Every finding on record at Westminster Village Health

Based on observation, interview and review of other facility documentation it was determined that the facility failed to have a functioning call bell system. Findings include: 12/9/25 10:57 AM room [ROOM NUMBER] - During initial observations the surveyor discovered that the call bell was not functioning. There was no sound and the light outside of the doorway was not lit after the call bell was pressed. E25 (LPN) confirmed the finding.12/9/25 12:05 PM room [ROOM NUMBER] - During initial observations the surveyor discovered that the call bell was not functioning. E26 (CNA) confirmed the finding. E26 then notified E25 (LPN) who immediately placed a call to the maintenance department. The surveyor then tested the call bell function across the hall in room [ROOM NUMBER] and the call bell did not function. 12/9/25 12:07 PM room [ROOM NUMBER] - During initial observations the surveyor discovered that the call bell was not functioning. E27 (CNA) confirmed the finding. 12/9/25 12:08 PM room [ROOM NUMBER] - E28 (MT) arrived and changed the bulb to room [ROOM NUMBER]. The call bell continued to not function. 12/9/25 12:12 PM - The surveyor observed that all the call bells in the remaining rooms on the 400 hallway were tested and E25 (LPN) and E28 (MT) confirmed the call bells were not functioning. E28 radioed his supervisor E29 (Maint. Dir.). 12/9/25 12:15 PM - The surveyor observed that all the call bells on the 200 hallway were tested and E29 (Maint. Dir.) confirmed the call bells were not functioning. 12/9/25 12:19 PM - The surveyor observed that all the call bells on the 300 hallway were tested and E29 (Maint. Dir.) confirmed the call bells were not functioning. E29 (Maint. Dir.) stated, There was a power surge this morning that maybe the issue.12/9/25 12:23 PM - The surveyor observed that all the call bells on the 500 hallway were tested and the call bells were not functioning.12/9/25 12:27 PM - The surveyor observed that all the call bells on the 100 hallway were tested and E32 (CNA) confirmed the call bells were not functioning and that the personal pagers that alert the CNA's when a call bell is activated were also not functioning. 12/9/25 12:31 PM - During an interview E1 (NHA) confirmed that E29 (Maint. Dir.) notified him that the call bell system in the facility was not functioning. E1 stated I have reached out to the call bell company and I am reviewing the call bell logs. E2 (DON) is ensuring care of the residents. The surveyor requested a copy of the call logs. 12/9/25 12:33 PM - During an interview E2 (DON) stated, We are trying to locate small bells in the meantime, and we have all staff rounding on the floors. 12/9/25 12:53 - 1:05 PM - The surveyor accompanied E29 (Maint. Dir.) to tour all resident hallways and verified call bell system was functioning. E29 (Maint. Dir.) stated, we had to reboot the system. 12/9/25 1:39 PM - E1 (NHA) provided the surveyor with call bell logs. Review of the logs revealed a lack of call bell activation starting at 7:31 AM. 12/9/25 1:39 PM - E1 (NHA) provided the surveyor with a timeline response that documented the following:12:33 PM - Continuous monitoring was started on all the hallways and dining rooms. 12:49 PM - All call bells functional.12:50 PM - An audit was started and completed of all rooms and pagers. An hourly audit will be completed of random rooms for twenty-four hours to make sure call bells are working properly. 12/9/25 3:15 PM - The surveyor was provided with copies of continuous observation logs for all hallways that documented rounds during time that call bells were not functioning in the facility. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on observation, record review and interview it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards. Findings include:12/15/25 8:39 AM - During a tour of the facility's short-term unit refrigerator an undated unlabeled sandwich and an expired pudding cup dated 12/10/25 was discovered. 12/15/25 9:00 AM - Review of the facility's food temperature logs lacked evidence that temperatures were taken prior to serving the following meals:11/13/25 breakfast, lunch and dinner.11/20/25 lunch.11/26/25 dinner.11/28/25 dinner.12/4/25 lunch. 12/15/25 9:52 AM - During an interview E21 (DDS) confirmed the undated and expired foods. E21 then confirmed the unrecorded food temperature logs. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview, it was determined that for one (R16) out of one resident reviewed for accidents, the facility failed to notify a physician of a significant injury of unknown source that was determined to be a right fifth toe fracture. Findings include:A review of R16's clinical record revealed: 7/15/25 - R16 was admitted to the facility with a diagnosis including, but not limited to, CVA and abnormal gait.8/1/25 4:00 PM - A progress note documented that R16 was transferred to the hospital after a fall in the facility.8/1/25 11:40 PM - A progress note documented R16 returned from the hospital after a fall with the following: purple bruising to the right fifth toe and right flank, scattered bruising to the left lower leg.8/2/25 12:35 AM - A progress note documented bruising to R16's right fifth toe.8/4/25 2:58 PM - A mobile X-ray provider performed an X-ray of R16's right foot at the facility. The X-ray report revealed a fracture at the base of the right fifth toe. 8/4/25 3:00 PM - A doctor's order was documented to complete an X-ray of R16's right foot. There was a lack of evidence that the facility consulted the doctor for R16 from 8/1/25 to 8/3/25 of significant bruising to the right fifth toe.12/15/25 11:35 AM - During an interview, E4 (supervisor) stated that the expectation with an unwitnessed fall with injuries would be that the nurse would call the supervisor to assess the resident at that time. E4 confirmed that she would have notified the doctor, family, completed the incident report, and reported to the state agency.12/15/25 3:05 PM - During an interview, E2 (DON) confirmed no call was made to the physician for R16 when there was an injury of unknown source to his right fifth toe.12/16/25 3:40 PM - Findings were reviewed with E1 (NHA), E2 and E3 (Executive Director) during exit conference.

Based on interview and record review, it was determined that for one (R16) out of four residents reviewed for accidents, the facility failed to report an injury of unknown source in timely manner. Findings include:A review of R16's clinical record revealed:7/15/25 - R16 was admitted to the facility with a diagnosis, including but not limited to CVA and abnormal gait.8/1/25 5:45 AM - A progress note documented R16 had a fall un-witnessed in the TV/dining room. 8/1/25 11:40 PM - A progress note documented R16 returned from the hospital with the following: purple bruising right fifth toe and right flank, scattered bruising to left lower leg.8/4/25 1:00 PM - A progress note R16 documented a stat order for x-ray of the right foot.8/4/25 - An X-ray report was performed and revealed a fracture at the base of the right fifth toe. 8/5/25:8:26 AM - A facility incident report documented R16 had a swollen right fifth toe that occurred on 8/1/25.12/15/25 11:35 PM - During an interview E4 (RN) confirmed that during an unwitnessed fall with injuries, she would get a call from the nurse, and they would assess the resident. E4 confirmed that she would have notified the doctor, R16's family, completed the incident report and reported to the state agency the same day regarding R16's fifth toe. E4 confirmed and revealed a supervisor's book that states incidents shall be submitted electronically to the Division of Long Term Care Residents Protection.12/15/25 3:05 PM - During an interview, E2 (DON) confirmed that the medical doctor on call was not notified when R16 returned on 8/1/2025 from the hospital with bruising and purple discoloration to the right fifth toe. 12/16/25 3:40 PM - Findings were reviewed with E1 (NHA), E2, and E3 (Executive Director) during exit conference.

Based on record review and interview it was determined that for one (R8) out of two residents reviewed for limited ROM the facility failed to develop a care plan that addressed the residents limited ROM and interventions to prevent further contractures. Findings include: Review of R8's clinical record revealed: 4/14/22 - R8 was admitted to the facility with multiple diagnoses including dementia and an impairment to the right middle finger. 7/8/25 - A physician's order was written for R8 to have a rolled washcloth placed in the right hand. Completion of the task was signed by nurses in R8's TAR. 12/11/25 10:05 AM - Review of R8's care plans lacked evidence of a care plan that addressed R8's contractures and the rolled wash cloth intervention used. 12/11/25 10:21 AM - During an interview E2 (DON) confirmed there was no care plan to address R8's contractures. E2 stated, there is no care plan because she is on hospice E2 then initiated a care plan for R8's contracture and use of the rolled washcloth. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview it was determined that for one (R67) out of two new admissions reviewed the facility failed to adhere of standards of practice when the initial care plan and admission assessment were not completed by a Registered Nurse. Findings include: The state of Delaware Board of Nursing Professional Regulations Decision Tree 2024 indicated that admission assessments and initial care plans must be completed by a Registered Nurse.Review of R67's clinical record revealed:11/14/25 - R67 was admitted to the facility.11/14/25 - A baseline care plan was created for R67 by E20 (LPN).11/14/25 - An admission assessment that documented the clinical details such as vital signs, skin condition, care needs and general condition of R67 upon arrival to the facility was completed by E20 (LPN).12/16/25 2:34 PM - During an interview E20 (LPN) confirmed she completed R67's admission assessment and initial care plans. E20 stated, Yes, I completed them and I did have an aide assist me with positioning for the skin assessment. 12/16/25 3:30 PM - During an interview E2 (DON) stated, LPNs are allowed to complete the admission and care plan according to our policy.12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview it was determined that for one (R20) out of three residents reviewed for transmission-based precautions the facility failed to ensure that a physician was notified promptly of laboratory results. Findings include:Review of R20's clinical record revealed: 12/8/25 - A physician's order was written for R20 to have a urinalysis culture and sensitivity test completed. 12/11/25 - R20's urinalysis culture and sensitivity was collected by the contracted laboratory. 12/13/25 - The results of R20's urinalysis culture and sensitivity were relayed to the facility by phone to E24 (LPN). R20's progress notes lacked evidence that E24 relayed the results to R20's physician or nurse practitioner. 12/15/25 - A copy of the results of R20's urinalysis culture and sensitivity were reviewed by E23 (NP), two days after the results were known. 12/16/25 2:00 PM - During an interview E22 (ADON/IP) and E2 (DON) confirmed the facility the delay in notification without explanation. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview it was determined that for one (R20) out of three residents reviewed for transmission-based precautions the facility failed to ensure that laboratory reports were filed in the clinical record. Findings include: The facility policy on diagnostic services last updated 12/24/24 indicated All test results will be maintained in the clinical record. Review of R20's clinical record revealed: 12/8/25 - A physician's order was written for R20 to have a urinalysis culture and sensitivity test completed. 12/11/25 - R20's urinalysis culture and sensitivity was collected by the contracted laboratory. 12/16/25 1:00 PM - Review of R20's clinical record lacked evidence of the results of R20's urinalysis culture and sensitivity was collected by the contracted laboratory on 12/11/25. 12/16/25 2:00 PM - During an interview E22 (ADON/IP) provided the surveyor with a copy of the results of R20's urinalysis culture and sensitivity and confirmed it was not in R20's clinical record. E22 stated, they were waiting to be filed. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview it was determined that for two (R1 and R20) out of five residents reviewed for immunizations the facility failed to offer pneumococcal vaccination as required. Findings include: The facility policy on immunizations last updated 2/19/25 indicated, Each resident is offered a pneumococcal immunization. The residents medical record includes documentation that indicates the following: That the resident or resident's legal representative was provided education .That the resident either received the pneumococcal immunization or refusal. 1. 1/22/25 - R20 was admitted to the facility. 2. 6/25/25 - R1 was admitted to the facility. 12/15/25 12:35 PM - Review of resident's immunization records lacked evidence of pneumococcal immunization or declination for R1 and R20. Surveyor requested evidence of declination or consent from E2 (DON). 12/16/25 10:22 AM - During an interview E2 (DON) and E22 (ADON/ICP) provided consents dated 12/15/25 day of surveyor request. E2 confirmed that R1 and R20 had not been offered immunization prior. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on record review and interview it was determined that for one (R7) out of five residents reviewed for unnecessary medication review the facility failed to adequately complete monitoring for side effects of a resident on psychotropic medications. Findings include: The facility policy on consultant pharmacist recommendations last updated 7/9/25 indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber. Review of R7's clinical record revealed: 7/16/25 - R7 was admitted to the facility with multiple diagnoses including dementia with psychotic disturbance, psychotic disorder with delusions and schizophrenia. 7/16/25 - An AIMS assessment was completed for R7 that scored the resident as a 3, indicative of mild risk of side effects as a result of antipsychotic medications. 7/17/25 - A physician's order was written for R7 to receive quetiapine, an antipsychotic twice a day. 8/18/25 - A consultant pharmacist medication regimen review (MRR) completed for R7 recommended the following Resident is currently receiving quetiapine. Her baseline AIMS assessment completed 7/16/25 shows a score of three, which indicates abnormal movements were observed. Due to current antipsychotic therapy can, we have an order to repeat AIMS assessment? 8/21/25 - R7's primary care provided responded in agreement with the 8/18/25 MRR and documented Repeat AIMS. 12/12/25 - Review of R7's clinical record lacked evidence that a repeat AIM's assessment was completed. 12/12/25 1:19 PM - During an interview E2 (DON) confirmed the finding and stated, I was on vacation they did another psychiatric assessment instead. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on interview and record review, it was determined that for one (R67) out of three residents reviewed for hydration, the facility failed to offer sufficient hydration. Findings include:The facility policy on hydration last updated 12/24/24 indicated, To enable all residents to be hydrated. Facilities will have a process in place to ensure that all residents receive sufficient amounts of fluids, based on individual needs, to maintain proper hydration and health. Review of R67's clinical record revealed: 11/14/25 - R67 was admitted to the facility with multiple diagnoses including mild cognitive impairment. 11/14/25 - A baseline care plan created for R67 indicated a risk of hydration concerns. 11/15/25 6:04 PM - A progress note in R67's clinical record documented, Residents husband in facility and asked nurse to speak with son over phone call regarding a request for IV placement for nutrients until Monday due to resident not eating and drinking per son and husband, on call was made aware of request and gave order to have labs in AM, CBC and CMP and to call back when the results are received to determine further intervention and to assist resident in feeding and drinking at this time. Husband made aware and husband expressed that he is not sure why we cannot use labs from hospital and nurse expressed that these were the orders we received at this time and on call wants to review results tomorrow. husband verbalized understanding and is assisting resident with dinner at this time. 11/15/25 7:08 PM - A progress note in R67's clinical record documented, Resident ate approx. 75% of dinner with 240ml of fluids with husband assistance. 11/17/25 - A progress note in R67's clinical record written by E23 (NP) documented, [R67] was found resting in bed her son present concerned about decreased oral intake and hydration. Son stated patient had 20% of her lunch today. We discussed starting nutritional supplementation like Glucerna and he agreed .Decreased oral intake. Order for Glucerna three times a day Continue to monitor oral intake Assist with feeding monitor hydration. 11/17/25 4:00 PM - E30 (RD) completed a nutrition summary for R67 that documented a mini nutrition score of 6.0; with 0 - 7 points indicated malnourishment. 11/17/25 6:49 PM - A nutrition/dietary note in R67's clinical record documented, admission nutrition review: [AGE] year old female admitted with diagnosis of mild cognitive impairment. Decreased intake . Estimated nutrient needs are Fluids: 1500 mL. Nutrition intervention: RD would recommend adding 237 mL Glucerna supplement daily for optimal nutrient intake. 11/18/25 - A five-day MDS assessment documented that R67 had memory problems, cognitive impairment with a BIMS score of 00 and was dependent for assistance with eating/drinking. 11/18/25 - A physician's order was written for R67 to receive Glucerna, a diabetic liquid meal supplement three times a day. A day later than E31 (NP) progress note that indicated R67 should be started on the supplement. The order did not include measuring amount of supplement consumed. November 2025 - Review of R67's record of fluid intake for the following dates indicated less than the recommended amount of 1500ml daily:11/14 - 240 ml evening.11/15 - 540 ml total.11/16 - 420 ml total.11/17 - 540 ml total.11/18 - 140 day morning and afternoon. 11/18/25 - R67 was sent to the hospital for evaluation after a fall and did not return to the facility. 12/15/25 11:07 AM - During an interview CG1 a relative of R67 stated, [R67] was malnourished and they didn't want to give an IV for fluids. They wanted to take labs first that isn't the only indicator of dehydration! Why wait when they know she wasn't taking much in. We had to feed her. 12/16/25 11:10 AM - During an interview E30 (RD) stated that drinking less than 1200 ml at least would be too little fluid per day. E30 then confirmed that R67's recommended amount was 1500 ml specific to [R67] I used her current body weight. I did an assessment on 11/17, and I saw she had decreased po intake and fluids. 12/16/25 1:50 PM - During an interview E31 (CNA) confirmed that R67 required assistance with eating and drinking. 12/16/25 2:34 PM - During an interview E20 (LPN) stated, When I came in the beginning of the shift, I got in report that they wanted IV fluids [E23 (NP)] was in the room with them, the labs came and she was like she's not dehydrated but wanted supplement and I said we can do the Glucerna. E20 confirmed that percentage of consumption is usually documented for supplements. There was no evidence that the facility monitored R67's fluid intake. 12/16/25 3:45 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on observation, interview and record review it was determined for one (R31) out of one resident sampled for respiratory care the facility failed to provide professional standards of practice by ensuring R31's BiPap equipment was stored in a protective plastic bag when not in use. Findings include:A review of R31's clinical record revealed: 11/5/25 - R31 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease, congestive heart failure and obstructive sleep apnea. 11/5/25 - A physician's order for R31 documented BiPap application off in the AM and on at night at bedtime assist with application of BiPap to use with 3L (liters) oxygen. R31's treatment administration record lacked evidence of an order to place the respiratory equipment in a plastic bag. 11/11/25 - A review of a five-day MDS admission assessment documented R31 was cognitively intact. 12/10/25 9:35 AM - During an interview E6 (RN) reported [R31's] respiratory equipment should probably be in a plastic bag but it probably isn't. E6 went to R31's room and confirmed the respiratory equipment was not in a plastic bag E6 stated, Nope it's not in a plastic bag. E6 changed the tubing and place the BiPap mask and tubing in a plastic bag. 12/10/25 9:50 AM - An interview and observation with E2 (DON) confirmed R31's BiPap and tubing was not in a plastic bag. 12/10/25 10:27 AM - R31's treatment administration record was updated with a new order Ensure BiPap mask in bag when not being utilized every shift. 12/16/25 4:00 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON) and E3 (ED).

