Every finding on record at Willowbrooke Court at Country House

Based on interview and record review, it was determined that for one (R1) out of five residents reviewed for unnecessary medications, the facility failed to ensure that R1's physician order for weekly blood pressure (BP) monitoring on Mondays was completed. Findings include: Review of R1's clinical record revealed: 5/22/24 - R1 had a physician's order for blood pressure every week on Mondays for diagnosis of high blood pressure. According to the monthly electronic MARs, R1 was receiving the following medications for a diagnosis of high blood pressure from December 1, 2024 through February 18, 2025: - Cardizem daily; - Hydrochlorothiazide daily; and - Atenolol twice a day. Review of the R1's clinical record for the weekly blood pressures revealed that 10 out of 12 scheduled opportunities, R1's blood pressure was not checked per the physician's order. 2/25/25 11:30 AM - During a combined interview with E2 (DON) and E3 (RNAC/Supervisor), finding was reviewed and acknowledged. No further information was provided to the Surveyor. 2/26/25 3:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2, E13 (ED) and a representative from the Ombudsman's office.

Based on clinical record review and interview, it was determined that for one (R3) out of one resident reviewed for hospitalization, the facility failed to send a copy of a hospital transfer notice to the Office of the State Long-Term Care Ombudsman. Findings include: Review of R3's clinical record revealed: 1/10/25 - R3 was admitted to the facility with multiple diagnoses, including the aftereffects from a fall, heart disease, chronic pain, diabetes and anemia. 1/15/25 - R3 experienced severe stomach pain with diarrhea, and the R3 was sent to the hospital for an evaluation, and was admitted to the hospital. 2/25/25 1:15 PM - During an interview, E1 (NHA) stated that the facility failed to send a copy of the hospital transfer notice the State Long-Term Care Ombudsman for the R3's 1/15/25 hospitalization. 2/26/25 3:30 PM - Findings were reviewed during the exit conference with E1, E2 (DON), E13 (ED) and a representative from the Ombudsman's office.

Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings include: 2/5/24 from 8:22 AM to 8:35 AM, observation of the kitchen with E1 (NHA) revealed the following: - observed 1/4 tray of cake (vanilla with chocolate icing) and a full tray of sloppy joe were undated in the refrigerator; - observed a full tray of frozen dough that was not covered completely and undated, a plate with two pieces of cooked chicken was uncovered and undated and a clear bag of chicken nuggets was undated in the walk-in freezer. Finding was immediately confirmed with E1 (NHA). 2/9/24 at 3:30 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).

Based on record review and interview it was determined that for one (R4) out of five residents reviewed for clinical records, the facility failed to ensure that R4's medical records were complete and readily accessible as evidenced by the failure to upload the attending physician notes in the EMR (electronic medical record). Findings include: 5/21/20 - R4 was admitted to the facility. 1/23/23 - R4 was seen by E6 (MD) for R4's required 60 day visit. 3/27/23 - R4 was seen by E6 for R4's required 60 day visit. 5/6/23 - R4 was seen by E6 for R4's required 60 day visit. 6/26/23 - R4 was seen by E6 for R4's required 60 day visit. 8/28/23 - R4 was seen by E6 for R4's required 60 day visit. 10/23/23 - R4 was seen by E6 for R4's required 60 day visit. 2/8/24 - There was no evidence in R4's EMR of the 1/23/23, 3/27/23, 5/6/23, 6/26/23, 8/28/23 and 10/23/23 encounter or the subsequent progress note by E6. 2/9/24 3:30 PM - Findings were reviewed at the Exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).

Based on record review and interview, it was determined that for one (R8) out of five residents reviewed for physician services, the facility failed to ensure the resident was seen for the required physician visits. Findings include: R8's clinicial record revealed: 12/5/23 - R8 was admitted to the facility. Review of R8's clinical record revealed the absence of an initial comprehensive visit by the Physician. 2/8/24 at 2:03 PM - During a combined interview, finding was confirmed with E1 (NHA) and E3 (Regional Clinical Director). 2/9/24 at 3:30 PM - Finding was reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director), E4 (RN Unit Manager) and E5 (ADON).

Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required training on abuse, neglect and exploitation was completed for one (E8) out of 12 randomly sampled staff members. Findings include: Review of E8's personnel records revealed: 12/21/21 - The first day of assignment at the facility for E8 (Enrichment Assistant). 4/26/22 at 12:50 PM - In an interview, E1 (NHA) confirmed that E8 did not receive his abuse, neglect and exploitation training. Findings where reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 4/26/22 beginning at 3:15 PM.

Based on review of clinical records, interviews and review of facility and other documentation as indicated, it was determined that for 1 (R48) out of 1 death record the facility failed to have an effective system to coordinate, document and implement DNR code status. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. For R48, the facility failed to ensure that a physician or nurse practitioner discussed DNR code status with the resident and/or the resident's legal representative upon admission to the facility on [DATE]. R48 had an acute medical emergency at the facility on [DATE] and Emergency Medical Services (EMS) personnel responded. The facility failed to show proper DNR code status paperwork when requested by EMS personnel. The facility's failure to coordinate, document and implement R48's DNR code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25, was identified as an Immediate Jeopardy (IJ) on [DATE] at 3:44 PM. IJ was abated on [DATE] at 2:30 PM. Additionally, for two (R1 and R14) current residents with DNR orders, the facility failed to ensure the State DMOST form, also indicating the same DNR status, was signed by the physician in accordance with State law and facility policy. For one (R8) a current resident, the facility failed to ensure the physician had a discussion with the resident or legal representative in accordance with facility policy and State law before writing a DNR order. Findings include: The facility's policy and procedure entitled Do Not Resuscitate (DNR), last revised on ,[DATE], stated, Policy. Cardiopulmonary resuscitation (CPR) is administered to any resident suffering a cardiac or respiratory arrest, unless that resident has a 'do not resuscitate (DNR)' order. A DNR order is permitted if the resident or his/her legal representative has discussed the ramifications with their physician or nurse practitioner as allowed per state regulations and the physician or nurse practitioner has placed the appropriate order in the resident's medical record. A DNR order does not permit the facility to refrain from sending the resident to the hospital if, in the professional staff's opinion they cannot provide needed care for the resident. PR[NAME]EDURE: .If a resident does not wish to receive CPR, the resident or staff member must inform his/her attending physician or nurse practitioner. .The resident's legal representative can inform the physician or nurse practitioner if the resident is incapacitated or unable to make his/her wishes known. .The attending physician or nurse practitioner must discuss with the resident and/or family and/or legal representative what a DNR order involves. .Any legal representative deciding on a DNR must base the decision on the resident's wishes, including the resident's religious and moral beliefs; or, if the resident wishes are not known, in the resident's best interest. .The attending physician or nurse practitioner must then write a DNR order and a progress note in the resident's medical record. NOTE: the state designated DNR form will suffice as the progress note. .The progress note must state that the DNR was requested and that the physician or nurse practitioner discussed the DNR order with the resident or the resident's legal representative. Review of Title 16 of the Delaware Code, Chapter 25 Health-Care Decisions, stated, . Section 2501 Definitions . (b) 'Agent' shall mean an individual designated in a power of attorney for health care to make a health-care decision for the individual granting the power . (h) 'Health-care decision' shall mean a decision made by an individual or the individual's agent . regarding the individual's health care, including: . (2) Acceptance or refusal of . orders not to resuscitate; . (4) Execution of a DMOST form pursuant to Chapter 25A of this title . Section 2503 Advance health-care directives . (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after consultation with the attending physician . and in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent . Section 2508 Obligations of health-care provider (a) Before implementing a health-care decision made for a patient, a supervising health-care provider, if possible, shall promptly communicate to the