy or that the NP was notified. 2/17/18 (12:06 PM) - Nutrition Note documented family spoke with dietician about decline in intake over past few days since R255 refused 3 meals and only ate 25% when consuming meals. Discussed diarrhea and possible nutrition supports such as BRAT (banana, rice, applesauce and toast) diet and consider snacks of yogurt, ice cream and house shake, if tolerates without increase in diarrhea. Wasted appearance with STAT labs ordered. Nursing reports that fluids encouraged and may possibly need IV (intravenous) fluids depending on labs. RD to follow for acceptance of supplements and meal intakes. Noted in orders that resident is to be fed all meals and snacks until his condition improves. 2/17/18 (12:50 PM) - Nursing Progress Note documented R255 with increased weakness and poor appetite. Spoke with physician and STAT labs ordered. Family at bedside encouraging fluids frequently. Sodium level returned at 160 (136-145). 2/17/18 (1:50 PM) - Nursing Progress Note documented resident had unplanned transfer (sent out 911 to emergency department). 2/17/18 - Ambulance care report documented the ambulance arrived at the facility at 1:38 PM and found R255 was unresponsive at 1:42 PM but was alert and following commands by 1:47 PM. Resident with altered mental status and, per (facility) staff, high potassium. Family reported R255 was acting appropriate the evening prior (2/16/18) but was talking at lunch time but was weak and not himself. Review of R255's Hospital Records revealed: - 2/17/18: admitted to hospital with admission [DIAGNOSES REDACTED]. [MEDICAL CONDITION] due to poor oral intake and C.diff diarrhea. Abnormal electrolyte blood tests: Sodium 161 (136-145), Chloride 136 (98-107), Potassium 5.2 (3.5 - 5.1). Impaired kidney function blood tests: BUN 30 (7-18), Creat 1.70 (0.67-1.17). - 2/18/18: Weight 53.1 kg (measured) = 116.8 pounds. - 2/18/18 Nutritional Assessment: included nutrition [DIAGNOSES REDACTED]. Start tube feeding and increase to goal rate of 55 mL per hour. - 2/20/18: Renal (kidney) Consult documented acute kidney injury probably related to hypovolemia (low amount of fluid in body). During an interview with E23 (NP) on 5/21/18 around 10:00 AM when asked what kind of lab tests are ordered when residents have diarrhea or vomiting, E23 said all kinds including potassium, renal (BUN, creatinine), sodium, complete metabolic panel, and sometimes CBC but it depended on the resident. During an interview with E2 (DON) on 5/21/18 around 11:50 AM to clarify whether I&O was to be a nursing or physicians order, it was determined that it could be either, but the fluid guidelines must be ordered. During an interview with E18 (Corporate Nurse) on 5/22/18 around 10:50 AM E18 confirmed weekly weights were not completed following admission and there was no acknowledgement or notification for the low blood pressures. R255 experienced harm due to the facility's failed to: - monitor intake and output and laboratory tests when the resident was experiencing diarrhea from [MEDICAL CONDITION] (C.diff) infection. - monitor the resident's weight in the presence of C.diff diarrhea. - report continued diarrhea to the NP after treatment ended and the NP was documenting resolution. - acknowledge, repeat, monitor or notify the NP when the blood pressure was extremely low. During the survey it was identified that there were two other residents experiencing diarrhea and/or vomiting that did not have fluid guidelines or I &O performed. 2. Review of R72's clinical record revealed: R72 had watery and loose stools prior to 4/28/18 hospitalization . 5/10/18 - R72 returned to facility after treatment for [REDACTED].diff infection with persistent diarrhea. May, (YEAR) - Review of physicians' orders, eMAR and eTAR found guidelines for additional fluids were not ordered and intake and output monitoring was not performed in the presence of loose and watery stools. 3. Review of R74's clinical record revealed: 4/14/18 - R74 was sent to the hospital for vomiting. 5/5/18 - Diarrhea stool presumptive positive for C.diff infection. May, (YEAR) - Review of eMAR and eTAR found R74 continued with watery and loose stools and fluid guidelines for additional fluids were not ordered. Intake was recorded by nurses since the resident received nutrition by tube feeding. Findings were reviewed with E1 (NHA), E2 and E3 (ADON) at the exit conference on 5/23/18 at 11:45 AM.