Based on observation, interview, record review, and review of other facility documentation it was determined that for one (R1) out of four residents sampled for wandering and elopement the facility failed to ensure adequate supervision to prevent R1 from eloping putting the resident at serious immediate jeopardy and risk of a serious adverse outcome. R1, a resident that was confused was able to elope from the facility on 9/27/25 by climbing out of the window in R1's room. R1 walked across the facility's back parking lot and then proceeded to walk across a busy roadway to an area where there was a raised curb, a sloped hill with trees, shrubs and brush. R1 was missing for seven minutes. An immediate jeopardy (IJ) was identified starting on 9/27/25. Due to corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 10/1/25. Findings include:A policy titled Elopement last reviewed by the facility 12/24/24 documented Facilities will identify residents at risk for elopement and develop a plan to prevent unauthorized resident absences from the facility. To prevent elopement and identify action steps to be taken in the event of an unauthorized resident absence from the facility.A policy titled Wandering Management last reviewed by the facility 12/21/23 documented It is the policy of Presbyterian Senior Living to identify residents at risk for wandering and to develop an individualized plan to prevent unauthorized exit from the community. Residents will be evaluated for potential wandering during an elopement evaluation completed on admission, quarterly and as needed for a change in condition.Review of R1's clinical record revealed:9/18/25 - R1 was admitted to the facility with diagnoses including but not limited to congestive heart failure, anemia, falls and premature heartbeats. 9/18/25 - A review of a facility admission elopement evaluation documented R1 was not at risk for elopement. 9/22/25 3:08 AM - A facility progress note documented [R1] found in the hallway all dressed up and carrying his bag trying to leave the facility, when asked 'where are you going' [R1] stated 'I thought everyone left already.' R1 was redirected back to the room. Wander guard placed to right hand. 9/22/25 7:10 AM - Review of a facility elopement evaluation revealed R1's wandering behavior was a pattern and goal directed. Further review of the evaluation revealed R1 wandered aimlessly, non-goal directed and behavior likely to affect privacy of others. 9/22/25 - A review of R1's care plan for elopement revealed [R1] was at risk for wandering and disoriented to place and had impaired safety awareness. Wander guard to right risk at all times.The facility investigation documented the following timeline for R1's elopement on 9/27/25:9/27/25 11:10 AM - A facility progress note documented [R1] was alert, confused and fixated on paying taxes and redirected several times.9/27/25 1:37 PM - The facility's security videotape recorded R1 walking by the back loading dock. 9/27/25 1:40 PM - R1 called F1 (Family) and reported to being held hostage by facility and wanted to call the police. F1 contacted E5 (RN) regarding the call. E5 proceeded to R1's room observed that the window screen was removed and initiated a search for R1.9/27/25 1:42 PM - E6 (LPN) observed R1 outside while on lunch break. 9/27/25 1:43 PM - E9 (Receptionist) received a call from a driver that R1 was walking on the road waving for traffic to go around. 9/27/25 1:44 PM - E7 (Activity Staff) and E5 ran out of the building and observed R1 across the road with E6.9/27/25 1:45 PM - R1 was combative with E5, E6 and E7. R1 refused to come back to the facility.9/27/25 1:47 PM - A police officer drove past and turned around to see if assistance was needed. The officer asked R1 to sit in the back of the police vehicle and EMS was notified as R1 continued to refuse to return to the facility. 9/27/25 2:07 PM - EMS arrived to take R1 to the hospital for evaluation and treatment. 9/27/25 2:20 PM - E5 notified F1 and physician of R1's elopement from the facility. 9/27/25 3:09 PM - R1 was discharged from the hospital in stable condition to home with family. 10/2/25 12:20 PM - During an interview, E5 reported R1 was fixated on leaving the facility to go and get taxes done. E5 redirected R1 at 1:15 PM and 1:20 PM. E5 added that F1 called to report a call from R1 about being held hostage and wanting to call the police. E5 went to R1's room and observed the screen was out of the window and started to search for R1. E5 heard E9 talking to the person that called and then ran out the facility to search for R1. E5 stated, [R1] was across the street with [E6] and refused to come back to the facility. The police called EMS they took [R1] to the hospital.10/2/25 12:31 PM - During an interview E6 reported while on lunch break a couple drove up and said, there is an elderly man down by the school and thought [R1] was a resident from the facility. E6 asked them to notify the front desk, and I walked across the street to where [R1] was.10/2/25 12:42 PM - During an interview, E12 (RN) reported R1 had periods of confusion and had been fixated on paying taxes and needed to be redirected several times.10/2/25 1:03 PM - During an interview, E7 reported going outside and observed E6 across the road with R1, and that E5, E6 and E7 tried to assist R1 safely back across the road. R1 refused. 10/2/25 1:06 PM - An interview with R1's care giver E8 (CNA) revealed R1 was assisted with bathing and toileting that morning. E8 confirmed R1 was last seen around 1:30 PM after taking R1 to the room to rest. 10/2/25 1:29 PM - During an interview E2 (DON) reported R1 had a Wander guard device and stated, we found that the order was not there for the Wander guard to be checked, R1's care plan reflected the risk for elopement and the Wander guard to be checked and on at all times.10/3/25 9:09 AM - During an interview E9 reported receiving a call from a woman that didn't provide a name that R1 was walking down the road directing traffic around to cross the road. In addition, E9 stated, [E5] heard me talking on the phone and ran out the facility. E9 then stated, [R1] had to of climbed out the window, that would have been the only way to get out I was at the front desk. [R1] didn't come through the lobby.10/3/25 9:43 AM - An interview with E10 (ESD) confirmed immediately following the elopement an audit was completed on R1's window the emergency restraint bar was noted to have been disengaged. The facility's root cause analysis of the elopement identified R1 removed and disengaged the safety latch on the window in the room and climbed out of the window. R1 possessed the physical ability to exit the building through the window without staff awareness. There was no alarm feature on window to alert staff. R1 possessed the physical strength and problem-solving ability to release the safety latch on the window and climb out without an alert to staff as windows are not alarmed. The facility's plan of correction included: Residents with wander guards and residents that possessed the physical ability to climb out of a window were all placed on 1:1 supervision and observation.Residents with wander guard devices had orders for checking placement and function.Window audits started immediately with R1's room and all other resident windows on 9/27/25 and completed by the maintenance department.Audits for elopement will be conducted weekly for four weeks, then monthly for two weeks. Random review of up to five resident records including newly admitted residents with high-risk elopement scores and care plan interventions to ensure accuracy. Window alarm sensors were ordered on 9/30/25 and were delivered to the facility 10/8/25. Installation to resident windows were started on 10/8/25 by the maintenance department. Residents at risk for elopement will remain on 1:1 supervision and observation until all window alarm sensors have been installed. 9/27/25 - 10/1/25 - Elopement drills, re-education and review of the facility's policy titled Elopement were validated and completed for all full-time, part-time, agency staff and PRN (As Needed Staff). 10/3/25 - Staff interviews with E4 (SW), E8 (CNA), E11 (CNA) and E12 (CNA) confirmed staff education and elopement drills had been completed.Based on the review of the facility's thorough investigation, documented response, completion of in-service training and elopement drills, audits and staff interview the immediate jeopardy was determined to be past non-compliance with a correction date of 10/1/25. 10/8/25 3:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ED) at the exit conference.

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 10/21/24 9:14 AM - During the initial tour of the kitchen, there were no buckets containing sanitizing solution for storing wet wiping clothes used for sanitizing food preparation surfaces. 10/21/24 9:38 AM - During a tour of the kitchen, E12 (Cook) tested the sanitizing solution in the three compartment sink, directly at the source two times. Both attempts indicated the level of chemical concentration was not at a sufficient level to provide proper sanitization. An interview with E12 later that day revealed the facility had been using the incorrect type of chemical test strips when testing the sanitizer levels in the kitchen. 10/21/24 9:42 AM - During a tour of the kitchen, there were three compromised food cans with dented sides, which were not separated from the cans of food being served to the residents. 10/21/24 10:23 AM- During a tour of the kitchen, the ice scoop was being stored inside the ice machine laying on top of the ice exposing the ice to contaminants from the handle. 10/21/24 11:35 AM During a review of the food temperature logs, the facility kitchen records had no food temperatures recorded for twenty-three (23) meals out of three-hundred thirty-six (336) meals sampled. Temperatures of cooked foods and cold ready to eat foods were not being consistently recorded prior to being served. Fish, meat, and poultry must be heated to an appropriate specific temperature depending on the type of food and the method used to prepare it. Vegetables must be heated to one hundred thirty-five (135) degrees Fahrenheit (F), and cold ready to eat foods must be held below forty-one (41) degrees (F) to maintain food safety. 10/21/24 3:23 PM - Findings were confirmed with E12 (Cook). 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on record review and interviews, it was determined for three (R16, R32, and R217) out of eighteen residents in the investigative sample, the facility failed to ensure the MDS was accurate. Findings include: 1. Review of R16's clinical record revealed: 9/28/24 - R16 was admitted to the facility. 10/4/24 - An admission MDS documented that R16 had restraints. These restraints included bilateral bed rails. 10/21/24 - An observation of R16 in bed with bilateral side rails in place, used as an enabler bar for turning and repositioning. 10/25/24 1:48 PM - An interview with E6 (RNAC), E7 (RNAC) and E1 (NHA) revealed that the MDS was miscoded for R16 and discovered when surveyors requested the Matrix. E1 stated that E7 is in training and miscoded the MDS. E1 provided evidence that the MDS was corrected. 2. Review of R32's clinical record revealed: 10/2/24 - R32 was admitted to the facility. 10/4/24 - An admission MDS documented that R32 had restraints. These restraints included bilateral bed rails. 10/22/24 - An observation of R32 in bed with bilateral side rails in place, used as an enabler bar for turning and repositioning. 10/25/24 1:48 PM - An interview with E6 (RNAC), E7 (RNAC) and E1 (NHA) revealed that the MDS was miscoded for R32 and discovered when surveyors requested the Matrix. E1 stated that E7 is in training and miscoded the MDS. E1 provided evidence that the MDS was corrected. 3. Review of R217's clinical record revealed: 9/20/24 - R217 was admitted to the facility. 9/26/24 - An admission MDS documented that R217 had restraints. These restraints included bilateral bed rails. 10/22/24 - An observation of R217 in bed with bilateral side rails in place, used as an enabler bar for turning and repositioning. 10/25/24 1:48 PM - An interview with E6 (RNAC), E7 (RNAC) and E1 (NHA) revealed that the MDS was miscoded for R217 and discovered when surveyors requested the Matrix. E1 stated that E7 is in training and miscoded the MDS. E1 provided evidence that the MDS was corrected. 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on record review and interview, it was determined that for one (R37) out of eighteen residents reviewed in the investigative sample, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings. Findings include: Review of R37's clinical record revealed: 10/3/24 - R37 was admitted to the facility. 10/16/24 - A careplan meeting interdisciplinary note revealed that the following attendees were present: R37, family member, nursing, therapy, CNA, Social worker, and dietary. 10/25/24 9:22 AM - An interview with E6 (RNAC) confirmed that physician or physician's representative did not participate in R37's care plan conferences. E6 stated the physician reviews residents monthly but not in coordination with the care plan meetings. 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on record review and interview, it was determined that for two (R1 and R27) out of six residents reviewed for unnecessary medication review, it was determined that the facility failed to follow physician orders. Findings include: 1. Review of R1's clinical record revealed: 10/22/18 - R1 was admitted to the facility with diagnoses including diabetes mellitus. 8/12/21 - A physician's order documented Lantus 100 units/ml, administer 30 units subcutaneously in the evening (hold for finger stick blood sugar less than 100). 2/17/24 4:01 PM - Review of the MAR revealed R1's glucose was 78 ml/dl. Although R1's glucose was less than 100, E5 (LPN) administered the Lantus. 10/24/24 11:41 AM - During an interview, E5 (LPN) revealed if the doctor writes a parameter to hold insulin for low blood sugars, then E5 holds the insulin. E5 further revealed if the blood sugar was excessively high or low, the doctor is notified and then E5 would document the blood sugar level in the MAR. 10/24/24 12:17 PM - An interview with E3 (LPN) confirmed that she documented a blood sugar of 78 and that Lantus 30 units was administered subcutaneously. 46988 2. Review of R27's clinical record revealed: 12/5/22 - R27 was admitted to the facility. 12/21/22 - A physician's order was written for midodrine HCL 2.5 mg one tablet by mouth three times a day before meals. Alert please note parameters: hold for systolic blood pressure (SBP) greater than 130. 11/2023 - A review of the November 2023 MAR revealed that on 11/5/23 R27 documented a blood pressure listed of 152/81 and a signature indicating midodrine medication was administered. 11/1/23 - 11/16/23 - A consultant pharmacist's medication regimen review documented that R27 recommendation to read parameters closely for holding midodrine. Order is to hold midodrine for SBP greater than 130 but dose is documented as administered on November 5 at 9:00 AM when blood pressure is 152/81. 10/24/24 2:31 PM - An interview with E14 (LPN) confirmed that midodrine was signed off on 11/5/23 at 9:00 AM, even though parameters indicated to not administer. The facility lacked evidence that the aforementioned irregularity was addressed. The progress notes lacked evidence of monitoring related to medication being administered outside of the parameters. 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on observation, interview and record review it was determined that for two (R21 and R37) out of two residents reviewed for incontinence, the facility failed to provide services to restore bowel and bladder continence. Findings include: 1. Review of R21's clinical record revealed: 12/22/23 - A policy titled Bowel and Bladder training documented the objective is to retrain a formerly continent resident or reduce incontinence in residents with stress or urge incontinence.Procedure 1. determine eligibility for retraining program using the Bowel and Bladder UDA. A bowel or bladder UDA is assigned with each new admission, quarterly, annually and with each resident significant change. Upon completion the bowel and bladder evaluation is reviewed to determine if voiding diaries are needed in order to ascertain resident toileting plans. 3. Establish scheduled toileting program. 4. Determine appropriate incontinence aids to assist in obtaining continence. 6. Establish an individualized bowel or bladder program for each resident. 7. Place approaches on the individual resident's care plan. 8/29/24 - R21 was admitted to the facility. 8/29/24 6:40 PM - A bowel and bladder evaluation documented that R21 was totally dependent for toileting with one staff assistance. It also documented that R21 had an indwelling catheter and frequently incontinent of bowel. 8/30/24 - A care plan was initiated for R21 for continence issues with a goal to regain bowel control within ninety days. Interventions were to assist R21 with bedpan use upon rising, before and after meals, at bedtime and every two hours on overnight shift; use of incontinence products; and voiding diary as needed. 8/2024 - The CNA task flow sheet for August 2024 revealed that R21 was incontinent of bowel two times. R21 was continent of bowel one time. The CNA flow sheet lacked evidence of following the individualized interventions for R21 listed in the care plan. The flow sheet documented bowel function, control, appliances, and consistency every shift. 9/2024 - The CNA task flow sheet for September 2024 revealed that R21 was incontinent of bowel seventeen times. R21 was continent of bowel three times. The CNA flow sheet lacked evidence of following the individualized interventions for R21 listed in the care plan. The flow sheet documented bowel function, control, appliances, and consistency every shift. 9/4/24 - An admission MDS assessment documented R21 was dependent for toileting with one staff assistance. The MDS also documented that R21 was always incontinent of bowel and that R21 was not on a toileting program. 10/2024 - The CNA task flow sheet for October 2024 revealed that R21 was incontinent of bowel seventeen times. R21 was continent of bowel zero times. The CNA flow sheet lacked evidence of following the individualized interventions for R21 listed in the care plan. The flow sheet documented bowel function, control, appliances, and consistency every shift. 10/21/24 10:56 AM - In an interview R21 stated that she uses a bedpan and is able to verbalize the need for elimination. R21 stated that prior to admission she used the toilet until her increased difficulty walking. 10/24/24 11:04 AM - In an interview with E15 (NP) stated that the expectation is for nurses and CNA's to monitor for changes in continence and report changes to the provider if any occur. 10/24/24 11:35 AM - In an interview with E14 (LPN) revealed that the facility does not have a set toileting program and that staff should be consistently monitoring resident's for bowel and bladder changes. E14 indicated that the CNA's do check and change every two hours and that is the toileting program. E14 stated that R21 is not on a toileting program other than the every two hours check and change. 10/29/24 1:40 PM - During an interview, E16 (CNA) stated that R21 does not use a bed pan and that she does not offer one to R21. There was no evidence that the facility attempted to restore bowel function for R21. 2. Review of R37's clinical record revealed. 10/3/24 - R37 was admitted to the facility. 10/3/24 - A care plan was initiated for R37 to remain continent of bowel and bladder through ninety days with interventions of using incontinence products (briefs, fracture pan), voiding diary as needed, and assist to bedpan/ toilet per request. 10/9/24 - An admission MDS documented R37 was dependent for toileting with one assist, frequently incontinent of bladder and always incontinent of bowel. 10/2024 - The CNA task flow from 10/3/24 to 10/31/24 documented R37 was incontinent of urine fifty four times out of eighty four opportunities, which was 63% of the time throughout the month. R37 was continent of urine seven times. The CNA flow sheet lacked evidence of following R37's individualized interventions listed in the care plan. The CNA flow sheet documented bladder function, voiding, toilet use or appliances, incontinence products, and control. 10/21/24 1:40 PM - An interview with R37 revealed that she is continent and able to voice when she has to use the bathroom. R37 stated that at times she becomes incontinent waiting for staff assistance to the toilet. 10/24/24 11:35 AM - During an interview, E14 (LPN) revealed that the facility does not have a set toileting program and that staff should be consistently monitoring resident's for bowel and bladder changes. E14 indicated that the CNA's do check and change every two hours and that is the toileting program. E14 stated that R37 is not on a toileting program other than the every two hours check and change. 10/29/24 1:40 PM - During an interview, E16 (CNA) stated that R37 does not use a bed pan and that R37 is not on a toileting program. 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on observation and interviews, it was determined that for one (R47) out of eight residents sampled for food the facility failed to follow menu requests. Findings include: 10/21/24 10:11 AM - A random observation of R47's breakfast tray revealed oatmeal, cheerios, scrambled eggs, raisin toast and hot tea. The meal ticket showed R47 was supposed to have apple juice, oatmeal, fresh whole apple, fried egg, cinnamon wheat toast, 2% milk and coffee or hot tea. The tray was missing apple juice and a fresh whole apple. The meal ticket showed R47's dislikes as: chocolate, gravy, apples, eggs, milk or pork and to serve soft fruits. R47 stated they bring her food that she doesn't like. 10/21/24 10:20 AM - An interview with E8 (CNA) confirmed that R47 did not have apple juice or a substitute and did not have a fresh whole apple or any substitute. E8 stated that there was no apple juice left and offered to give R47 cranberry juice. E8 stated that the kitchen makes up the tray and we bring the trays to the resident rooms. 10/22/24 9:32 AM - A random observation of R47's breakfast tray revealed cranberry juice, cheerios, bacon, sausage and hot tea. The meal ticket showed R47 was supposed to have apple juice, cream of wheat, fresh whole orange, scrambled eggs with onions, wheat toast, 2% milk and coffee or hot tea. The tray was missing a fresh whole orange and scrambled eggs with onions. The meal ticket showed R47's dislikes as: chocolate, gravy, apples, eggs, milk or pork and to serve soft fruits. R47 stated that she cannot eat pork and would not be able to eat the bacon or the sausage and would only eat the cheerios. 10/22/24 9:37 AM - An interview with E9 (RN) confirmed that R47 did not have a fresh orange or a substitute and confirmed the rest of the items on the breakfast tray. E9 offered sliced oranges to give to R47. E9 confirmed that R47's dislike of pork on the meal ticket and that R47 received bacon and sausage. 10/23/24 10:03 AM - An interview with E10 (Dietary Regional Support) revealed that the kitchen staff follow the meal ticket and plates the items according to the meal ticket. If a food item is a disliked item, it is not to be plated on the tray. If something is not available, we are to offer a substitution of the same nutritional value. E10 stated that the staff who plated R47's tray was filling in from the independent living side and had not plated trays before. 10/23/24 10:21 AM - An interview with E11 (Dietician) confirmed that if a food item is not available a substitute that is nutritionally equivalent is needed. 10/31/24 3:00 PM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Review) that included time frames for different steps in the MRR process. Findings include: 12/05/23 12:50 PM - A review of the facilities policy titled, Consultant Pharmacist Reports, lacked information regarding the time frames for a pharmacist response for urgent medication recommendations. The MRR policy did not meet the expected time frame requirements. 10/31/24 - An interview during exit conference with E1 (NHA) confirmed the MRR policy did not meet the expected requirements for urgent medication response times. 10/31/24 9:45 AM - Findings were reviewed with E1 (NHA) , E2 (DON), and E4 (Executive Director) at the exit conference.