patient the decision made and the identity of the person making the decision. The decision of an agent .does not apply if the patient objects to the decision to remove life-sustaining treatment, providing that the objection is (1) by a signed writing or (2) in any manner that communicates in the presence of 2 competent persons, 1 of whom is a physician .Chapter 25A Delaware Medical Orders for Scope of Treatment Act . (c) . (DMOST) means a clinical process to facilitate communication between healthcare professionals and patients . The process encourages shared, informed medical decision-making. The result is a DMOST form, which contains portable medical orders that respect the patient's goals for care in regard to the use of CPR and other medical interventions . (e) .(1) Is used on a voluntary basis . (3) Is not valid unless it meets the requirements for a completed DMOST form as set forth in this chapter . (4) Is intended to provide direction to emergency care personnel regarding the use of emergency care and to health-care providers regarding the use of life-sustaining treatment by indicating the patient's preference concerning the scope of treatment, the use of specified interventions . (7) Must be signed by a health-care practitioner . The Delaware Basic Life Support Protocols, Guidelines and Standing Orders for Prehospital and Interfacility Patients by the Delaware Office of Emergency Medical Services (EMS) and the Delaware Health and Social Services Division of Public Health, effective [DATE], stated, .Current guidelines for do not resuscitate orders .Do Not Resuscitate Order (DNR) .Delaware Medical Orders for Life Sustaining Treatment (DMOST). A DMOST form is a medical order sheet based on the person's current medical condition and wishes .The DMOST form will clearly indicate the patient's wishes concerning life-sustaining treatment and CPR .Section B: . (CPR) . Section E: Review of Orders with Patient. Documents that orders were reviewed with patient or their representative .Section F: Signatures. EMS provider must review this section to ensure it is signed by the patient (or their authorized representative) and healthcare provider . 1. Review of R48's clinical record revealed the following: [DATE] - A copy of R48's advance directive was in the clinical record. The advance directive stated, .I designate the following individual as my Agent to make health care decisions for me: . F2 (Spouse of R48) .I hereby designate additional or successor Agent: . F3 (Family Member of R48) . Qualifying Conditions: Terminally Ill - (selected) Option 3: Do not Prolong Life . Serious Illness or Frailty - (also selected) Option 1: My Agent will make decisions on my behalf: In the event I have a serious Illness or frailty and I am unable to understand, make or communicate my wishes, I direct that my Agent make all medical decisions on my behalf . [DATE] at 10:25 AM - The hospital Discharge Summary stated, .Condition at Discharge stable . [DATE] at 12:45 PM - R48 was admitted to the facility for rehabilitation and intravenous (IV) antibiotic therapy status [REDACTED]. [DATE] at 11:45 AM - A Social Service note, written by E17 (SW), stated, Meeting with resident's spouse, (name) who with resident's permission is signing admission paperwork. Spouse feels resident 'is not herself'. All paperwork completed .He/she has POA (Power of Attorney) with (other family member name) as back up PO[NAME] Code status discussed. Spouse states resident wants DNR status, reported to nursing. D/C (discharge) goal uncertain with current medical conditioning and physical functioning level .Spouse is at bedside most of day. [DATE] at 1:19 PM - A verbal physician's orders [REDACTED]. By entering the verbal physician's orders [REDACTED]. [DATE] at 1:36 PM - A History & Physical (H&P) was completed by E5 (Physician). The H&P did not address R48's code status. [DATE] at 5:31 AM - The EMS Prehospital Care Report revealed that BLS (Basic Life Support) personnel arrived at the patient (R48) on [DATE] at 5:31 AM. The report stated, .Upon arrival of ALS (Advanced Life Support) and BLS crews Pt (patient) was unresponsive pulse less (sic) and apnic (sic) (not breathing) laying supine (on back) on the floor .Pt was found on floor this morning by Facility staff and pt was unresponsive so they called 911 .Facility advised BLS crew that Pt has a DNR however Facility did not have proper DNR paperwork on hand for BLS crew. Pt's (spouse) wished for resuscitation efforts to be initiated by BLS crew. No bystander CPR was being preformed (sic) prior to BLS arrival . [DATE] at 9:11 AM - A late entry nurse's note, written by E19 (RN) stated, Nurse checked on pt at (midnight) .PT WAS SLEEPING soundly, no s/s (signs/symptoms) distress noted . Visual observation on hall way during the night pt sleeping and no s/s distress. Another rounds (sic) done at 3:50 AM and pt was on his/her bed with [MEDICAL CONDITION] on. At 4:56 AM upon entering pt room he/she was found on the floor, pt did not respond to verbal commands but had positive faint carotid (neck) pulse/resp. pt respond (sic) lethargically to sternal rub. immediately contacted .911, md, and spouse. 