Based on record review, review of other facility documentation, interviews and observations it was determined that the facility failed to perform a comprehensive assessment in order to ensure the provision of care and services to one (R1) out of 7 sampled residents who sustained a superficial partial-thickness burn (also known as a second degree burn that affects the top two layers of the skin) to her left hand when soup spilled during her lunch. Due to the lack of a comprehensive assessment, the facility failed to identify the presence of a deep partial thickness burn (a second degree burn that extended deeply into the second layer of skin) to the upper front of R1's left thigh that occurred at the same time as the hand burn. The lack of a complete assessment resulted in treatment that failed to be provided until seven hours after the hand burn which was a delay in the care and service to treat this burn. Findings include: R1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of an incident report dated 3/16/13 revealed that at 12:45 PM, R1 was eating her lunch and spilled her soup on her hand and sustained swelling and redness to her fingers and the palm of her left hand. R1 was eating her lunch alone in her room. R1's nurses notes documented on 3/16/13 at 1:09 PM that R1 was experiencing pain, which was a change from the previous state, to her palm and fingers of her left hand. Her left hand and fingers had redness and swelling from a burn. There was no evidence that the facility performed a comprehensive assessment for R1 to ensure there were no other injuries/burns related to the spilled soup. Review of R1's physician orders [REDACTED]. Review of a second incident report dated 3/16/13 (no time) documented that at 12:45 PM, R1 was feeding herself a bowl of soup and spilled the soup on her left hand and left thigh resulting in second [MEDICAL CONDITION] both areas. On 3/16/13, R1's nurses notes documented at 8:02 PM (7 hours later) that R1 acquired a burn to her left anterior thigh with a blister that measured 6.5 centimeters (cm.) by 8.5 cm. and was, swollen, red and warm. The notes continued to document a second area observed to R1's thigh that measured 14.5 cm. by 10.0 cm. Review of R1's physician order [REDACTED]. Review of R1's record failed to provide evidence documenting that, on 3/16/13, the physician had completed a visual observation or assessment of these burns. Review of the facility's investigation for the 3/16/13 burn revealed the following: E6, Certified Nurse's Aide, documented that she was passing out lunch plates and placed R1's meal in front of her which included the soup. E6 came back 10-15 minutes later and R1's soup was spilled on the floor and E6 cleaned up the floor. E6 documented R1 did not mention anything about her hand. E6 left and returned after 10-15 minutes. R1 told her she burned her hand on her tea. E6 documented R1 had iced tea and must have burned her hand on the soup. R1's hand was red and puffy. E6 immediately called E7, Registered Nurse. E6 documented that she did not notice R1 had spilled the soup on her legs or pants. E7, Registered Nurse documented in her statement for the incident report that she saw R1's hand and told E6 Certified Nurse's Aide to apply a cold compress to her hand. E7 did not notice any spillage to R1's leg or pants. E7 stated that she left R1 with E16, Registered Nurse/Charge Nurse and continued with her medication pass. Neither E7 nor E16, performed a comprehensive assessment immediately after they identified the burn to R1's left hand to ensure she had no other injuries related to the spilled soup in order to provide care and services as needed. E12, Certified Nurse's Aide documented that she worked on the 3-11 shift on 3/16/13. E12 documented, that after offering to toilet R1 several times, at 8:00 PM, (seven hours after the burn occurred) R1 agreed to be toileted. E12 also documented that when she pulled R1's pants down and sat her on the toilet she noticed R1 had huge blisters on her left upper thigh. E12 immediately notified E13, Registered Nurse. E13 documented she observed R1's thigh on 3/16/13 . There was a severe burn approximately 7 centimeters joined to 2 others that were approximately 5 centimeters each. All 3 were fluid filled. On 4/4/13 R1'[MEDICAL CONDITION] her left hand and left thigh were evaluated by E14, Plastic Surgeon. E14 documented in his report that R1 had a history of [REDACTED]. R1 was seen for further evaluation. Upon evaluating R1, E14 documented that review of systems was somewhat limited due to R1's minimal responsiveness, however R1 did answer questions. E14 documented that his impression was that R1 had a superficial partial-thickness burn to her left hand and a deep partial-thickness burn to her left anterior thigh. Both of these areas appeared to have viable residual skin. E14 also documented that R1 may develop a residual scar to her left anterior thigh that could be treated conservatively On 10/8/13 at 10:45 AM an observation was done with E5, Wound nurse, of R1's left hand and left anterior thigh. R1's left hand skin was intact. R1's left anterior thigh had a large scar that measured 12 cm. by 4 cm. with a 1 cm. x 1 cm. open area that was not healed. E5 applied a dressing to the open unhealed area. The facility failed to perform a comprehensive assessment of R1 immediately after it was determined that soup spilled and burned her left hand to ensure there were no other injuries related to the spilled soup. Due to the lack of an immediate comprehensive assessment R1 failed to receive the care and services to treat the burn to her left thigh until seven hours after the facility documented the burn occurred. The above findings were reviewed with E1, Administrator, E2, Director of Nursing, E3, Assistant Director of Nursing and E4, Dietary Manager on 10/8/13 at approximately 2:15 PM.