Based on observation, interview and record review, it was determined that for three (R71, R68 and R43) out of six residents reviewed for abuse, the facility failed to ensure that R71, R68 and R43 were free of sexual abuse by R16, a resident with a history of sexually inappropriate behavior. The facility's failure to monitor R16 allowed the sexual abuse of R71 on 9/14/22, R68 on 11/16/22 and R43 on 12/16/22. An Immediate Jeopardy (IJ) was identified starting 9/14/22. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 12/16/22. Findings include: A facility policy and procedure titled, Abuse, Neglect or Exploitation, revised 10/24/22, documented, Policy .each resident is provided with a safe environment where they are not subject to mental, physical .and sexual abuse .Objective: Residents are protected from real or perceived abuse .Standard: The facility is committed to ensuring that each resident is free from verbal .or sexual abuse Review of R16's clinical record revealed: 3/15/21 - R16 was admitted to the facility with diagnoses including depression, anxiety, mood disorder and dementia. 3/21/21 - R16's admission MDS assessment revealed that R16 had severe cognitive impairment. During the seven-day review period R16 was exhibiting behavioral symptoms of the sexual nature directed towards himself. In addition, R16 wandered during the seven-day review period. R16 required supervision and setup help only for transfer and required supervision during walking and locomotion. 2/16/22 - A care plan was developed for R16's inappropriate sexual behaviors related to dementia. R16's interventions included but not limited to monitor and document episodes of behavior, psych evaluation and offer early breakfast. R16 had physician's orders for: -2/18/22 behavior documentation every shift for sexually inappropriate behavior. -2/21/22 psych consult for sexually toward behavior; -2/23/22 divalproex (Depakote) increased from 125 mg 1 capsule twice a day to 2 capsules twice a day for mood disorder. A review of R16's CNA Daily Charting from February through April 2022 revealed that R16 was being monitored by the CNAs every shift from 2/18/22 through 4/25/22. From 4/26/22 through 4/30/22, R16 was monitored by the CNAs hourly and every shift. 4/22/22 7:04 AM - A psychiatry note by P3 revealed that on 4/21/22, R16 was seen for follow up psychotropic medication adjustment - lexapro initiated .monitor and notify provider of any change in condition or ongoing behavior escalation. A. R71 9/1/22 - R71's quarterly MDS assessment revealed that R71 had severe cognitive impairment. R71 required supervision and setup help only during transfer, walking and locomotion. 9/14/22 - A facility incident report submitted to the State Agency documented that, Staff member observed (R16) with his hands inside the waistband of (R71)'s pants. Per witness it appeared that R16 was attempting to fondle R71. R16 was redirected at which time he removed his hand from R71's pants, he continued to pet her hand and forearm in an affectionate manner. Residents were redirected into separate areas of the unit. (Police) were notified. R16 had a new physician's orders for: 9/14/22 - psychiatry consult for worsened sexual behaviors. 9/14/22 - laboratory CBC, BMP 9/16/22 1:02 PM - A psychiatry note by P3 revealed that on 9/15/22, R16 was seen secondary to staff witnessing R16 inappropriately touching a female resident (R16) . engages easily in conversation .discussed concern with (R16's) inappropriate behavior - touching female residents. (R16) acknowledges behavior and states ok when advised not to repeat behavior .No new pharmacological recommendation 9/19/22 - A facility follow up report submitted to the State revealed that R16 was cognitively impaired with poor decision making. R16 had a referral for placement in the dementia unit and the female resident (R71) was moved to a different unit. Review of R16's records revealed that R16 was on every 15 minutes checks on 9/14/22 from 10:30 AM until 10:30 PM daily. A review of R16's CNA Daily Charting from 9/1/22 through 9/15/22 revealed that R16 was monitored by the CNAs hourly and every shift. Although the facility had monitoring in place for R16, the facility failed to protect R71 from sexual abuse. B. R68 9/18/22 - R68's quarterly MDS assessment revealed that R68 had severe cognitive impairment. R68 required extensive assist of one staff member for transfer, non-ambulatory and required extensive assist of one staff member for locomotion on the unit. A review of R16's CNA Daily Charting (electronic) from 9/16/22 through 11/15/22 revealed that R16 was monitored by the CNAs every shift. 11/16/22 - A facility incident report submitted to the State Agency documented that, Staff witnessed (R16) with his hand inside (R68's) shirt rubbing her breasts as she was sleeping in a chair in a common area TV room. Staff immediately intervened and redirected R16, separating residents .police report filed Review of R16's records revealed that the licensed nurses monitored R16: - every 15 minutes check on 11/16/22 from 8:50 AM until 11/17/22 9:00 AM. - every 30 minutes check on 11/17/22 from 10:30 AM until 11:00 PM. - every hour check from 11/17/22 11:00 PM until 11/18/22 7:00 AM. Review of R16's CNA flowsheet revealed that R16 was also monitored by the CNAs hourly from 11/16/23 11:00 PM until 11/17/23 6 PM. R16 had physicians' orders for: -11/16/22 trazodone 50 mg tablet give 1/2 tablet (25 mg) by mouth three times a day for anxiety disorder; -11/16/22 Depakote level in am (11/17/22) notify (psych MD) of result; -11/17/22 psych consult; -11/17/22 referral to psych unit; -11/18/22 laboratory urinalysis to rule out urinary tract infection; -11/18/22 olanzapine 5 mg 1 tablet at bedtime for delusional disorders; -11/16/22 behavioral monitoring every hour and to document sexual inappropriate behavior; -11/25/22 behavioral monitoring and to document behaviors and any side effects for psychotropic medications: antianxiety, antidepressant, antipsychotic, mood change, crying, withdrawn, target behaviors: wandering, pacing, resisting care, sexually inappropriate behavior, delusions .monitor and document for suicidal ideation; -12/2/22 escitalopram 10 mg dose was decreased back to 5 mg 1 tablet daily. 11/17/22 10:05 PM - R16's nurse progress note by E25 (LPN) documented, MD (physician) in facility and assessed resident due to .inappropriate behavior, new order received for CMP, progressive UA (urinalysis) and CBC to be done in AM (morning) .psych consult, which was done this day, refer to psyche unit, and if needed, 1:1 supervision, per MD all was discussed with DON and ADON 11/21/22 8:54 AM - A psychiatry note by P3 revealed that on 11/17/22, R16 was seen secondary to inappropriately touching a female resident and psychotropic medication use review .(R16) .not a great conversationalist today; discussed concern with (R16's) inappropriate sexual behavior - touching female resident earlier in the week. R16 does not elaborate on incident but begins to cry .has exhibited similar behavior in the past - last noted .behavior is impulsive yet resident is typically aware of wrong doing .No new pharmacological recommendation .is a recurrent behavior unfortunately for (R16) likely due to progressing cognitive decline and impulsivity. 11/21/22 - A facility follow up report submitted to the State revealed that R16 had a diagnosis of dementia with behavioral disturbance and advance impairment in cognition. R16's medications were reviewed and adjusted. R16 was on hourly safety checks and behavior monitoring. Although the facility had monitoring in place for R16, the facility failed to protect R68 from sexual abuse. C. R43 9/22/22 - R43's quarterly MDS assessment revealed that R43's cognition was severely impaired. R43 required extensive assist with one staff member for transfer, walking on unit and locomotion. 12/16/22 - A facility incident report submitted to the State Incident Reporting Center documented that R16 who was confused, placed his hands inside the upper chest area/clothing of a female resident (R43) but was immediately redirected. R16 had a physician's order for: -12/16/22 1:1 supervision for sexual inappropriate behavior; -12/19/22 obtain Depakote level in am (12/20/22), then LFT (liver function test) in 2 weeks; -12/19/22 if Depakote level is less than 50, then increase Depakote to 375 mg by mouth two times a day and repeat Depakote level and LFT in 2 weeks; -12/19/22 olanzapine 2.5 mg 1 tablet by mouth every morning - administer only if Depakote level is therapeutic (50-100); -12/19/22 follow up with psych services at next visit to facility. 12/16/22 - Review of R16's care plan interventions related to his sexually inappropriate behavior included R16 placed on one-to-one supervision and referrals made to psych facilities. 12/20/22 - A facility follow up report submitted to the State revealed that R16 had advanced dementia and had exhibited sexually inappropriate behavior. R43 was immediately removed from the area. R16 was placed on 1:1 supervision 24 hours a day, family members and police were notified .and an order to consult inpatient psych for evaluation and treatment. R16 was transferred to a (psych hospital) on 12/20/22. Although the facility had monitoring in place for R16, the facility failed to protect R43 from sexual abuse. Further review of R16's records revealed that 1:1 supervision continued 24 hours a day upon his readmission to the facility on [DATE] through March 2023. From March 2023 through April 2023 R16's 1:1 supervision was decreased to day shifts and evening shifts. From April 2023 to 5/31/23 the 1:1 supervision was decreased to just day shift until 5/31/23. After 5/31/23 R16's monitoring was decreased to hourly monitoring and remains on the hourly monitor through the present. 10/12/23 9:55 AM - In an interview, E5 (LPN) stated, resident is being monitored hourly for inappropriate sexual behaviors like touching female residents. He used to be in the LTC unit but since his re-admission early this year, they moved him here in the short-term unit. He has been behaving well and there have been no incidents of inappropriate behavior. He has been calm. 10/18/23 8:30 AM - In an interview, E6 (CNA) stated that resident (R16) is currently being monitored hourly and that resident did not have any sexually inappropriate behavior. 10/18/23 11:19 AM - An immediate jeopardy (IJ) was called and reviewed with the facility leadership, including E1 (NHA), E2 (DON) and E24 (Corporate Clinical Nurse Consultant). During this conference, both E1 and E2 confirmed that there had been no other incidents of sexually inappropriate contact by R16 with other residents after the 12/16/22 incident. 10/18/23 - E1 (NHA) presented to surveyor an acceptable documentation of corrective action plan that was fully abated on 12/16/22. The facility's corrective actions at the time of the incident included: -R16 on 1:1 supervision and then was sent to a psych hospital on 12/20/22. -R16 was maintained on 1:1 supervision upon his return to the facility on [DATE]. -All residents had potential to be affected and reviewed. -Any resident identified as an accused perpetrator will be relocated or have frequent monitoring. -Ongoing monitoring of corrective actions to ensure behaviors did not occur. This was verified by review of facility documents and interview with facility staff and residents. 10/18/23 11:19 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E24 (Corporate Clinical Nurse Consultant).

Based on record review, interview, observation and review of other facility documentation, it was determined, for one (R19) out of four residents sampled for accidents, that the facility failed to ensure the resident received adequate supervision and fall prevention measures appropriate for a resident with severe cognitive impairment. R19's fall on 9/18/21 resulted in harm when R19 broke his neck, resulting in pain and limited use of his right arm affecting the ability to feed himself. Findings include: The facility policy entitled Falls Management (revised 8/10/21) identified that interventions are to be re-evaluated after each fall. When changes are added to the care plan involving new interventions these new interventions need to be dated. Any occurrence of falls along with interventions will be documented in the nursing notes. The assessment process will include an investigation using the Fall Investigation analysis sheet. This is to help identify the root cause and whether or not the fall was avoidable or unavoidable. Review of R19's clinical record revealed: 12/28/20 - R19 was admitted to the facility with diabetes and dementia (brain disorder with memory loss, poor judgement, personality changes, disorientation, loss of mental functions such as memory and reasoning that interferes with a person's daily functioning). 1/21/21 - A care plan for falls was initiated (last updated 8/5/21) and included fall prevention interventions: answer calls, anticipate needs, keep call bell within reach, provide [verbal] safety reminders, keep room well lit and clutter free, therapy to evaluate and treat, non-slip socks/shoes at all times, perimeter mattress (mattress with raised sides to help reduce rolling out of bed), soft touch call bell, visual sign to remind him to call for assistance before transfer, vital signs as needed for dizziness or lightheadedness due to medications. Encourage / remind [verbally] to use rolling walker (3/20/21 after fall). Therapy evaluate for balance, intermittent [verbal] reminders to use walker and call for assistance with transfers, medication review, restorative ambulation program (4/28/21 after fall). Offer toileting / bedpan around 11:30 PM, Physical Therapy to evaluate (5/17/21 after fall). Interventions of providing verbal reminders to call for help as well as physical therapy evaluations were repeated in response to falls in April and May 2021. 1/21/21 - A care plan for ADLs (Activities of Daily Living) included that R19 needed limited assist with one staff person for transfers, used a rolling wheeled walker with limited assistance from one staff member and was independent for eating. 6/24/21 - A fall risk assessment documented that R19 was a moderate risk for falls with a score of nine (ten or more indicated a high risk for falls). 6/27/21 - A Quarterly MDS assessment was completed and revealed R19 had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 4 (0-7 equals severe impairment). July - August 2021 - Review of facility fall investigations revealed that R19 experienced multiple falls: 7/12/21 (8:40 PM): R19 stated he fell , skin tear sustained. The care plan was updated on 7/13/21 to include recent room move, staff will continue to offer verbal reminders and cue resident to use call bell. R19 had dementia with severe cognitive impairment which affected his short term memory, reasoning and judgement. The facility added verbal reminders for R19 to call for help, which had already been included several times in the care plan. A person with severe cognitive impairment cannot remember verbal reminders. 7/17/21 (4:00 PM): Seated on the floor with his back against the bed, no injury, room door closed, not wearing non-slip footwear as in care plan. Care plan updated 7/18/21 to offer toileting around 3:30 PM. Interventions included signs to call for help before getting up which was previously in the care plan. The facility added written reminders (signs) to call for help. A person with dementia and severe cognitive impairment cannot understand the written reminders. There was no evidence that the facility verified that R19 could read the written reminders where they were posted or understand the meaning of the wording. 7/18/21 (6:45 PM): Seated on the floor with his back against the wall, skin tear. Interventions included to offer [verbal] reminders to call for help. The facility added verbal reminders to call for help, which had already been included several times in the care plan. It was clear that this severely cognitive impaired resident with dementia could not remember the verbal reminders as he had fallen three times within one week. 8/4/21 (12:15 PM): Laying on the floor on his back, re-opened previous skin injury. Care plan updated 8/5/21 with PT/OT evaluation for balance strengthening and gait training, orthostatic blood pressure checks (checking BP and heart rate when sitting and standing to see if the BP drops which can cause dizziness). Elastic compression stockings to legs to help keep the BP from dropping when standing) was added on 8/11/21. There was a lack of thorough fall investigation to determine the root cause of the falls as evidenced by incomplete and inaccurate information related to the medications R19 received that could have contributed to his falls: - 7/12/21: blood pressure medication, insulin and anticoagulant. - 7/18/21: antidepressant, insulin and anticoagulant medications. - 8/4/21: insulin. Review of fall risk assessments found that after the 7/12/21 fall, R19 was at high risk for falling. 8/10/21 - A Physician Progress Note documented falls with a reduction of BP (blood pressure) when standing leading to dizziness . recommended trial of elastic stockings to legs. August 2021 - The pharmacy consultant's medication regimen review recommended to check glucose (blood sugar) with falls. The physician response was to defer the recommendation until the following month. 9/17/21 10:42 PM - A nursing progress note documented [R19] found lying near bathroom door as if he was trying to go there, lying on left side at approx (approximately) 2140 (9:40 PM), minimal injury noted with skin tear to right arm, resident able to move all extremities and had complaint of minimal pain, PRN (as needed) tylenol given with good effect. VS (vital signs) stable and neuro checks WNL (within normal limits). [R19] unable to specify what he was trying to do . stated he didn't (sic) hit his head . assessed by 2 nurses and supervisor, able to move all extremities . assisted back to bed with education to use call bell if needing assistance. MD made aware via teamhealth book (book where notes are written for the medical team), POA will need to be updated in the morning. 9/17/21 - Review of the facility fall investigation and written statements obtained during the investigation included: R19 was in the middle of treatment for low glucose when he fell at 9:40 PM. E13 (CNA) assisted [R19] back to bed at 9:15 PM after taking the resident to the toilet and that E13 helped R19 get into bed 3 times in around 30 minutes. After the fall R19 was verbally educated to use the call bell if needing assistance. R19 had severe cognitive impairment which affected his memory, reasoning and judgement. There was no evidence that the facility implemented additional interventions or increased supervision after the 9/17/21 fall. This severely cognitive impaired resident with dementia could not remember the verbal reminders to call for help before getting up. 9/18/21 - Review of a facility fall investigation revealed that around 4:45 AM during rounds, found [R19] on his left side on the floor. He was alert, verbally responsive and able to make needs known. Assisted up from floor, able to move all extremities and new neuro check initiated and brought to the dining room for close observation. Able to ambulate on his own with assist of his walker. Sustained skin tear on his left hand and dressing applied. No acute distress. [R19] was [verbally] encouraged to call for help at all times. 9/18/21 - Review of E16's (CNA) written statement about the fall included that the CNA last toileted R19 at 2:30 AM when he walked to bathroom using his walker with staff assistance. E16 last saw R19 at 4:10 AM. When I returned back from my lunch break nurse told me [R19] was on the floor. 9/18/21 7:36 AM - A nursing progress note documented POA was updated on falls and skin tears, no questions at this time, reassured POA that staff is monitoring resident and will keep POA updated on any changes. resident sitting comfortably in dining area at this time. 9/18/21 9:57 AM - A nursing progress note documented This nurse was called . resident had 2 fall (sic) one on 3-11 last evening on one on 11-7 last night. Resident now stating neck and back are hurting and . resident not able to ambulate as usual d/t (due to) pain. Team Health called and notified of the same that stated to give tylenol 325 mg (2 tabs) 3 times a day and if there is no improvement then call back. R19's eMAR revealed he received tylenol at 8:30 AM. 9/18/21 12:49 PM - A nursing progress note documented [R19] was medicated for pain but stated that he was still having pain, resident noted to not being able to stand freely, needed two staff members to assist with standing, after standing, resident could not self ambulate with his rolling walker as usual, resident cont (continued) to c/o(complaint of) neck and back pain, resident also noted with raspy voice and difficulty swallowing and difficulty in holding his head up, this nurse called his daughter and a message was left. On call MD was called and new order received to send resident to the ER for evaluation. 9/18/21 6:51 PM - A nursing progress note documented that R19 was being admitted due to a fracture to his C7 and pneumonia, residents daughter is aware, nursing supervisor and [physician] made aware. 12/8/21 9:03 AM - During a random breakfast observation, staff was feeding R19 his breakfast. 12/9/21 9:00 AM - During a random observation two signs were visible hanging in R19's room to remind him to use the call bell and wait for help to get up. One sign was on the wall across from the foot of the bed and the other to the right of the closet across from R19's lounge chair. 12/9/21 9:10 AM - During an observation staff was encouraging R19 to feed himself, but the resident just sat, stared and did not attempt to self feed. 12/17/21 at approximately 10:55 AM - During an interview E29 (OT) stated that she had been working with R19 to improve his right arm movement and strength since he had impairment after he broke his neck. 12/20/21 10:05 AM - During an interview, E15 (LPN) stated that before the fall R19 could take himself to the toilet using his walker and use the call bell. Now, he was more confused. 12/20/21 10:59 AM - During an interview with E1 (NHA in Training) and E2 (DON), the Surveyor to reviewed R19's falls and the incomplete fall investigations. The Surveyor pointed out that many interventions added in response to a fall, were previously in the care plan, including non-skid footwear and reminders to use the call bell E2 stated that she understood that interventions to be added should not already be included in the care plan. The Surveyor explained that when current interventions were not effective then additional measures would be warranted. E2 offered no further information. The facility continued to remind R19 verbally and with signs to call for assistance prior to getting up. R19 had severe cognitive impairment which affected his memory, reasoning and judgement. A person with dementia who was severely cognitive impaired cannot understand written reminders or remember the verbal reminders to call for help before getting up. There was no evidence that the facility identified the reasons for R19's falls or implemented additional interventions or increased supervision when the current fall prevention measures were ineffective. After the 9/18/21 fall, R19 was diagnosed with a broken neck, experienced pain and developed the limited ability to use his right arm. R19's residual right arm impairment affected his ability self feed and to ambulate due to not being able to use his wheeled walker. Findings were reviewed during the exit conference on 12/20/21 at 4:05 PM with E1 (NHA in Training), E2 (DON), E3 (Executive Director), E4 (Medical Director), and E5 (ADON), E9 (Regional Nurse), and E30 (Ombudsman) participated by telephone.

Based on observation, record review, interviews and review of facility documentation, it was determined that for 2 (R62 and R33) out of 34 sampled residents, the facility failed to ensure the resident environment remained as free as possible of accident hazards and each resident received adequate supervision to prevent accidents. For R62, the facility failed to provide adequate supervision to prevent him from falling on 8/30/17, which resulted in his emergent transfer to the ED for a [MEDICAL CONDITION] requiring 12 sutures. R62 sustained harm from the 8/30/17 fall. For R33, the beauty shop failed to be free of accident hazards. Findings include: 2/18/15 - The facility's Falls Management Program stated: Any occurrence of falls along with the interventions will be documented in the nursing notes. Any fall that involves a potential actual head injury will include follow up neurological checks .will be documented on The Neurological Assessment Flow Sheet. When a resident sustains a fall, the assessment process will include an investigation using the Fall Investigation Analysis Sheet. Ongoing monitoring and continuous quality improvement is achieved through the At Risk Team that meets weekly to review new admissions identified as being at risk, residents having falls and residents on a fall prevention program. Individualized care plan developed includes measurable objectives and time frames. Care plan for a resident assessed as at risk for falls will be developed at the time the risk is identified with ongoing evaluation and revisions documented. Care plan updated at the time the incident occurs includes the date of the new intervention and with measurable objectives and timeframes. Interventions will address those elements determined by the investigation as probable causal factors that contributed to the fall. Updates, reviews and revisions as indicated by the At Risk Team at the weekly meeting. 1. Review of R62's clinical record revealed the following: 6/16/16 - R62 was admitted to the facility with [DIAGNOSES REDACTED]. 6/22/17 - R62 was care planned for a history of falls with no major injury. The interventions included: monitor the resident every shift; anticipate resident's ADL needs; orient the resident to ask for assistance when transferring; ambulate with walker and one staff assist; toilet when resident attempts to get up out of chair or bed; hourly hospitality checks; frequent toileting; team approach to monitoring the resident; ensure wheels are locked in wheelchair at all times; monitor for increase agitation/restlessness that may be an indicator for the resident needing to be toileted; and orient the resident with the rollator when ambulating. 6/16/17 - Annual MDS assessment revealed that R62 was moderately cognitively impaired and was a limited assist with support of 1 person for ambulation person. R62 had 1 fall without injury. 6/28/17 - Approach of monitor resident closely and assist resident to walk with a rollator was added to the care plan. 7/21/17 at 9:59 AM - ID Note - The At Risk Team met and discussed R62's 7/20/17 fall with no injuries. The root cause determined to be unsteady gait and loss of balance. The only new intervention was to continue to encourage resident to use walker. 8/1/17 at 4:40 AM - Incident Report - Description - Resident fell while trying to walk unsupervised. R62 was trying to hit staff fell and hit the back of his head. Neurological Assessment Flow Sheet and Fall Investigation Analysis Sheet not provided with the Incident report. 8/1/17 at 6:03 AM - ID Note - R62 was sitting on the floor from a fall. A head to toe assessment was done and two hematomas were noted on the back of head. E40 (RN) called the physician. An order was given to send R62 out to be evaluated at the hospital. Neuro checks were initiated per the note. Neurological Assessment Flow Sheet was not available from the facility. 8/1/17 at 7:16 AM - ID Note - R62 fell in the TV room trying to sit in the recliner (referring to the 4:40 AM fall). 8/1/17 - Hospital record - R62 with a history of recurrent falls presented to ED as an unwitnessed fall. A CT of the head, spine, chest and abdomen as well as x-rays of elbow and knee were done. Results indicate a hematoma to the back of the head without internal bleed. Wounds noted were: abrasion to the back of the head; a left lower leg skin tear; left elbow skin tear; and abrasion to nose. The fall investigation follow up notes state: R62 was attempting to ambulate without assist, fell and hit his head. He was sent to the ED. The investigation packet provided did not include interviews, Neurological Assessment Flow Sheet, the assessment process, or a Fall Investigation Analysis Sheet. The facility failed to identify conflicting information that was in the reports concerning the specifics of R62's fall. One note indicated the resident fell trying to hit staff and one note indicated he fell trying to sit in a recliner. The facility failed to monitor resident closely and assist resident to walk with a rollator. 8/3/17 at 6:50 PM - ID Note - Indicated that R62 was readmitted to the facility from hospital and placed on one to one supervision to prevent falls. 8/4/17 at 1:26 PM - ID Note - Per directive from E2 (DON) E37 (LPN) discontinued R62's one to one supervision stating resolved and family notified. The reason for discontinue was not documented in the note. 8/8/17 - Psych Nurse Practitioner increased Trazadone from 75 mg to 100 mg daily at bed time for [MEDICAL CONDITION]. Trazadone is an antidepressant used for its sedating effects to help with sleep. 8/10/17 at 10:12 AM - ID Note - R62 was reviewed by the At Risk Team status [REDACTED]. A root cause was not determined based on the note or the investigation packet provided by the facility. Medications were reviewed at this team meeting and it was agreed that R62 was taking appropriate medications for R62's diagnosis. R62 is care planned for both pharmacological and non-pharmacological pain relief methods. The note mentions care plan interventions for repositioning frequently, pressure relieving mattress, moisturizing lotion twice daily and as needed. The Risk Team agreed that all care plans are appropriate. There was no evidence that any new interventions were considered. 8/12/17 at 5:25 PM - Incident Report - R62 fell and caught by the nurse who lowered R62 to a chair without injury. 8/12/17 at 5:59 PM - Incident Report - A second fall - Resident walking with CNA and fell hit his forehead on hand rail. R62 sustained a skin tear (2 cm x 1.0 cm) to the elbow. The investigation packet provided did not include interviews, Neurological Assessment Flow Sheet, the assessment process, or a Fall Investigation Analysis Sheet for either of the falls on 8/12/17. The facility did have an Interview Statement Form for Investigative Purposes Falls completed for an 8/12/17 fall at 7:15 PM. R62 and E42 were walking. R62 fell and hit his forehead on the side rail. R62 sustained a skin tear to left elbow. E42 statement revealed R62 was toileted at 5:30 PM and ate at 7:00 PM. E6 (LPN) statement revealed that R62 was walking with E42 and fell to the floor hitting his forehead on the hallway railing. R62 sustained a skin tear to the elbow. While the incident report documented a fall at 5:59 PM on 8/12/17 noting that R62 hit his forehead and suffered a skin tear, the CNA interview documents a fall at 7:15 PM on 8/12/17 with the same outcomes. 8/14/17 at 5:45 AM - Incident Report - R62 fell over his walker, onto the floor, after pulling the TV off of the TV stand. E41 (LPN) could get to him to prevent the fall. E62 suffered a pinky skin tear. The investigation packet provided did not include interviews, Neurological Assessment Flow Sheet, the assessment process, or a Fall Investigation Analysis Sheet for the fall on 8/14/17. The facility failed to follow the care plan approach to monitor the resident closely. 8/23/17 at 11:25 PM - Incident Report - Resident found lying on his back on the floor in front of his wheelchair in the TV room with an abrasion on his right elbow and skin tear on his right middle finger. There are three Interview Statements Form for Investigative Purposes each stating he was found on the floor in the TV room. The CNA took him to the bathroom at 11:10 PM and returned R62 to the TV room in his wheel chair placing him in front of the TV. The fall was unwitnessed and R62 was care planned to be closely monitored. 8/24/17 at 1:46 AM - ID Note for fall on 8/23/17 at 11:25 PM - R62 found on the floor on his back. Injuries included a right elbow abrasion (1.5 cm x 1.5 cm) and a right middle finger skin tear (1.5 cm x 0.5 cm). 8/24/17 at 3:53 AM - ID Note - for a fall on 8/23/17 at 11:25 PM - R62 found on floor in TV room during change of shift. He was laying on his back in front of his wheel chair. R62 sustained an abrasion (1.5 cm x 1.5 cm) and a skin tear (1.5 cm x 0.5 cm) to the right middle finger. Doctor notified. 8/24/17 - Care Plan updated to include one new approach to place resident within arm's length. 8/30/17 at 5:10 AM - ID Note - R62 was monitored all night until about 5:10 AM. R62 was found on the floor while the aide was on her way from the bathroom. R62 was found in a pool of his blood from a laceration sustained on the head. 911 was called and R62 was taken to the hospital 8/30/17 - R62 was emergently transferred to the ED and admitted to the hospital for evaluation. 8/30/17 - According to hospital record R62 with history of recurrent falls presented to ED having an unwitnessed fall in the morning. It was reported that he was found face down at the nursing home with a lot of bleeding from a cut to the fore head that requires sutures, small cut to the nose and left ring finger. The facility failed to supervise R62 at an arm's length. Furthermore, R62 was emergently transferred to the hospital and did suffer injuries requiring sutures. 8/31/17 - At Risk Team Meeting to discuss falls, behavioral symptoms and R62's post fall status. R62 is currently in the hospital. R62 has a history of falls (6 this month) and 2 of the six have resulted in an injury requiring hospitalization . According to current notes from the hospital, the occurrences are more of a recurrent problem for him secondary to ambulatory dysfunction and inability for him to be rehabilitated due to his severe dementia and behavioral issues. 9/2/17 - R62 was discharged from the hospital and returned to the facility with [DIAGNOSES REDACTED]. 2/8/18 at 9:06 AM - Interview with E2 (DON) - Surveyor provided a list of fall dates and requested investigations for R62's (MONTH) falls. 2/9/18 at 11:20 AM - Requested fall investigations for R62's (MONTH) falls from E2. 2/12/18 at 8:45 AM - Interview with E2. Requested R62's fall investigation documentation. 2/12/18 12:10 PM - Interview with E4 (RNAC) and E1 (NHA). Requested care plans with interventions, investigation notes, MAR and TAR and any additional documentation on how R62's falls were being addressed. 2/13/18, at approximately 4:00 PM, neither E1 nor E2 had provided more information on the prevention of R62's falls. R62 sustained 6 falls in (MONTH) (YEAR). There is no evidence prior to 8/24/17 that the facility implemented new interventions after the falls. When the 8/24/17 approach for place resident at arm's length was developed, the facility failed to implement this intervention. The resident fell again and sustained injuries. The facility failed to provide adequate supervision to prevent falls and injuries resulting in a hematoma on 8/1/17 and laceration with 12 sutures on 8/30/17. 2. A random observation, on 2/7/18 at 10:50 AM, R33 was observed in the beauty shop, sitting in the chair with the nasal cannula and oxygen being administered at 2 liters via portable oxygen tank. E23 (subcontracted beautician) was observed drying R33's hair using a hand held hair dryer at a distance of less than 12 inches from R33's nasal cannula. At 10:51 AM, surveyor immediately requested termination of the use of the dryer and interviewed E23 , who related that she was not aware that this was an accident hazard. At 10:55 AM, interview with E1 (NHA) revealed that the facility had no policy to address the acceptable distance from the heat source and the nasal cannula. E1 verbalized that he would develop the policy immediately. At 1:00 PM, the facility provided a copy of such policy indicating the heat source must be at least 12 inches away from the nasal cannula. Findings reviewed with E1, E2, E20 (ED), and E32 (RCN) on 2/12/18 at approximately 4:00 PM.

Based on observation, record review, interview and review of product information, it was determined that the facility failed to ensure residents were free from significant medication errors for two (R361 and R313) out of 34 sampled residents. For R361, the facility failed to administer Humalog and [MEDICATION NAME] on the evening of admission. The resident experienced elevated blood sugars and was admitted back to the hospital with DKA. For R313, the facility failed to adhere to the product information for [MEDICATION NAME], thus, failed to administer the insulin within the acceptable timeframe. Findings include: The facility's Back-up Pharmacy Policy effective 5/2/16 documents: Upon receipt of medication order from Westminster Village Dover and a determination made that there is an emergent need for a timely delivery of this medication for administration to a patient, either by electronic message through IMAR or a phone call from the facility, The (name of pharmacy) will transfer the order to a local pharmacy and deliver . 1. Cross refer F684, example #2. The following was reviewed in R361's record: R361 was admitted to the facility on [DATE] at 5:30 PM with [DIAGNOSES REDACTED]. The following was reviewed in R361's clinical record: 10/31/17 6:53 PM - ID note - Resident admitted from (hospital name) at 5:30 PM alert and oriented x2 with periods of confusion. Review of body system done and medications verified with the primary care physician. 10/31/17 - admission orders [REDACTED]. 10/31/17 - MAR documented the [MEDICATION NAME] was not administered pending pharmacy delivery. The Humalog insulin was not on the (MONTH) MAR to administer with dinner even though the resident arrived at dinner time. It was transcribed to start on 11/1/17 with breakfast. Review of the Omnicell and E-kit (stock medications) content lists revealed the [MEDICATION NAME] was available on the unit. Review of MAR and POS lacked evidence that a FSBS was done on 10/31/17 (dinner and bedtime, indicated on MAR with ordered insulin) after admission to the facility. The MAR listed the [MEDICATION NAME] to be administered at 9:00 PM but documented it was not administered because it had not arrived from the pharmacy. 11/1/17 - MAR documented the FSBS at breakfast - 489, lunch - 435, dinner 489 and bedtime 491. There was no evidence that the elevated BS was addressed or that the MD was contacted. 11/2/17 3:01 AM - ID note documented vital signs WNL. 11/2/17 10:08 AM - ID note documented: This nurse informed by the CN that the residents blood glucose check is reading high with [MEDICATION NAME] went to assess resident, resident diaphoretic with chills bedding soaked from sweat, he had received 10 units of insulin rechecked blood glucose level still reading high with [MEDICATION NAME] . 11/2/17 10:16 AM - ID note documented: Upon assessing this patient he appeared to be clammy and had vomited. Pt. finger stick read Hi [MEDICATION NAME] on the glucometer, pt was given 10 units of Humalog as ordered. This did not lower his glucose after being checked again .E9 (MD) was then called and ordered to send the pt. to (hospital name) . 11/2/17 11:17 AM - ID note documented; Received call from (lab name) at around 10 AM in the process of getting ready to send resident to the hospital that the glucose (from morning lab work) was 700 . 11/2/17 - Review of hospital records revealed the resident had [DIAGNOSES REDACTED]. 2/08/18 2:27 PM - Interview with E36 (LPN) revealed that the list of medications available on the unit were on the side of the medication storage unit, the list included a bottle of [MEDICATION NAME]. E36 stated that at all nurses have access to these medications. 2/08/18 2:51 PM - Interview with E2 (DON) revealed that she did not remember this resident and would have to review the chart. 2/09/18 09:56 AM - Interview with E5 (RN) and E4 (RNAC) revealed that nurses should get medications from the Omnicell when they have not been delivered from the pharmacy. It was also revealed that if a FSBS is >400 the MD should be consulted and the doctor usually has a sliding scale insulin order on the residents record. 2/09/18 10:38 AM - Interview with E7 (LPN) stated on 11/2/17 the lab had been in around 7:30 AM to draw R361's blood and it would have been around 8:30 - 9:00 AM when she got to the resident to do the morning BS and insulin. E7 revealed that the documentation of a 0 for FSBS was an error on 11/2/17 it was actually reading Hi. She added the resident was diaphoretic and clammy when she was doing her morning rounds. The doctor was called and the resident was to go to the ED. Around the same time the lab called with a critically high BS reading of 700. When asked at what FSBS would she contact the MD, E7 stated it depends on their individual scale but round 380 to 400. E7 was asked to check the MAR for a scale and it was revealed that there was no scale for the resident 10/31 - 11/2/17. 2/09/18 11:34 AM - Interview with E9 revealed that he did not remember this resident but generally he would expect a call for FSBS >400 and <60 and if the reading is 400 - 450 a change in insulin may be made with a reassessment the next day. When asked about the [MEDICATION NAME] not being administered E9 stated that he should have been consulted, usually the facility calls him. 2/09/18 12:08 PM - Interview with E6 (LPN) revealed she remembers R361 being up, talking and oriented on 11/1/17 into 11/2/17 because she worked 3 - 11 PM and stayed over into the next shift. The note she wrote at 3:00 AM was just vital signs and no FSBS was done. 2/09/18 4:21 PM - Interview with E1 (NHA), E2, E20 (Executive Director), and E32 (Corporate nurse) revealed that the facility had no formal [MEDICAL CONDITION] protocol or policy. It was revealed that the physician's usually write their own parameters for insulin and contacting the physician for high and low BS. The above findings were reviewed and no further information was provided. The facility offered no further information on the concerns expressed on 2/11/18 prior to exit. The facility failed to administer ordered insulin upon admission to the facility and failed to identify elevated BS requiring reassessment and physician consultation. This resulted in R361 being admitted to the hospital with [REDACTED]. 2. During medication observation on 2/8/18 at 4:11 PM, E7 (LPN) administered Novlog insulin, 5 units for a fingerstick blood sugar reading of 321 to R313. An interview with E7 immediately after the observation revealed that the dinner delivery to the unit was scheduled for 5:30 PM, approximately one hour and fifteen minutes later. At approximately 4:15 PM, surveyor interviewed E17 ( RN Supervisor), who verbalized that [MEDICATION NAME]can be administered up to 30 minutes prior to the meal. During this interview, the surveyor requested for the facility to provide the information. Upon retrieving the [MEDICATION NAME] product information, it was revealed that the insulin should be administered no more than 5 to 10 minutes before the meal. E17 immediately notified E7 of this information and E7 offered and R313 consumed half of a tuna sandwich. At 5:35 PM, the meal cart arrived in the unit and at 5:38 PM, R313 was provided her dinner. Findings reviewed with E1 (NHA), E2 (DON), E3, E4, E20 (ED), and E32 (RCN), on 2/12/18 at approximately 4:00 PM.