Based on record review, staff interviews, and other interviews as indicated it was determined that one (1) of seven (7) residents reviewed (R1) failed to receive the necessary treatment and services to promote healing of pressure sores that were present on admission and prevent new pressure sores from developing. R1 was admitted to the facility with five stage 2 pressure sores. The facility failed to provide all treatment and services to promote healing as required by R1's care plan as well as by facility policies / procedures. During R1's two week stay in the facility, two of the pressure sores (left and right heels) improved, however, the three separate pressure sores of the right and left buttocks and sacrum became larger and deeper forming one larger pressure sore with eschar tissue (necrotic or dead tissue). Surgical debridement (removal of dead, damaged tissue to improve healing) of this pressure sore was required. Findings include: R1 was admitted to the facility on [DATE]. R1 had [DIAGNOSES REDACTED]. R1 had previously been in the facility in 2009 and was known to have a history of skin breakdown. The facility's admission nursing assessment on 4/19/12 indicated that R1 was at high risk for further skin breakdown due to very limited mobility (required extensive staff assistance for moving in bed) and skin that was often moist (due to incontinence (involuntary urination)). E7, the unit manager of R1's unit, confirmed on 3/5/13 at 2:05 PM that R1 was incontinent of urine, used disposable undergarments, and was assisted with toileting every 2 hours by the staff. Minimum Data Set (MDS) assessments for 4/26/12, 5/3/12, and 5/11/12 indicated that R1 required extensive assistance of 2 staff members for moving in bed and was incontinent of bowel and bladder at times. Turning and repositioning every 2 hours was required by R1's care plan addressing "actual skin breakdown" (initiated on 4/19/12), but implementation of this instruction was not documented by facility staff until 4/27/12, a week after R1 was admitted . The facility's consultant dietitian (E4) recommended on 4/23/12 that R1 receive a high protein nutrition supplement drink but no supplement drink was provided to R1 by facility staff until 5/1/12, over a week later. Initial assessment by the facility's wound nurse (E3) on 4/21/12 indicated that the sacral pressure sore measured 2 cm by 2 cm by 0.2 cm deep; the right buttocks pressure sore was 1.5 cm by 1 cm by <0.2 cm deep; and the left buttocks pressure sore was 1.5 cm by 1 cm by <0.2 cm deep. In addition, E3 documented that the skin surrounding these sores was macerated (softened from exposure to moisture) and inflamed (red and warm) indicating increased risk for further skin breakdown. Pressure sore measurements obtained on 4/30/12 by E3 indicated that R1's sacral and buttocks pressure sores increased in size and depth compared to 4/21/12. The following day on 5/1/12, the facility obtained a low air loss mattress (a surface that reduces pressure and moisture) for R1 and began to provide the protein supplement drink as recommended by E4 on 4/23/12. These services had not previously been provided to R1. There was no evidence that the facility provided R1 with more frequent turning / repositioning and more frequent incontinence care despite the increased size and depth of the sacral area pressure sores. In an interview on 3/5/13 at 1:40 PM, E4 stated that R1's pressure sores of the heels were healing and she (E4) questioned the nursing staff about why the sacral pressure sores weren't healing. In an interview on 3/5/13 at 2:05 PM, E7 stated that R1 would holler during care, wouldn't stay turned and would sometimes throw the pillows used to position her (R1) on her side. The first reference found in the clinical record to R1 being uncooperative with care was a nursing note dated 5/1/12 and timed 9:05 AM. There was no care plan addressing refusals or resistance to care until 5/3/12 (2 weeks after admission). On 5/2/12, E5, the attending physician for R1, documented that R1 "continues to be placed in chair for long" periods and that R1 had a "sacral pressure sore secondary to sitting too long". E5 wrote an order for [REDACTED]. It could not be determined from record review whether facility staff complied with this order. The order was listed on R1's Medication Administration Record [REDACTED]. Interview with CNA (Certified Nursing Assistant) E9 on 3/11/13 at 11 AM revealed that on some days R1 would be in her wheelchair from after breakfast to the end of day shift (3 PM) with assistance for toileting and repositioning every 2 hours. On 3/11/13 at approximately 12 noon, CNA E10 stated that on a typical day R1 would be in her wheelchair for about 3 hours. E10 recalled being told at one point that R1 should go back to bed after physical therapy. New approaches to minimize or reduce R1's sacral pressure and exposure to moisture while up in her reclining wheelchair were not identified and implemented by the nursing staff after it became clear that existing approaches were ineffective (sacral area pressure sores worsening). Despite the lack of healing of the sacral area pressure sores, the consultant dietitian (E4) questioning the lack of healing and the physician's orders [REDACTED]. On 3/6/13 at 1:50 PM, interview with F2, the foster care giver R1 resided with, revealed that she asked to see R1's buttocks area after being alerted