Based on observation, record reviews, interviews and review of facility and other documentation, it was determined that for 3 (R55, R361, and R50) out of 34 sampled residents, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans, resulting in harm for 2 (R55, R361) out of 3 residents. For R55, the facility failed to asses and monitor the blood sugar, for approximately 27 days, as she received insulin daily. This resulted in R55's emergent transfer and admission to the hospital for [DIAGNOSES REDACTED]. For R361, the facility failed to ensure the administration of insulin as ordered, the monitoring of FSBS, medical consultation of elevated BS resulting in two hospitalization s for DKA. For R50, after ordering a new diuretic the facility failed to follow-up with the attending physician to obtain an order for [REDACTED]. Findings include: 1. The manufacturer's prescribing information for [MEDICATION NAME] insulin, last revised on 3/2015, stated, [MEDICATION NAME] is a long-acting .insulin .Once daily administration should be given with the evening meal or at bedtime .WARNINGS AND PRECAUTIONS .Monitor blood glucose in all patients treated with insulin .[DIAGNOSES REDACTED] is the most common adverse reaction of insulin therapy and may be life-threatening .Blood glucose monitoring is essential in all patients receiving insulin therapy .Severe [DIAGNOSES REDACTED] can lead to unconsciousness .and may result in temporary or permanent impairment of brain function or death The timing of [DIAGNOSES REDACTED] usually reflects the time-action profile of the administered insulin formulations. Other factors such as changes in food intake (e.g. amount of food or timing of meals), exercise, and concomitant medications may also alter the risk of [DIAGNOSES REDACTED] .As with all insulins, use caution in patients with [DIAGNOSES REDACTED] unawareness and in patients who may be predisposed to [DIAGNOSES REDACTED] ( .patients who fast or have erratic food intake) .DRUG INTERACTIONS .A number of medications affect glucose metabolism and may require insulin dose adjustment and particularly close monitoring. The following are examples of medications that may increase the blood glucose-lowering effect of insulins including [MEDICATION NAME] and, therefore, increase the susceptibility to [DIAGNOSES REDACTED]: oral antidiabetic medications .After subcutaneous injection of [MEDICATION NAME] in .patients with diabetes, insulin .concentrations had a relatively constant concentration/time profile over 24 hours with the maximum .concentration .reached between 6-8 hours post(after)-dose . Review of R55's clinical record revealed the following: 12/7/17 - R55 was admitted to the facility for short-term rehabilitation with [DIAGNOSES REDACTED]. 12/9/17 - R55 was care planned for Diabetes which stated, needs monitored for hyper/hypo-glycemic reactions. R55's care plan goal stated, will maintain accu-check and FBS of 60-300 unless otherwise ordered by MD x 90 days. The care plan interventions included, but not limited to: Medications as ordered; monitor for s/s of [DIAGNOSES REDACTED] .; .Monitor blood glucose levels thru capillary checks per MD order- See POS for monitoring frequency, rotate draw site. Notify MD if beyond ordered parameters; Monitor labs as ordered .Report abnormal results to MD for follow up orders; Monitor and record daily meal intakes. Report changes in appetite, notify MD as indicated; Offer HS nourishment per recommendations of RD/LDN or MD. Record intakes and note inconsistencies in intake and acceptance. 12/12/17 - Review of the POS included the following ordered medications for R55's [DIAGNOSES REDACTED].>- [MEDICATION NAME]- inject 36 units subcutaneously at bedtime (8:01 PM); - [MEDICATION NAME] 10 mg tablet - take 1 tablet orally BID (9:01 AM and 5:01 PM); and - [MEDICATION NAME] 1,000 mg tablet - take 1 tablet orally BID with meals (9:01 AM and 5:01 PM). Further review of R55's POS revealed the absence of a physician's orders [REDACTED]. 12/14/17 - R55's BMP and HgbA1C lab results, which were drawn at 6:53 AM, revealed: - fasting Glucose was low at 66 - normal range 70 to 140; - HgbA1C was high at 7.1 - normal range 4.0 to 6.0. 12/14/17 at 8:40 PM - A nurse's note stated that she called E35 (on call physician for E8, physician) with R55's lab results and was told to fax the lab results to E8's office. 12/14/17 at 9:08 PM - A faxed transmission verification report revealed that the labs were faxed to E8. There was no evidence in R55's clinical record as to the physician follow-up response to her abnormal labs. 12/29/17 - The pharmacist's monthly medication review of R55's clinical record failed to identify that accuchecks were not being performed on a diabetic resident who received insulin daily. 1/1/18 to 1/3/18 - Review of R55's meal intakes revealed the following: - 1/1/18 - 100% meal intakes for breakfast, lunch and dinner; - 1/2/18 - no recorded meal intakes for breakfast and lunch. 50% meal intake for dinner; and - 1/3/18 - no recorded meal intakes for breakfast and lunch. 100% meal intake for dinner. Review of R55's clinical record lacked evidence of snack consumption from 1/1/18 through 1/4/18. 1/4/18 at 7:47 AM - A nurse's note stated, Resident found unresponsive approx. 5:50 AM, breathing normally, foamy sputum around the mouth, skin pale and clammy, no response to verbal/painful stimuli Vital Signs> 96.3 (temperature), 140/77 (blood pressure), 118 (heart rate), 96% (pulse ox) on room air. resident noted FULL code and diabetic. blood sugar reading 26. [MEDICATION NAME] injection administered at 6:05 AM and 911 services activated .(fasting blood sugar) at 5 min post [MEDICATION NAME] 31, and 71 (at) 10 min post (after) [MEDICATION NAME]. EMS arrived at this time . 1/4/18 - R55 was emergently transferred via 911 and admitted to the hospital. 1/5/18 at 8:52 PM - The hospital record stated, .presented to the ED with [DIAGNOSES REDACTED] .EMS documented BS 26 .subsequently patient received [MEDICATION NAME] IM and her FS improved then dropped again and she had to be placed on D5 (intravenous solution). Reviewing her medication we noticed that patient is on long acting insulin [MEDICATION NAME] (36 units) .[MEDICATION NAME] (10 mg) BID and [MEDICATION NAME] .Continue [MEDICATION NAME] 1,000 bid, [MEDICATION NAME] 10 units, and hold [MEDICATION NAME] . 2/7/18 at 1:52 PM - During an interview, E17 (RN Supervisor) confirmed that R55's blood sugar should have been checked as she was on 36 units of insulin daily. 2/9/18 at 10:12 AM - During an interview, E8 (physician) confirmed that accuchecks were not ordered from R55's admission date of [DATE] until she was readmitted from the hospital on [DATE] status [REDACTED]. 2/12/18 at 4 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON). The facility failed to monitor R55's blood sugar as she received insulin daily, which resulted in R55's emergent transfer and admission to the hospital for [DIAGNOSES REDACTED]. 2. The American Diabetes Associations Standard of Medical Care in Diabetes - (YEAR) states that medical providers in long term care facilities should be called as soon as possible if a resident's glucose values greater are than 250 mg/dL within a 24 hour period (Source: Diabetes Care (YEAR) Jan; 41 Supplement 1: S119-S125.) Cross refer F760, example #1. The following was reviewed in R361's clinical record: R361 was admitted to the facility on [DATE] at 5:30 PM with [DIAGNOSES REDACTED]. 10/31/17 6:53 PM - ID note - Resident admitted from (hospital name) at 5:30 PM alert and oriented x2 with periods of confusion. Review of body system done and medications verified with the primary care physician. 10/31/17 - admission orders [REDACTED] Humalog insulin at meal times; 10u at breakfast, 16u at lunch and 18u at dinner For DM; [MEDICATION NAME] 52u at bedtime for DM; Carvedilol 12.5 mg AM and evening for heart failure;[MEDICATION NAME] in morning for infection; [MEDICATION NAME] 25 mg take 2 morning and evening for anti rejection/kidney transplant; [MEDICATION NAME] 80 mg morning and evening for heart failure; Potassium 20 meq take two morning and evening for low potassium. There was no order for the frequency of FSBS, any parameters for blood sugar readings and no sliding scale insulin orders to cover elevated blood sugars. 10/31/17 - MAR documented the following medications were not administered pending pharmacy delivery; [MEDICATION NAME], Carvedilol, [MEDICATION NAME], Cipro, [MEDICATION NAME], and Potassium. The Humalog was not on the (MONTH) MAR to administer with dinner even though the resident arrived at dinner time. Review of the Omnicell and E-kit (stock medications) content lists revealed the [MEDICATION NAME], Carvedilol, Cipro, and Potassium were all available on the unit. Review of MAR and POS lacked evidence that a FSBS was done on 10/31/17 (dinner and bedtime, as indicated on MAR with ordered insulin) after admission to the facility. The MAR listed the [MEDICATION NAME] to be administered at 9:00 PM but documented it was not administered because it had not arrived from the pharmacy. 11/1/17 - MAR documented the FSBS at breakfast - 489, lunch - 435, dinner 489 and bedtime 491. There was no evidence that the elevated BS was addressed or that the MD was contacted. 11/2/17 3:01 AM - ID note documented vital signs WNL. 11/2/17 10:08 AM - ID note documented: This nurse informed by the CN that the resident's blood glucose check is reading high with [MEDICATION NAME] went to assess resident, resident diaphoretic with chills bedding soaked from sweat, he had received 10 units of insulin rechecked blood glucose level still reading high with [MEDICATION NAME] . 11/2/17 10:16 AM - ID note documented: Upon assessing this patient he appeared to be clammy and had vomited. Patient (pt). finger stick read Hi [MEDICATION NAME] on the glucometer, pt was given 10 units of Humalog as ordered. This did not lower his glucose after being checked again .E9 (MD) was then called and ordered to send the pt. to (hospital name) . 11/2/17 11:17 AM - ID note documented; Received call from (lab name) at around 10 AM in the process of getting ready to send resident to the hospital that the glucose (from morning laboratory work) was 700 . At the time of re-admission to the hospital the facility had not obtained the [MEDICATION NAME]. R361 missed 4 doses. 11/13/17 2:35 PM - Resident readmitted to facility from hospital. Admitting [DIAGNOSES REDACTED]. Re-admission orders [REDACTED]. No FSBS schedule or parameters were ordered. There were no hypo or [MEDICAL CONDITION] parameters ordered. 11/13/17 dinner BS 346 11/14/17 breakfast BS 305 11/14/17 lunch BS 297 11/14/17 dinner BS 470; no physician consult noted. 11/14/17 bedtime BS Hi 11/14/17 10:05 PM - ID note resident blood sugar reading high on the glucometer, E9 was called and notified about the high blood sugar. An order was given Humalog 10u x 1 dose and to give Humalog 5 u after lunch (sic, should have been breakfast), Humalog 10 units after lunch and Humalog 10 units after dinner. Resident had no symptoms. Continue to monitor. Although the EMR noted a physician order [REDACTED]. 11/15/17 MAR stated 8:01 AM BS 431 order for 10 units at breakfast, inject 16 units (unclear why this was at end of order without a designated time). The nurse documented giving 10 u. No evidence MD was contacted about elevated BS. There was no evidence the additional 5u were administered after breakfast as referenced 11/14/17 at 10:05 PM. 11/15/17 10:21 AM - ID note stated that resident at MD appointment. 11/15/17 11:35 AM - ID note office called and informed nurse that resident who had an appointment in the office this AM was being sent to (hospital name) ER per cardiologist reading elevated FSBS in the 400's and abnormal EKG . 8:32 PM ID note pt returned from (name of hospital) to facility at approx. 6:00 PM with [DIAGNOSES REDACTED]. Writer called and verified Humalog orders with E9. The facility sent the resident to an appointment with an elevated BS without consulting the primary physician. 11/15/17 Sliding Scale Humalog insulin orders: 120-150 2 u 151-200 4 u 201-250 6 u 251-300 8 u 301-350 10 u 350-400 12 u > 400 14 u and call MD 11/15/17 9:01 PM - MAR documents FSBS 494 and MD ordered a one time order of [MEDICATION NAME] 20 u, the [MEDICATION NAME] 45 u was discontinued by the MD. It was unclear why the [MEDICATION NAME] was discontinued. 11/16/17 3:37 AM - ID note Resident FSBS noted with a reading of High x2. Previous check at HS 494 and had received one time dose 20 u of [MEDICATION NAME] per MD. MD notified of current high reading and given orders to send resident to ER for further evaluation EMR arrived 0335 (3:35 AM). 11/16/17 8:53 AM - ID note - .admitted with DKA. 11/20/17 7:31 PM - ID note pt admitted to facility at 2:35 PM from (hospital name) .all meds verified with E9. 11/21/17 11:28 PM - ID note the patient received new insulin orders per endocrinology specialist dated 11/21/17 .this included to call the specialist if BS >450. 11/27/17 2:59 AM - ID note at 12 AM this CN was notified by the RN supervisor that the patient was found on the floor. The CN arrived to the patient's room and found the patient on the floor .the patient stated I want to go to the bathroom to shower. There was no mention of the BS in this note. 11/27/17 8:45 AM - ID note the patient had two episodes of vomiting this shift, and continues to have signs and symptoms of [MEDICAL CONDITION] with increasing blood sugars throughout the shift @ 12:00 AM BS 499, @ 2:00 AM BS 474, @ 4:00 AM BS 434, @ 6:00 AM BS HI [MEDICATION NAME]. MD called and gave new orders to send the patient to ED for further evaluation. 11/27/17 8:45 AM - ID note resident transported via stretcher to (hospital name) at 8:45 AM per E9. It was not clear why there was a gap between a high BS with [MEDICATION NAME] at 6:00 AM and transport to the hospital at 8:45 AM 11/28/17 9:27 AM - ID note .resident admitted to ICU with DKA. 2/08/18 2:27 PM - Interview with E36 (LPN) revealed that the list of medications available on the unit were on the side of the medication storage unit, the list included a bottle of [MEDICATION NAME]. E36 stated that at all nurses have access to these medications. 2/08/18 2:51 PM - Interview with E2 (DON) revealed that she did not remember this resident and would have to review the chart. 2/09/18 09:56 AM - Interview with E5 (RN) and E4 (RNAC) revealed that nurses should get medications from the Omnicell when they have not been delivered from the pharmacy. It was also revealed that if a FSBS is >400 the MD should be consulted and the doctor usually has a sliding scale insulin order on the residents record. 2/09/18 10:38 AM - Interview with E7 (LPN) stated on 11/2/17 the lab had been in around 7:30 AM to draw R361's blood and it would have been around 8:30 - 9:00 AM when she got to the resident to do the morning BS and insulin. She stated that the resident was diaphoretic and clammy when she was doing her morning rounds. The doctor was called and the resident was to go to the ED. Around the same time the lab called with a critically high BS reading of 700. When asked at what FSBS would s/he contact the MD, E7 stated it depends on their individual scale but round 380 to 400. E7 was asked to check the MAR for a scale and it was revealed that there was no scale for the resident 10/31 - 11/2/17. 2/09/18 11:34 AM - Interview with E9 (MD) revealed that she did not remember this resident but generally he would expect a call for FSBS >400 and <60 and if the reading is 400 - 450 a change in insulin may be made with a reassessment the next day. When asked about the [MEDICATION NAME] not being administered E9 stated that he should have been consulted, usually the facility calls him. 2/09/18 12:08 PM - Interview with E6 (LPN) revealed she remembers R361 being up, talking and oriented on 11/1/17 into 11/2/17 because she worked 3 - 11 PM and stayed over into the next shift. The note she wrote at 3:00 AM was just vital signs and no FSBS was done. On 11/27/17 an SBAR was written for the fall. E6 added that the resident's wife told her that the resident fell a lot around that same time at night because he did not like to be wet after an incontinence episode and would try to go get cleaned up. After review of the ID note of FSBS readings, E6 stated that she would have called the supervisor and there should have been follow-up with the MD. The sliding scale from the endocrinologist was reviewed but is was unclear if she knew it was part of his treatment record. 2/09/18 3:00 PM - Interview with E3 (ADON) about 11/14/17 order associated with 10 PM ID note confirmed that it was confusing and that the order was on the POS but not on the MAR. 2/09/18 4:21 PM - Interview with E1 (NHA), E2, E20 (Executive Director), and E32 (Corporate nurse) revealed that the facility had no formal [MEDICAL CONDITION] protocol or policy. It was revealed that the physicians usually write their own parameters for insulin and contacting the physician for high and low BS. The above findings were reviewed and no further information was provided. The facility offered no further information on the concerns expressed on 2/11/18 prior to exit. The facility failed to ensure R361 received ordered insulin on the day of admission and failed to intervene when FSBS were over 400. This resulted in hospitalization on [DATE] for DKA. The facility continued to fail to identify and intervene for FSBS over 400 resulting in an ED visit on 11/15/17 for [MEDICAL CONDITION] and a hospitalization on [DATE] again for DKA. 3. Review of R50's clinical records revealed: 1/9/18 - admitted to the facility from the hospital following treatment for [REDACTED]. 1/9/18 - An admission order included a medication to treat high blood pressure and to hold the medication if systolic BP was less than 100 or heart rate was less than 50. 1/10/18 through 1/31/18 - Medication Administration Record (MAR) documented, the medication was administered daily, as ordered and did not require the medication to be held due to his SBP was greater than 100 or heart rate was 50 or less. 1/11/18 - Laboratory blood test results revealed, R50's potassium level was 4.0, within the normal range of 3.5-5.1. 1/17/18 - A physician's orders [REDACTED]. daily for swelling of bilateral lower extremities. 1/18/18 and timed 12:48 PM - IDT Note by E5 (LPN), will follow-up with MD to get new labs BMP. Record review lacked evidence of a follow-up for an order for [REDACTED]. While using this medicine, you may need frequent blood tests.https://www.drugs.com/[MEDICATION NAME].html). 1/31/18 - MAR documented that the medication was held due to BP of 99/59. Record review lacked evidence, that the facility staff recognized the change in condition, as evidenced by [MEDICAL CONDITION] of BP of 99/59. In addition, failed to identify the need to conduct a comprehensive clinical assessment and failed to identify the need for a repeat BP. (Normal blood pressure in adults is lower than 120/80 mmHg. [MEDICAL CONDITION] is blood pressure that's lower than 90/60 . https://www.nhlbi.nih.gov.). 2/1/18 at approximately 10:05 AM - Surveyor was present when E5 (LPN) entered room to obtain R50's BP utilizing a wrist BP machine. R50 was sitting up in bed when reading of 90/45 was obtained and E5 asked, How are you feeling? and R50 replied that he was feeling dizzy. 2/1/18 - MAR documented that the medication was held due to BP of 90/45. Again, record review lack evidence that the facility recognized that BP of 90/45 was [MEDICAL CONDITION], failed to identify the need to conduct a comprehensive clinical assessment, and failed to identify the need to obtain a repeat BP. 2/2/18 and timed 5:40 AM -IDT Note by E10 (RN Supervisor) documented R50 requested to be seen by E9. R50 states that he feels like he was getting weaker. 2/2/18 and timed 6:17 AM - A fax documentation, completed by E10, faxed to E9's office, stated that that R50 stated he is getting weaker, not eating or drinking much and he states he can hardly move his arms. 2/2/18 at 9:11 AM - MAR documented further descending BP of that the medication was held due to BP of 88/46 by E5. Despite the fact R50 had three days of descending BP, increasing weakness, record review lacked evidence that the facility recognized and identified this as a significant change in condition, including the fact that the weakness may be related to low potassium). (Mild [DIAGNOSES REDACTED] (serum potassium 3 to 3.5 mEq/L) rarely causes symptoms. Serum potassium < 3 mEq/L generally causes muscle weakness and may lead to paralysis and [MEDICAL CONDITION]. http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/[DIAGNOSES REDACTED]) 2/5/18 at approximately 10:00 AM - Surveyor interviewed E17 (RN Supervisor) who reportedly contacted E9's office earlier on 2/5/18. Surveyor inquired what information was communicated to E9 and E17 verbalized that she read E10's IDT Note timed 5:40 AM. E17 verbalized that she did not review the fax documentation in which R50 verbalized that he could barely lift up his arms due to weakness. E17 proceeded to communicate this information to E9's shortly after this interview and obtained an order for [REDACTED]. 2/6/18 - BMP indicated potassium low at 2.9. 2/6/18 and timed 8:15 PM - Potassium supplement 40 meq. by mouth one dose and 10 meq. daily, repeat BMP in one week. 2/7/18 at approximately 3:00 PM - An interview was conducted with E5. Surveyor inquired when she had to hold the medication to treat high blood pressure due to R50's low BP, whether E5 had taken a repeat on 2/1/18 and/or 2/2/18. E5 verbalized she thought she did but did not recall the reading or where this would have been documented. In addition, confirmed no repeat BP was documented in the MAR or in the IDT notes for these dates. 2/9/18 at approximately 2:45 PM - An interview with the facility's Medical Director, E8 was conducted. E8 related, upon reviewing R50's initial History and Physical dated 1/10/18, E8 verbalized that BMP should have been ordered to be completed 1-2 weeks after starting of the [MEDICATION NAME] on 1/17/18. E8 related when a resident's BP was low compared to the resident's baseline, the facility must complete a repeat BP. If the BP remains low or [MEDICAL CONDITION], the staff must conduct a complete comprehensive clinical assessment and report this to the attending physician. Additionally, E8 confirmed when R50 was complaining about weakness, a possible symptom of [DIAGNOSES REDACTED], the facility staff should have recognized the need to conduct a comprehensive clinical assessment and report accurate and complete information to E9. Findings reviewed with E1 (NHA), E2 (DON), E20 (ED) and E32 (RCN) on 2/12/18 at approximately 4:00 PM.

Based on record review, observation and interview it was determined that the facility failed to ensure that, for one (R29) out of 30 sampled residents, appropriate treatment and services were performed to prevent further decrease in range of motion. The facility failed to: measure bilateral joint function routinely; consistently implement a left elbow splint; and consistently perform ROM. This resulted in the inability to ascertain specific contracture measurements along with a reduction in the length of time the resident could maintain the left elbow at 90 degrees. Findings include: Review of R29's clinical record revealed: 5/5/14 Admission nursing note - [DIAGNOSES REDACTED]. May, 2014 - R29's Therapy documentation revealed the resident was seen by OT for left elbow contracture management which improved the straightening of the resident elbow from (minus) -55 degrees (elbow was most of the way bent with the hand near the shoulder) to (minus) -25 degrees (elbow able to straighten a little, but still not able to reach a 90 degree angle). There was no evidence in the record that any of the resident's joints (i.e., hips, knees, shoulders) were measured by therapy. 8/7/14 Physicians' order - Passive range of motion (PROM) to left upper and left lower extremities for 15 minutes twice daily. There was no order for the left elbow splint. R29's Care Plan problems and approaches (9/12/14, last revised 8/12/15):- Resident requires extensive/total assistance with ADLs related to left side weakness. Approaches included palm protector to right hand at all times, remove for hygiene (this approach added 8/12/15). The care plan did not include the use of the left elbow splint. - Resident is on restorative nursing program for range of motion to the left arm and leg (initiated 9/12/14 by OT, reviewed quarterly and not revised). Approaches included: * Perform PROM to left arm and leg for 15 minutes twice daily. * Notify nurse of any refusals and document such. * Assess and document restorative participation and response to program quarterly and PRN for change in abilities, note barriers to participation and endurance, review goals and approaches with interdisciplinary team quarterly and PRN with changes in resident condition, review goal and approaches as needed to maximize participation and independence levels. * Assess for pain during movement and ROM, medicate per order, monitor for effectiveness of medications, apply warm moist pack if ordered, or massage joints with warm lotion before or after treatment if necessary and desired. 10/02/14 through 1/3/15 Therapy documentation - R29 met the goal for wearing the 90 degree left elbow splint for 2.5 hours. 4/14/15 Nursing note - SBAR to physician to reinstate order for brace (splint) to left arm. There was never an order for [REDACTED]. 5/18/15 Physicians' order - Tylenol at bedtime (9:00 PM) for mild pain. 6/2/15 through 9/18/15 Therapy documentation - Initial goal for left elbow splint was to use the splint for 2 hours. Goal was met for elbow splint and use of adaptive cup. (There was no order for the left elbow splint, nor was it included within the CNA documentation.) 6/3/15 Nursing note - Skin tear to left elbow noted by therapist this morning .under R29's brace .Resident to have lotion applied to left arm prior to applying brace. Brace should be removed and skin should be assessed for any irritation / breakdown every shift. 6/8/15 Nursing note - Resident noted to have two new skin tears above the left elbow under brace/splint . Spoke with therapy who recommended discontinuation of left arm brace. SBAR faxed to physician. (There was no order in the record to discontinue the left elbow brace.) The use of the the left elbow splint was discontinued without attempts to pad or revise/replace the splint to minimize skin tears while preventing worsening of the left elbow contracture. Review of 10/1/15 - 12/31/15 electronic CNA documentation found no entry for the left elbow splint. The twice daily entry for ROM recorded the number of minutes performed and rated the resident tolerance of the treatment. Of the 184 ROM treatments, 159 were either not tolerated, or tolerated poor to fair, by the resident. - 157 treatments (85.3%) lasted 15 minutes. - 4 treatments (2.2%) lasted 10 minutes. - 13 treatments (7.1%) refused, lasted zero minutes. - 10 with no information. The CNA documentation flowsheet was not personalized for R29 since it included every care approach available within the documentation software, even items that would not be appropriate or specific for the resident (for example healed skin tears and discontinued lateral wheelchair support cushion were not removed). 2/15/16 through 3/25/16 Therapy documentation - seen for left elbow splint use. Initial goal for left elbow splint was to use the splint for 30 minutes (1.5 hour reduction from prior therapy goal). Discussed the possibility of contracture management with use of medication. OT to reassess after trial of medication. 5/22/16 Physicians' order - Tylenol at 6:30 AM prior to getting out of bed for pain. (The trial of medication was not ordered until two months after the OT recommendation. There was no evidence in the record that the use of hot packs for muscle relaxation or a stronger pain medication was considered, or attempted, prior to ROM or use of the elbow splint.) Review of 6/1/16 - 8/24/16 electronic CNA documentation found no entries for the left elbow splint. The twice daily entry for ROM recorded the number of minutes performed and rated the resident tolerance of the treatment. Of the 166 ROM treatments, 155 were either not tolerated, or tolerated poor to fair, by the resident. - 118 treatments (71.1%) lasted 1 to 5 minutes. - 7 treatments (4.2%) lasted 7 to 10 minutes. - 44 treatments (26.5%) lasted 15 minutes. - 5 treatments refused (3.0%), [MEDICATION NAME] zero minutes. - 5 with no information. During the stage 1 interview with E16 (LPN) on 8/19/16 at 8:55 AM when asked if R29 uses splints for her contractures, E16 stated No, we do hand hygiene and she holds a rag (rolled up wash cloth) in her hands. We move her hands around when placing the rags. 8/19/16 (10:40 AM, 12:20 PM and 1:45 PM) - Observation of R29 found no left elbow splint in use. Resident with visible contractures to both elbows, wrists, hands and knees. 8/19/16 (1:30 PM - 2:05 PM) - During the stage 1 interview the resident attempted, but was unable to raise her right shoulder to push herself up on the wheelchair arm to straightened her body in the chair. The resident's right shoulder also had limited motion (i.e.,contracture). Resident observation found no elbow splint in use: - 8/22/16 (9:20 AM and 2:10 PM) - 8/23/16 (8:45 AM, 10:05 AM, 11:55 AM and 1:35 PM) - 8/24/16 (9:35 AM, 12:18 PM and 2:10 PM) An undated special instructions section within the CNA documentation software included: - Nursing staff to apply left elbow/arm brace per therapy. (Information to guide the CNA as to when, or for how long, to apply the left elbow splint was not included.) During an interview with E8 (COTA, Rehabilitation Manager) on 8/25/16 at 11:40 AM when reviewing R29's therapy, E8 stated the resident is a revolving door with us. She's on my list to be re-evaluated again within the next week. When discussing R29's currently-used adaptive equipment E8 confirmed the left elbow splint should still be in use. When asked about routine measurements of all joints, E8 stated the facility does not do that but were in the process of implementing them. We need to decide the form to document and the process for getting the information out to the staff. When the surveyor commented that R29 only gets ROM to the left side even though the right side also has contractures, E8 had no response. When asked how the resident tolerated ROM, E8 said not very great When asked if having medication before the ROM improved tolerance, E8 said I'm not sure. During an interview with E2 (DON) on 8/25/16 at 1:15 PM to review the special instructions section within CNA documentation program, E2 stated They're updated at care planning meetings and morning clinical meeting. It was pointed out by the surveyor that the entry for nursing staff to apply left elbow splint had no designation of time frame and skin tears remained in the section even though they healed nor relaxation strategies included in the care plan i.e., apply warm moist pack if ordered, or massage joints with warm lotion before or after treatment if necessary and desired. During an interview with E15 (CNA) on 8/25/16 at 2:35 PM E15 said she had cared for R29 for the past several months on day shift. E15 said ROM had been performed early in the morning before the resident's bath, and that R29 did not tolerate it very well. When asked if the resident uses any splints, E15 was not sure. With prompting by the surveyor, E15 located R29's left elbow splint in the resident's closet. (The splint was made of white plastic and had no cushioning visible on the interior side or edges of the two areas that wrap around the resident's upper and lower arm or the section that would press against the resident's crook of the arm to maintain a 90 degree angle.) The CNA looked at the splint and turned it over several times to read the notations on the splint (i.e., left, top, bottom). When asked if she ever used the splint, E15 said NO. During an interview with E14 (CNA) on 8/25/16 at 4:20 PM E14 said he cared for R29 for the past 4-5 months on evening shift. E14 said ROM had been completed after she's goes to bed and before I leave. E14 confirmed the resident does not tolerate the joint movements well. During an interview with E1 (NHA) on 8/26/16 around 10:30 AM while discussing the concern over the lack of joint measurement and the concentration of treatment to R29's left side, E17 (OT) joined the interview and stated that R29 would tense up if aware that ROM was to be performed but if relaxed, the resident had better tolerance. The decreasing length of tolerance for wearing the elbow splint was reviewed with E1 and E17. During an interview with E1 and E8 on 8/26/16 at 1:02 PM, E1 stated that R29's left elbow could get to 90 degrees when discharged from therapy in March, 2016. The surveyor reiterated that the length of time R29 could tolerate wearing the elbow splint diminished to 15 minutes from 2.5 hours due to pain, reflecting tightening of the muscles, a cause of contractures. The facility failed to establish baseline motion for R29's bilateral arm and leg joints and failed to monitor for changes over time. The left elbow splint was ordered nor was it included in the CNA documentation, resulting in the treatments not being performed to improve or prevent worsening of R29's left elbow contracture. R29 went from being able to tolerate wearing the 90 degree left elbow splint for 2.5 hours in January, 2015 to 2 hours in September, 2015. As of March, 2016 the resident was only able to tolerate wearing the elbow splint for 15 minutes. R29's ability to tolerate 15 minutes of ROM declined from 85.3% in December, 2015 to only 26.5% in August, 2016. There was no evidence in the record that this decline was identified. No evaluation or treatments were ever implemented to improve or prevent worsening the resident's right elbow contracture. These results were reviewed with E1 and E2 on 8/26/16 at 2:15 PM.