by an unidentified staff member that the sacral area pressure sores had worsened. F2 stated that she observed one large pressure sore with black tissue. F2 stated that the facility's wound nurse (E3) was present when F2 made this observation. A nursing note documented by E3 on 5/2/12 at 3:16 PM confirmed that she (E3) was with F2 when F2 observed the "open area" of R1's buttocks/sacrum. E3, however, did not describe the appearance, size, or color of the wound in this note. Two nurses (F3 and F4) employed by the State to monitor the care of mentally disabled clients such as R1 came to the facility and observed R1's sacral pressure sore at the request of F2. In documentation dated 5/4/12 F3 wrote that R1 had "an open area (sacrum) that appeared to be tunneling in quite deep" with a "golf ball size black area" along with "red areas with sloughing skin". On 5/6/12 pressure sore measurements obtained by E3 confirmed that the sacral, right buttocks and left buttocks pressure sores had enlarged and combined to form one unstageable pressure sore measuring 8.5 cm by 4 cm by 0.3 cm with 100% eschar (dead tissue). Daily monitoring of pressure sores was required by the facility's "Skin Integrity Care Delivery Process" including checking the status of the dressing and the status of skin tissue surrounding the pressure sore(s) but no daily monitoring was documented. While R1's sacral dressing was changed at least 13 times during her 2 week stay, actual assessment of the appearance of the pressure sores and the surrounding skin was only found on 3 dates (4/21/12, 4/30/12, and 5/6/12). On each of these dates R1's sacral area pressure sores had worsened. On 5/8/12 a wound specialist physician (E6) examined R1 and described what he identified as a "stage 4 sacral pressure ulcer" and recommended hourly turning of R1 and for R1 to "see surgeon for possible surgical debridement of sacrum, possible flap graft (technique used in plastic or reconstructive surgery)". On 5/11/12, R1 was discharged from the facility. Interview with F2 on 3/6/13 at 1:50 PM revealed that she wanted R1 to be discharged from the facility because her pressure sores of the sacral area had worsened while she was there. Documentation by E8, the facility's social worker, on 5/8/12 at 11:40 AM confirmed that F2 was crying and upset that R1 may need surgery due to wound issues and wanted to take her (R1) home. Discharge planning was then initiated by E8. According to a hospital discharge summary provided to the surveyor by F3 (State nurse), on 5/17/12, R1 had surgical debridement of the sacral pressure sore with the surgeon documenting "skin, subcutaneous tissue, fat, and muscle were debrided down to healthy bleeding tissue, all necrotic material was debrided". The surgeon documented that after this, the wound measured 8 cm by 6 cm by 3 cm deep.

Based on record review and interview it was determined that the facility failed to provide care and services to ensure wound healing for one (R10) out of 11 sampled residents. Findings include: The facility's policy and procedure for skin integrity management stated; 3.3 Perform wound observations and measurements weekly. 12.2 document appearance and condition of the wound weekly. Review the Nursing Admission assessment dated [DATE] revealed R10 was readmitted to the facility from the local hospital with three stage II pressure ulcers. There were two pressure ulcers on the right buttocks and one located on R10's left buttocks. The physician wrote an order dated 5/17/13 for Exuderm to sacrum every 3-5 days and as needed for stage II pressure ulcers. The care plan for actual skin breakdown related to history of pressure ulcers dated 5/20/13 included interventions to provide wound treatment as ordered and weekly wound assessments to include measurements and description of wound status. Review of the treatment record for May 2013 revealed a dressing change was completed for R10 on 5/17/13. On 5/23/13, R10's dressing was changed again 6 days later instead of 3-5 days as ordered. R10's Skin integrity report for May 2013 revealed wound measurements were completed for R10's three stage II pressure ulcers on 5/17/13. On 5/28/13 (11 days later instead of 7 days later) the facility performed another assessment with measurement and description of the wounds. On 5/29/13 at 10:00 AM interview with E5 (Registered Nurse/wound nurse) confirmed she did not change R10s dressings within the 3-5 days as ordered by the physician. E5 also stated that R10 was at [MEDICAL TREATMENT] during the day shift. E5 confirmed she failed to ask the night shift nurse to perform the dressing change for R10. E5 continued to state that she did not know R10 was due to have her wounds measured. The facility switched from computer to paper documentation. E5 relied on the computer to notify her when residents' wound measurements needed to be completed. On 5/29/13 at 10:20 AM E2 (Corporate Nurse) stated that the facility staff was provided training on the change from computer documentation to paper forms used for wound assessments prior to 4/23/13. On 5/29/13 at 1:25 PM E2 (Director of Nursing) confirmed the facility failed to follow the physician orders [REDACTED]. plan. On 5/29/13 at 2:20 PM E2 (Director of Nursing) stated that on 5/24/13 E6 (Assistant Director of Nursing/Unit Manger) identified the missed treatment and lack of wound assessment but failed to ensure it was corrected.