Based on record review, interview and observation it was determined that for, 3 (R41, R123 and R52) out of 30 residents sampled, the facility failed to ensure residents did not develop avoidable pressure ulcers (PU). For R123, R41 and R52, who were at high risk for PU development,t the facility failed to initiate pressure reducing and pressure relieving approaches to be consistently followed by staff. For R123, this resulted in the development of a stage 2 PU that advanced to an unstageable PU. For R41, this resulted in the development of two (suspected) DTI PUs. For R52, this resulted in the development of 2 stage 1, 1 stage 2 and 1 DTI PUs. It was also determined the facility failed to ensure one (R150) out of 30 sampled residents received the care and services to promote healing and prevent infections related to pressure ulcer dressing change. Findings include: 1. R123 was admitted [DATE] post hospitalization for an infection throughout his body. The following was reviewed in R123's clinical record: 3/18/16 - Admission sheet documented R123 was admitted with a stage 2 pressure ulcer to the to coccyx measuring 2.5 cm by 0.5 cm and a discoloration of the left hand. 3/18/16 - Braden scale score of 15 (18 or less considered high risk for skin breakdown). 3/18/16 - Interim plan of care for potential for skin breakdown due to decreased mobility included approaches to turn and reposition frequently, keep clean and dry, complete skin risk/Braden scale and use the acuity to assist in proper interventions. The facility was unable to provide a policy to address the Braden acuity with appropriate interventions. 3/18/16 10:29 PM - Nurse's note .resident had complaints of pressure toward (sic) right heel. No apparent breakdown present heel protector applied at night . The heel protector was not added to the special instructions sheet to let the direct care staff know it was a new approach. 3/19/16 - 3/31/16 - EMR Flow Sheet documented no or was left blank for the following: Heel protector - evening 8 out of 12 shifts; night 3 out of 13 shifts Elevate heels - evening 4 out of 12 shifts; night 4 out of 12 shifts This Flow Sheet was not personalized for R123 and included every care approach available on the computer system for staff to chart on, even items that would not be appropriate or specific for the resident. Undated - Special instructions do not include pressure relief or pressure reducing approaches. 3/25/16 - Admission MDS indicated the resident required extensive assistance with bed mobility, transfer, toileting and walking, had 1 stage 2 PU, pressure reducing chair and bed, and pressure ulcer care. The CAA triggered and the facility proceeded with care plan. 3/30/16 - Skin Evaluation Form noted a stage 2 PU measuring 1.5 cm by 2.0 cm was found on the bottom of the right heel. A treatment was started and the note indicated a heel protector would be applied at night. 4/1/16 - Nurse's note documented the resident's Braden score was 17 which is high risk .resident is care planned for turn and reposition frequently, pressure relieving (inappropriately identified, actually pressure reducing) mattress, cushion in chair, moisturizing lotion twice a day and as needed with care. 4/1 - 4/13/16 - Flow Sheet - EMR Flow Sheet documented no or was left blank for the following: Heel protector -evening 7 out of 13 shifts; night 3 out of 13 shifts Elevate heels - evening 2 out of 13 shifts; night 3 out of 13 shifts 4/5/16 - Skin evaluation form documented; stage 2 PU to right heel 3.0 cm by 3.0 cm with red/pink tissue to wound bed and area of yellow slough 0.4 cm by 1.5 cm. Macerated around edges, clean. The facility incorrectly staged the PU. The presence of slough indicates a deeper stage and depth and cannot be assessed making the PU unstageable. The facility incorrectly staged the PU as a Stage 2 when it was really unstageable. 4/1216 - Skin evaluation form documented; resident with unstageable wound to heel. Measurements were 3.5 cm by 3.2 cm. The nurses note on the form documented that there was an area of eschar 1.5 cm by 2.0 cm. 4/12/16 - Care plan for Pressure Ulcers: has an unstageable PU to the right heel interventions include: -provide treatment as ordered, use heel boot while in bed to alleviate pressure from foot, do not apply shoes to the affected foot, monitor and medicate for pain. 4/14/16 - Records indicate the resident was discharged home. An interview on 8/24/16 at 11:58 AM with E4 (ADON) revealed that when the record refers to heel protector it is a quilted boot with a velcro strap and incorrectly identified it as both pressure relieving and pressure reducing. This type of bootie is only pressure reducing. When asked what an order for [REDACTED]. An interview on 8/24/16 around 2:20 PM with E21 (CNA) and E22 (CNA) about how they get care instructions revealed that they used the special instructions area of the EMR and their own judgement. They went on to say that the special instructions are not always kept updated. When asked how they decide what approaches to implement for a resident when the EMR had populated all available care items they stated that they have to use their own judgement. If the resident came in with a heel bootie they continue to use it and they elevate the heels if they think the resident needs it. An interview on 8/24/16 around 2:30 PM with E10 (RN) revealed that she verbally communicates with the aide the needs of the resident. E10 is not sure what exactly is put in the electronic chart since she is fairly new here but has charted on the system. She described that you had to answer each area with a finding and that non-applicable was an option to use if it does not apply to that resident. An interview on 8/24/16 at 2:45 PM with E4 (ADON) revealed that aides get their instructions from the special instructions section of the EMR. When asked how they know which of the care areas in the EMR are specific to the resident she stated that she did not know she would have to ask the DON. An interview on 8/25/16 at 8:45 AM with E2 (DON) to review EMR charting done by the aides and nurses for care revealed that the care needs are suppose to be customized for the individual resident and the special instructions section is for additional resident specific information not covered by the Point of Care (name of program) charting system. E2 was able to review the EMR documentation for R123 and confirm it was not individualized for the resident. E2 also confirmed the special instructions section did not include information specific to pressure ulcer prevention. For R123 the facility failed to ensure pressure relieving and reducing approaches were consistently implemented. While the facility developed a care plan for the PU, as the PU increased in size there was no evidence that interventions were reevaluated for effectiveness, resulting in a worsening of the PU. 2. R41 was admitted on [DATE] with a broken upper right leg bone. The following was reviewed in R41's clinical record: 5/16/16 - Skin evaluation form on admission documented a wound of other type caused by pressure to her right calf measuring 4 cm x 5 cm by 0.1 cm. The facility later found out it was a trauma wound from a transfer by ambulance staff before admission to the facility. 5/16/16 - Nursing Physical Exam did not document any skin problems to the heels. The Braden Scale was assessed with [REDACTED]. 5/16/16 - Interim plan of care for R41 has potential for skin breakdown due to history of fragile skin, bruises and skin tear with the approaches: -wash after each incontinence and apply barrier, observe for signs of skin breakdown and notify physician of problems, keep skin clean and dry. 5/16/16 - Interim care plan for (resident name) has open area: skin tear to left shin area and pressure ulcer to the back of the right leg with the approaches: -treatment as ordered, keep pressure off area, keep clean and dry. There were no instructions in the care plan of how the pressure was to be kept off the area or what other pressure relieving / reducing approaches were to be used for this resident. 5/17/16 (print date) - Physician order [REDACTED]. Undated - EMR section special instructions did not include any pressure relieving/reducing measures. Although pressure relief / reduction was mentioned in the care plan the facility failed to initiate specific approaches for R41 including but not limited to the use of pressure reducing booties and elevating the heels. 5/23/16 - Admission MDS documented: moderate impairment for decision making, extensive assistance with bed mobility, toileting and transfer, 1 stage 1 and 1 stage 2 pressure ulcer, pressure relieving device for bed and chair, turn and reposition program, nutrition / hydration approaches and pressure ulcer care. The CAA triggered and proceed with care plan was indicated. 5/17 - 5/24/16 - Monthly Charting Flow Sheet answered no or were left blank for the following approaches: Turning and repositioning - 16 out of 24 shifts Elevate heels - 22 out of 24 shifts Heel protectors - 17 out of 24 shifts This Flow Sheet was not individualized for R41 and included every care approach available on the computer system for staff to chart on, even items that would not be appropriate or specific for the resident. 5/24/16 - Skin Evaluation Record documented the following new areas: - right dorsal top of foot - area noted red/purple top of foot daily - left heel boggy and with DTI area. - right heel boggy and with DTI area. Approaches to apply skin prep to bilateral heels bid and apply Prevalon boots to BLE while in bed were noted. The Skin Evaluation Record contained no measurements or description of the heel wounds but indicated the cause as pressure. 5/28/16 (print date) - Physician order [REDACTED]. 5/24/16 - skin prep to right top of foot, bilateral heels, right inner knee bid 5/24/16 - heel up cushion to bilateral heels when resident is in bed TID. Remove when up OOB. 5/25/16 - Prevalon boots to BLE while patient in bed. Remove when OOB 5/26/16 - Pressure Ulcers care plan for skin tear to right outer leg, pressure area to bilateral heels and ball of right foot and several deep tissue areas to BLE with the approaches: -Assess for cause of ulcer. Observe for pressure cause, friction and contributing factors; nurse to measure and monitor wound status progression or deterioration every week and notify MD and family of changes; reposition per positioning schedule (see plan of care); educated to shift weight often; assisted with turning and positioning; staff will assist with placing Prevalon booties to BLE to prevent skin breakdown; BLE will be elevated with Prevalon boots while in bed. There was no positioning schedule found in the plan of care. 5/31/16 - Skin Evaluation form for both heels documented that bilateral heels continue to be boggy and clear. There was no other description or measurements of the wounds. 6/7/16 - Skin Evaluation form documented the right heel was a red/purple DTI with measurements of 10.5 cm by 7.0 cm. The left heel was red/purple with 1.4 cm by 0.5 cm superficial open area with measurements of 6 cm by 5 cm. 6/7/16 11:49 AM - A nurses' note documented the left heel with 1.4 cm x 0.5 cm opening and that the NP and wound nurse looked at the wound; doppler (ultrasound) study ordered stat and wound care center referral was made. 6/8/16 - The ultrasound study showed advanced [MEDICAL CONDITION] arterial occlusive disease at both legs, meaning the resident did not have good blood flow to the lower legs and feet. 6/9/16 - A nurse's note documented the resident left facility at 12:55 PM for a MD appointment and was sent to the hospital from there. The resident did not return to the facility. An interview on 8/24/16 around 2:20 PM with E21 (CNA) and E22 (CNA) about how they get care instructions revealed that they use the special instructions area of the EMR and their own judgement. They went on to say that the special instructions are not always kept updated. When asked how they decide what approaches to implement for a resident when the EMR had populated all available care items they stated that they have to used their own judgement. If the resident comes in with a heel bootie they continue to use it and they elevate the heels if they think the resident needs it. An interview on 8/24/16 around 2:30 PM with E10 (RN) revealed that she verbally communicates with the aide the needs of the resident. E10 is not sure what exactly is put in the electronic chart since she is fairly new here but has charted on the system. She described that you had to answer each area with a finding and that non-applicable was an option to use if it does not apply to that resident. An interview on 8/24/16 at 2:45 PM with E4 (ADON) revealed that aides get their instructions from the special instructions section of the EMR, when asked how they know which of the care areas in the EMR that are specific to the resident she stated that she did not know she would have to ask the DON. An interview on 8/25/16 at 8:45 AM with E2 (DON) to review EMR charting done by the aides and nurses for care revealed that the care needs are suppose to be customized for the individual resident and the special instructions section is for additional resident specific information not covered by the Point of Care (name of program) charting system. E2 was able to review the EMR documentation for R41 and confirm it was not individualized for the resident. E2 also confirmed the special instructions section did not include information specific to pressure ulcer prevention for. 3. R52 was readmitted [DATE] with recurrent [MEDICAL CONDITION] and dementia. Review of R52's clinical record revealed: Care plan problem (initiated 11/5/14) risk for pressure ulcer related to decreased mobility, poor oral intake (revised 8/22/16 to add hospice). Approaches included: turn and position as tolerated, assess skin when turning or performing personal care, weekly skin checks. 3/31/16 - Braden scale score was 15 (18 or less is considered high risk for skin breakdown). The facility was unable to provide a policy that addressed the Braden score with appropriate interventions. 5/1/16 - 6/30/16 - CNA documentation for turning and elevating heels that documented no or was left blank: - Turning: 23 shifts - Elevate heels: 26 shifts 6/30/16 - Significant Change MDS assessment documented the resident had moderate cognitive impairment, daily rejection of care, no pressure ulcer. R52 required extensive assistance with bed mobility and personal hygiene. The resident did not walk and remained in bed. 7/1/16 - 7/31/16 - CNA documentation for turning and elevating heels that documented no or was left blank: - Turning: 12 shifts - Elevate heels: 10 shifts 7/21/16 (1:06 PM) Nursing note - Reddened bilateral heels. Left heel unblanchable with shallow blister 1.5 cm x 1.5 cm. Physician informed and ordered to elevate feet to prevent further sheer and pressure; apply skin prep to bilateral heels daily. (Left heel had a Stage 2 and right heel had a Stage 1 pressure ulcer) 7/22/16 (12:10 PM) Skin Evaluation Form - Left heel categorized as a suspected deep tissue injury (s)DTI. No fluid filled blister evident. Physician in facility and evaluated. Gave orders for skin prep, continue to float heels, and reposition frequently. 7/24/16 (10:53 AM) Nursing note - Redness on coccyx 2.5 cm x 1.75 cm. (Stage 1 pressure ulcer) 7/25/16 (10:55 AM) Nursing note - At 8:30 AM called by CNA to observe resident right hip noted non blanchable area with water filled cluster blister. Measurement 3 cm x 2.7 cm. Resident turn and position every 2 hours and as needed per resident tolerance. (Stage 2 pressure ulcer). 7/25/16 (1:25 PM) Nursing note - POA stated she saw the area (hip) on Sunday (7/24/16) when the CNA turned R52. Attempted to contact NP, but no answer. SBAR faxed to physician. 7/25/16 SBAR form - Information to physician included: Right hip bed wound, intact clustered blister measurement 3 cm x 2 cm. Poor meal intake, refuses care, significant change for months. Observed right hip intact wound related to poor meals/nutrition intake, skin prep every shift. Physician response by fax at 3:18 PM included: Please what does it mean by intact hip wound?? Wound care team to assess and confirm, off loading (elevate heels) by nursing, skin barrier as needed, it there is a wound we will need to address and I will review ASAP. 7/26/16 Physicians' order - Low air mattress (placed on bed 7/28/16 after mix up with delivery the day before). 7/26/16 (Skin Evaluation Forms) - Left heel has increased in size 1.8 cm x 1.8 cm. Area remains closed, treatment remains same with skin prep and floating heels. Await arrival of pravalon boots. Right heel redness 1.5 cm x 2 cm. Stage 1. CNA special instructions were not updated to include turning and positioning to avoid the right side, elevating heels, using pravalon boots after the development of a Stage 2 pressure ulcer on the left heel and right hip, and a Stage 1 to left heel and coccyx. 8/2/16 Nursing note - Persistent redness to the right lateral (outer) foot and ankle. Area is not open. (This was a Stage 1 pressure ulcer) 8/2/16 Skin Evaluation Forms - Left heel 1.8 cm x 1.8 cm DTI. Right heel 2 cm x 2.5 cm Stage 1(increased in size). Area to right hip healed. Resident denies discomfort to the area states has pain when she is moved. Will apply Allevyn to the area to protect and cushion. There was no evidence in the record that assessing / medicating for pain prior to positioning was considered. 8/5/16 - Effective date for hospice at 2:00 PM. 8/9/16 (11:49 AM) Nursing note - Area to lateral foot resolved. 8/11/16 - Braden scale score 11 (higher risk for skin breakdown than previous assessments). 8/13/16 - Significant Change MDS documented R52 had four pressure ulcers: - Stage 1: 2 - Stage 2: 1 - sDTi: 1 8/9/16 - Left heel 1.2 cm x 1 cm DTI. Right heel 2 cm x 2.5 cm Stage 1. 8/17/16 - Left heel 1 cm x 1.4 DTI. Right heel 1.4 cm x 2 cm Stage 1. 8/18/16 (2:10 PM) - Observed to be bed on left side. 8/19/16 (9:05 AM) - Observed in bed on right side. During a family interview conducted 8/19/16 at 11:04 AM with the POA, when asked if the resident gets the help she needs getting dressed, toileting, or cleaning his/her teeth? the POA responded the resident definitely could use more turning in bed. 8/19/16 (10:45 AM) - Observed in bed on left side. 8/19/16 (1:15 PM and 3:10 PM) - Observed in bed on right side. 8/20/16 Skin Evaluation Form - Unopened pressure sore noted right hip, purple with redness around the outside. turned and repositioned, no complaint of pain in area. Size 8.1 cm x 4.5 cm. (This is a sDTI) 8/22/16 - Care plan problem for pressure ulcer (sDTI right hip) (revised 8/23/16) included the following approaches: Assess for cause of pressure ulcer, nurse to monitor wound status weekly. Treatment as ordered, reposition from left to back only. Pressure reducing air mattress. Float heels when in bed. Apply barrier cream after every incontinent episode, offload pressure to areas of concern. Maintain linens free of wrinkles. Assess for pain and medicate as ordered. Evaluate effectiveness of pain medication , report ineffective pain management to physician for recommendation. The CNA special instructions section of the documentation record was not updated to include turning from left to back only. 8/1/16 - 8/23/16 - CNA documentation for turning and elevating heels that documented no or was left blank: - Turning: 7 shifts - Elevate heels: 9 shifts 8/23/16 Skin Evaluation Forms - Area to both heels resolved. Right hip is (remains) a closed DTI. Resident with multiple comorbidities including decreased mobility, end of life hospice care, incontinence, contractures, decreased oral intake calories and fluids. R52 denies pain unless moved. Resident repositioned as tolerated, reposition left to back only. Treatment will be skin prep and leave open to air. 8/23/16 (8:48 AM) - Observed in bed on left side. 8/23/16 (9:31 AM) Skin Evaluation Form - Right hip red outside with purple inside, closed 8.5 cm x 8 cm. Pressure ulcer stage listed as sDTI. 8/23/16 (10:30 AM) Observed in bed on back. At 1:00 PM on left side. During an interview with the resident's POA on 8/23/16 at 11:30 AM the POA stated they turn R52 every 2-3 hours around 60-70% of the time. There have been times when I'm here for 4 hours, and no one comes in to turn her. 8/24/16 (9:10 AM) - Observed in bed on left side asleep During a follow-up interview with the POA on 8/24 16 at 9:50 AM when asked if she recalled when the lack of turning over 4 hours occurred, POA stated this past Saturday (8/20/16) and on several occasions in the previous 2 weeks, unsure of those dates. 8/24/16 (11:30 AM) - discharged to home of POA with hospice. During an interview with E2 (DON) and E3 (ADON) on 8/24/16 between 12:57 PM - 1:20 PM to discuss R52, the surveyor found out that the resident started out on the short term unit and comfort care was suggested since R52 was not eating and had a general decline. The resident never wanted to get out of bed or do things for herself. The Skin Evaluation Forms were reviewed for the various pressure ulcers which included notes about resident refusals. It was confirmed that the special instructions were not updated since 7/5/16 to include preventative measures specific for the resident and that preventative measures were not consistently performed. 4. R150 was admitted [DATE] post hospitalization for rehabilitation with an unstageable left heel pressure ulcer. The facility's Nursing Procedure entitled Applying a Clean Dressing (Nursing Procedure Guide for Long Term Care, .2014) stated: -Set up your dressing supplies, and open packages. Place them on a disposable underpad or clean surface, as needed . - Apply treatment product according to directions. Use an applicator, tongue blade, or gauze sponge to spread on wound. So not to contaminate the product package . 8/10/16 physician's orders [REDACTED]. Observation of wound treatment on 8/23/16 at 2:00 PM by E12 (RN, TCU Unit Manager) revealed E12 failed to maintain proper infection control practices before and during the wound treatment. a.The clean barrier was not prepared properly for the supplies. E12 wiped the top of R150's over bed table with Dispatch® Hospital Cleaner Disinfectant Towels with Bleach wipes then immediately placed the wound care supplies on the wet table. E12 placed the Wound Measurement Stick (q-tip like non sterile applicator used to measure wounds) directly on the wet table which was later put into wound to measure depth. In addition, E12 did not clean the visible particle stains off the table. The manufacturer's directions on the wipes container stated: 1) Remove gross soil if visible (Gross contamination (visible soil) must be cleaned up first with soap and water, then followed by use of the bleach solution for disinfecting). 2) Wear gloves, then wipe surface with towel until completely wet. 3) To disinfect, allow surface to remain wet for 1 minute (Allow 2 minutes contact at room temperature for TB, and allow 5 minutes contact for [DIAGNOSES REDACTED]icile spores). 4) Wipe with a clean, damp cloth, allow to air dry, and discard used towel. b. E12 placed the contaminated Wound Measurement Stick in (to measure depth) and on (to measure height and width) the wound. c. E12 applied Santyl to the wound using her gloved finger which is a violation of facility procedure. During an interview on 8/24/16 at 9:00 AM E2 was informed of the wound treatment observations. The DON stated this observed practice did not conform with the expected wound care practice. Findings were reviewed with E1 (NHA) and E2 on 8/26/16 at 2:15 PM during the exit conference.

Based on record review, staff interviews, resident interview, and review of facility investigation documentation, it was determined that for one (1) of three (3) residents reviewed (R2) the facility failed to provide the resident with adequate supervision to prevent accidents. The facility lacked an effective system for ensuring that all staff who provided care to R2 were aware of and followed the established bathing procedure that had been used by R2's primary CNA for several years. This procedure provided direct visual supervision of R2's position in the bed and proximity (closeness) of a staff member to R2 when she was holding the upper rail to position herself on her left side during bed baths. During a bed bath on 11/3/14 when this procedure was not followed, R2's legs accidentally slid off the side of the bed causing her body to follow and land on the floor. R2 sustained fractures (broken bones) of both legs as a result of this accident. Findings include: Cross-refer F225 and F279. R2 resided in the facility for over three years and had [DIAGNOSES REDACTED] (unable to feel or move her legs). The care plan for R2 dated 10/2/14 identified that R2 required extensive to total staff assistance with lower body activities of daily living (things normally done daily such as bathing and dressing) due to generalized muscle weakness and decreased mobility. The care plan lacked specific instructions regarding how staff should assist and supervise R2 during bed baths. A nursing note dated 10/24/14 timed 12 noon revealed that R2's daughter had called the facility to express concern over R2 having a new CNA (E5) assigned to her after her long term CNA (E4) of several years was moved to a different assignment. According to this note, R2's new CNA (E5) would meet with the former CNA (E4) to go over R2's care preferences. According to an incident report dated 11/3/14, E5 (CNA) was providing care (bed bath) to R2 and when R2 turned herself onto her left side in bed her legs slipped off the side of the bed and then her whole body slid to the floor. R2 was sent to the hospital for evaluation and was determined to have fractures of both legs. The facility's attending physician documented in a note dated 11/7/14 timed 2 PM that R2 had fractures of both femurs (the long bone of the thigh) and was receiving follow-up treatment by an orthopedic surgeon. The orthopedic surgeon documented on 11/7/14 that R2's fractures were of the right knee and the left knee / femur and both legs were placed in immobilizers (soft, splint like devices strapped around each leg). Interview with R2 at 1 PM on 11/23/14 revealed that she had pulled herself over using the side rail as usual on the day of the accident (11/3/14). R2 explained that she is able to pull her whole body over and her legs roll over with her body but on 11/3/14 her legs were right on the edge of the bed and she (R2) didn't realize this due to her [DIAGNOSES REDACTED]. R2 stated that when E5, who was positioned behind R2 on the opposite side of the bed, was removing the sheets from the bed it accidentally caused R2's legs to slip from the bed followed by the rest of her body. Staff interviews revealed the following: -E3 (ADON) stated to the surveyor on 11/23/14 at 12:15 PM that this accident occurred shortly after E4 was no longer the primary CNA for R2 and that E5 was new at caring for R2. -E5 stated to the surveyor on 11/23/14 at 12:30 PM that while providing a bed bath to R2 on 11/3/14 E5 was on the right side of the bed when R2 pulled herself over on her left side facing the left side of the bed. E5 stated that R2's legs drifted off of the bed and then R2's body slid off onto the floor. E5 stated that she tried to hold onto R2's upper body to keep her from falling but was unable to do so. - E2 (DON) stated to the surveyor on 11/24/14 at 2:25 PM that the facility assigns CNAs to permanent assignments but due to unexpected circumstances E4 needed to be reassigned and E5 became the primary day shift CNA for R2. -E4 stated to the surveyor on 11/26/14 at 1:55 PM that she had been the primary CNA for R2 for several years and followed a specific process when bathing R2 in bed. E4 explained that R2 was weaker on her left side so whenever R2 was turning to her left side E4 would be on the left side of the bed standing by R2's legs where there was no bed rail. E4 stated to the surveyor several times that a care giver would need to be on the left side of R2's bed if R2 was lying on her left side. This position would mean that a care giver would have full visualization of R2's body placement in the bed. E4 stated that she provided a verbal description of this process to E5 in the presence of E3 but no notes were taken or instructions written. E4 stated that she did not do a demonstration of a bed bath for E4 or perform a bed bath of R2 with E4 prior to her assignment change. E4 stated that she was off work the date of the accident (11/3/14). The facility staff identified and followed a specific process for R2's bed bath for several years. When a staffing change occurred and R2 had a newly assigned CNA (E5), a verbal transfer of information occurred without any written instructions, care plan revision, or actual demonstration. Consequently, E5 was providing a bed bath to R2 alone on 11/3/14 with no verification by the facility that she (E5) understood the necessary supervision process used during R2's bed baths (remain on the left side of the bed near R2's legs when R2 was lying on her left side during a bath). On 11/3/14 while bathing R2, E5 was on the right side of the bed when R2 pulled herself onto her left side and her legs were on the very edge of the bed. Due to her position, E5 was unable to supervise the position of R2's legs and immediately intervene when R2's legs slid off of the bed. These findings were confirmed with E1(NHA) and E2 on 11/26/14 at 10:30 AM.

Cross refer to F325, example #2 Based on observations, interviews, record review, and review of facility policy, as well as hospital records, it was determined that the facility failed to ensure that one (R10) of 36 sampled residents received sufficient fluid intake to maintain proper hydration and health. The facility failed to identify that R10's fluid intake had declined and the facility failed to implement interventions to ensure adequate hydration to maintain health. R10 was hospitalized with acute [MEDICAL CONDITION] due to severe dehydration. Findings include: The facility's policy entitled, "Hydration' was reviewed. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10's quarterly Minimum Data Set (MDS) assessment, dated 2/12/10 indicated that his cognitive skills for daily decision making were "modified independence - some difficulty in new situations only." and he was coded as independent for eating. Observations of the R10 during the survey confirmed that he ate independently. R10's care plan for "Nutrition, risk potential, R/T (related to) mechanically altered diet.", dated 11/25/09, stated that the goal was, "Resident will maintain weight +/- 3 lbs. monthly and will show no signs of dehydration daily x 90 days." with a goal date of 3/2/10. One of the approaches listed was , "Encourage fluids. Off (offer) & enc (encourage) >/= (greater than or equal to) 120 ccs qid. (4 times a day) doc (document) consumed on MAR (Medication Administration Record). Give fluids of preference. Cola 8oz bid (twice a day) on snack list..." R10's Nutrition Assessment, dated 11/25/09, calculated his daily fluid needs to be 1770 ml. A dietary note of the same date noted a significant weight loss. E5 (dietitian) stated that R10's "...Fluid intake avg (average) 240 ml/meal, receives extra fluids between meals, consumes avg 80 ml..." She also noted that his beverage of choice was cola. Review of R10's Physician order [REDACTED]. R10's MAR and Meal Percentages sheets for 2/10 were reviewed. His total daily fluid consumption from meals and during medication pass times were as follows" 2/1/10: 1430 ml 2/2/10: 1040 ml 2/3/10: 1640 ml 2/4/10; 1780 ml 2/5/10, 2/6/10 and 2/7/10: Could not be determined because no meals were recorded on those days 2/8/10: 1270 ml 2/9/10: 1060 ml 2/10/10: 780 ml 2/11/10: 940 ml 2/12/10, 2/13/10 and 2/14/10: Could not be determined because no meals were recorded on those days. 2/15/10: 1537 ml 2/16/10: 840 ml 2/17/10: 1040 ml 2/18/10: 780 ml Of the 12 days that total fluid intake was recorded for R10, he only came close to meeting his daily requirement on two days. From the beginning of the month until the day that R10 was sent out to the hospital on [DATE], his daily fluid consumption showed a downward trend. There was no evidence that anyone was monitoring his decreasing daily intake of fluids. R10's weight record indicated he had two periods of significant weight loss beginning 1/10 to 2/10. The weights changes were 135.7 lbs. on 1/27/10 to 121 lbs. on 2/1/10 (10%) and from 130.7 lbs. on 2/8/10 to 123 lbs. on 2/15/10 (5%). There was no evidence that reweights were done to verify the changes. A dietary note, dated 2/8/10, stated , "Good intake fluids -- mostly colas." The next dietary note, dated 2/18/10, stated that the RD spoke to the resident about his weight loss and "...Res (resident) said he would be willing to drink E+ (Ensure Plus), and, in fact, drank one this am..." Review of nurse's notes from 2/8/10 through 2/18/10 lacked evidence that R10's fluid intake had declined nor was there any mention that fluids were being encouraged. Additionally there was no evidence that nursing was monitoring for signs and symptoms of dehydration even after his significant weight loss. A nurse's note, dated 2/19/10, stated, "Resident was reported to have poor PO (by mouth) intake...dry mucos (sic) membrane, poor skin turgor, resident is alert, MD notified, he gave order to send resident out to ER eval..." Review of R10's hospital records revealed a physician's consult, dated 2/20/10, which stated, "...Unfortunately Mr (name) also has developed acute [MEDICAL CONDITION]. His creatinine of 8.3 (normal range: 0.5 - 1.5) with a BUN (blood urea nitrogen) of 131 (normal range: 10 - 26) suggests predominately volume depletion and prerenal azotemia (accumulation of nitrogenous wastes usually caused by hypovolemia or low blood volume). Under the physical exam, the MD noted that the "..."Foley (catheter) reveals dark, concentrated urine, only 20 ml..." The assessment includes shock, dehydration and acute [MEDICAL CONDITION]. A subsequent hospital physician consult, dated 2/22/10, stated that the BUN and creatinine were going down after hydration with intravenous (IV) fluids. Laboratory data noted that the BUN was 75 and the creatinine was 3.1. Under "Impressions/Recommendations", the MD stated "[MEDICAL CONDITION] from dehydration, more of acute tubular acidosis and dehydration, causing the high BUN and creatinine than any kidney disease behind it, but it is hard to tell at this time, and we will need to hydrate him more to see the response..." Under, "Family History" the report stated, "There is no mention of [MEDICAL CONDITION] in available records." Subsequent lab values during R10's hospital stay were as follows: 2/25/10: BUN - 33; Creatinine - 1.5 2/26/10: BUN - 22; Creatinine - 1.3 2/27/10: BUN - 19; Creatinine - 1.3 2/28/10: BUN - 16; Creatinine - 1.3 3/1/10: BUN - 15; Creatinine - 1.2 3/2/10: BUN - 15; Creatinine - 1.2 The hospital discharge summary dictated 3/2/2010 stated the discharge [DIAGNOSES REDACTED]. Under hospital course this same report stated the patient was admitted to (name of hospital) on 2/19/2010 with acute [MEDICAL CONDITION]. Under lab data this report stated blood cultures on 2/19/2010 no growth. Urinalysis and urine cultures were nonrevealing. R10 was released from the hospital on [DATE] after his lab values came down to within normal limits following IV fluids. During an interview with E5 (dietitian) on 5/3/10, she stated that she tracked residents' fluid intakes at their annual assessments. She stated that extra fluids were ordered for R10 at her request and that she arranged through dietary to have colas delivered to him, however, she was not able to provide any evidence that R10 was receiving colas prior to his hospitalization . She stated the fluid intake recorded on the MAR would include any type of fluid consumed but does not specify what kind. The facility failed to closely monitor R10's fluid intake and failed to recognize the fact that his weight loss in 2/10 might have been related to fluid depletion. As a result, R10 became severely dehydrated and was hospitalized with acute [MEDICAL CONDITION].

Based on observations, record review, interviews and review of facility policy, it was determined that the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (R40) of 36 sampled residents. The facility failed to identify a significant weight loss for R40 for three weeks and failed to implement interventions to address the weight loss. Additionally, the facility failed to have a system in place to verify and analyze weight changes in a timely manner as evidenced by weights obtained for five additional residents (R10, R17, R68, R8 and R98) of 36 sampled residents. Findings include: The facility policy entitled, "Weights" was reviewed. Under the guidelines it stated that weights were to be, "Taken on a designated chair, with designated equipment... " and "...Variances of plus or minus 5 pounds or more for residents over 100 pounds or plus or minus 3 pounds or more for residents under 100 pounds require: A re-weigh within 24 hours; A report, by the charge nurse, to the physician, dietician, and responsible party..." Under the procedures it stated that staff obtaining the weight "...Report the weight to the licensed nurse who shall determine if loss or gain occurred..." 1. R40 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R40's weight record revealed the following: 12/28/09 - 112 lbs. 1/1/10 - 88.5 lbs. (20% weight loss in 4 days) 1/6/10 - 113.9 lbs. (reweight) 1/11/10 - 112 lbs. 1/14/10 - 111.4 lbs. 2/15/10 - 112 lbs. 3/15/10 - 113 lbs. 3/29/10 - 110.4 lbs. 4/5/10 - 98.5 lbs. (10% weight loss in 1 week) 4/12/10 - 111.5 lbs. 4/19/10 - 98.6 lbs. (11% weight loss in 1 week) 4/26/10 - 96.7 lbs. 4/29/10 - 99.4 lbs. (9% weight loss in 1 month) 5/3/10 - 98.9 lbs. (observed by the surveyor) R40's Physician order [REDACTED]. R40's care plan, 12/17/09, identified the problem, "Nut (nutritional) risk R/T (related to) leave 25% uneaten at most meals. Potential for dehydration R/T recent UTI (urinary tract infection)." The goal stated that the resident would, "Maintain or increase wt (weight) 1-2#/mo to 5# in 90 days..." Approaches included encouragement for the resident to consume >/= 76% of meals, to monitor meals and record, to weigh monthly or per protocol and record, and to report significant change to RD and MD. Review of R40's Nutritional Assessment, dated 12/17/09 revealed that her admission weight was 117 lbs. The dietary note written upon admission on 12/14/09, stated that the resident had no [MEDICAL CONDITION] (swelling) and that she was a good eater prior to her hospital admission. A subsequent note, dated 12/17/10, recommended the addition of a nutritional supplement, Ensure Plus three times a day since the resident was consuming < 75% of her meals. Subsequent nutrition notes on 1/6/10, 1/27/10 and 3/3/10 indicated that weight and intake monitoring would continue and no new recommendations were made. The next dietary note was dated, 4/28/10 and was written by a different dietitian who was filling in for the facility's regular dietitian who was on vacation. The note stated that R40's 4/26/10 weight indicated a significant weight loss from the previous month despite the resident receiving 3 Ensure Plus supplements a day. It stated that the resident, "May require additional assistance at mealtimes." No other interventions were recommended. However surveyor observations during the survey revealed the resident ate independently. Observations of R40 at meals during the survey from 4/28/10 through 4/30/10, revealed that the resident ate independently without assistance. Review of R40's meal intake records from 4/1/10 through 4/24/10, indicated that she consumed an average of 50% of her meals. Her Medication Administration Record, [REDACTED]. During an interview with E5 (dietitian) on 5/3/10, she stated that she did not request a reweight for R40 after her 4/19/10 weight which indicated a weight loss of 12.9 lbs. in one week because she assumed that it was an error. This was why she failed to contact the resident's physician. E5 stated that she was planning to wait to see what her monthly weight would be the first week of 5/10. The facility failed to have a system in place to identify weight changes and obtain reweights in a timely manner as per their policy. Nursing failed to monitor weights and alert the dietitian and physician to significant weight changes causing a delay in the analysis of the reason for the loss or gain. The facility initially failed to identify a significant weight loss for R40 on 4/5/10 and 4/19/10. When it was finally identified on 4/26/10, no new interventions were implemented to address the weight loss other than the recommendation for additional assistance. Cross refer F327 2. Review of R10's weight record revealed the following: 10/5/09 - 137.9 lbs. 11/30/09 - 130 lbs. (5% loss in 1 week) 12/23/09 - 132.5 lbs. 1/25/10 - 130.4 lbs. 1/27/10 - 135.7 lbs. 2/1/10 - 121 lbs. (10% loss in 5 days) 2/8/10 - 130.7 lbs. (8% gain in 1 week) 2/15/10 - 123 lbs. (5% loss in 1 week) 3/3/10 - 121 lbs. 4/22/10 - 122.6 lbs. R10's clinical record lacked evidence that a reweight was done to verify the three instances of significant weight loss. R10 was hosptalized on [DATE] for severe dehydration. 3. Review of R8's weight record revealed the following: 11/2/09 - 100.6 lbs. 11/9/09 - 116.9 lbs. (16% gain in 1 week) 12/23/09 - 113.4 lbs. R8's clinical record lacked evidence that a reweight was done to verify the resident's significant weight gain. 4. Review of R68's weight record revealed the following: 11/3/09 - 119.5 lbs. (chair scale) 12/3/09 - 123 lbs. (chair scale) 1/2/10 - 125.5 lbs. (chair scale) 2/1/10 - 129.9 lbs. (stand-up scale) 3/2/10 - 125.2 lbs. (lift scale) 3/3/10 - 131 lbs. (chair scale) 4/2/10 - 119.4 lbs. (chair scale, 8% loss in 1 month) R68's clinical record lacked evidence that a reweight was done to verify the resident's significant weight loss. Additionally, different scales were used to obtain weights on R68 making accuracy difficult to determine. Furthermore, the documentation makes it look like there were three different scales, when actually there were only two scales used (the stand-up scale is the same as the chair scale). 5. Review of R17's weight record revealed the following: 1/11/10 - 115 lbs. (chair scale) 1/18/09 - 121 lbs. (stand-up scale, 5% gain in 1 week) 2/1/10 - 121 lbs. (stand-up scale) 2/8/10 - 110 lbs. (chair scale, 9% loss in 1 week) 2/15/10 - 93 lbs. (stand-up scale, 15% loss in 1 week) 3/3/10 - 120.1 lbs. (lift scale, 29% gain in 2 weeks) 3/15/10 - 101 lbs. (stand-up scale, 15% loss in 12 days) 3/22/10 - 115 lbs. (chair scale, 13% gain in 1 week) 3/29/10 - 116.2 lbs. (chair scale) 4/5/10 - 118 lbs. (chair scale) 4/12/10 - 95 lbs. (stand-up scale, 19% loss in 1 week) 4/26/10 - 116.2 lbs. (chair scale, 22% gain in 1 week) R17's clinical record lacked evidence that reweights were done to verify the resident's significant weight changes. Additionally, different scales were used to obtain weights on R17 making accuracy difficult to determine. During an interview with E24 (Certified Nurse Aid/CNA), on 4/30/10, she stated that when the CNA's obtained a resident's weight, they entered it into their computer system but they did not compare it to the previous weight. She stated that the dietitian reviewed the weight weekly and then would let the CNA's know if a reweight was needed. Interview with E5 (dietitian) on 5/3/10 revealed that nursing was suppose to identify a weight change, but she stated that, "In reality, I do." She stated that after she identified the weight change she, she notified the Director of Nursing or the Assistant Director of Nursing so that a reweight could be obtained. E5 stated that she reviewed the residents' weight about four times a month, usually weekly. She verified that it could be a week before a reweight was obtained. 6. R98 was admitted to the facility on [DATE] due to right ankle fracture and had a cast. Record review revealed admission weight of 184 pounds (#) on 3/2/10 and only one other weight of 168.8 # (approximately 15 # or 8% loss from the previous weight) on 4/23/10 (approximately seven weeks since the initial weight). Record review lacked evidence of a weekly weight for four weeks or a reweight to verify the weight obtained on 4/23/10. Subsequent to the surveyor's inquiry on 4/30/10, the facility obtained R98's weight on 4/30/10 which was 170.2 # (approximately 13 # or 7.5% loss since admission). An interview with E5(dietitian) on 5/3/10 at approximately 1 PM revealed that E5 only had one weight on admission for R98 and was not notified of the approximately 15 # variance on 4/23/10. E5 related the confirmed weight loss on 4/30/10 was primarily due to the removal of the cast from the right ankle and intermittent loose bowels, however, she did confirm that the facility failed to obtain weekly weights for four weeks and failed to obtain a reweight following the 4/23/10 weight for R98. The facility failed to have a system in place to identify weight changes and obtain reweights in a timely manner as per their policy. The facility failed to monitor weights for all six residents listed above and failed to alert the dietitian and the physician to significant weight changes causing a delay in the analysis of the reason for the loss or gain. This resulted in a failure to immediately implement interventions for two residents, R40 and R10 to address their significant weight loss issues.