911 arrived, spouse and .(family member) present. Police officer onsite .Medics MD pronounced pt without signs of life . [DATE] at 10:12 AM - E6 (NP) electronically signed the verbal physician's orders [REDACTED]. [DATE] - The facility's investigation of R48's death on [DATE] failed to identify that R48 had an incomplete DNR code status at the time of the acute medical emergency. The facility failed to identify that R48's incomplete DNR code status was not completed in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. [DATE] at 7:37 AM - During an interview, E19 (RN) stated that at 4:56 AM, he/she entered R48's room with IV antibiotic medication to administer. E19 stated that R48's right side upper body was leaning against the bed and R48's lower body was on the floor with all the bed linens/blankets underneath him/her. E19 stated that he/she called for help, performed a sternal rub, and checked R48's pulse which was faint. E19 stated R48 was lethargic. E19 stated that he/she lowered R48 to the floor, stepped out of the room and asked E20 (CNA) to stay with R48. E19 stated that he/she called 911, F2 (R48's spouse), E2 (DON) and the on-call physician. E19 stated, And before I even called 911, F2 asked me 'Is somebody coming? Is somebody coming?' E19 stated, Yeah, help is on the way, help is on the way. Because I had to put papers together. I assigned the other nurse and the cna to be there in that room. E19 stated that F2 came immediately and phoned F3 (R48's family member) from R48's room. E19 stated that upon arrival, EMS personnel asked to see the document to make sure R48 was a DNR. E19 stated that he/she told them verbally. E19 stated that he/she printed everything and showed them the eMAR and eTAR, which stated DNR. E19 stated that EMS personnel were given a bunch of documents to show them proof that R48 had the status of a DNR. E19 stated that the documents were: plan of care, face sheet, doctor's H&P, eMAR and eTAR. E19 stated that the EMS personnel asked F2 (R48's spouse) if he/she wanted CPR as F2 was present in the room. E19 stated that F2 said yes. E19 stated that EMS personnel proceeded to give R48 CPR and then a short while later they pronounced him/her. E19 stated that he/she knew R48 was a DNR because he/she reviewed the eMAR/eTAR when the resident was admitted to the facility. E19 stated that was the first thing he/she looked at because you never know, anything could happen. [DATE] at 12:56 PM - During an interview, E6 (NP) confirmed that he/she gave the verbal physician's orders [REDACTED]. When asked if he/she wrote any progress notes in R48's clinical record, E6 stated no after reviewing the electronic clinical record. When asked if he/she had any discussion about code status with R48 and/or R48's family, E6 stated no. [DATE] at 8:38 AM - During an interview, E17 (SW) confirmed that he/she had a code status discussion with F2 (Spouse). E17 stated that F2 (Spouse) wanted a DNR code status for R48. E17 stated he/she could not remember who he/she told, probably the nursing supervisor. E17 stated that nursing passes the information on to the Physician/NP. When asked what the procedure was for DNR code status, E17 stated that the Physician/NP meets with the resident/family and has a conversation and then documents the code status in the clinical record and enters a physician order. [DATE] at 9:26 AM - During an interview, E5 (Physician) stated that R48's spouse (F2) was not present during the History & Physical on [DATE]. E5 stated that he/she did not want to have the code status discussion since the family was not present and he/she left R48's code status section blank on the [DATE] History & Physical. [DATE] at 2:10 PM - During a telephone interview, E22 (RN) stated that between 5 and 5:30 AM he/she went into R48's room to see what was happening. E22 stated that no one else was in the room. E22 stated that he/she did not see R48 on the bed and went further into the room and saw R48 on the floor in between the two beds. E22 stated that he/she observed R48's lips were blue, hands were cold, able to move his/her fingers, and checked R48's brachial (arm) and carotid (neck) pulses. E22 stated there was no pulse. E22 stated he/she went to look for E19 (RN) and found E19 returning to the room (in conflict with E19's (RN) interview on [DATE] when E19 stated that he/she asked E20 (CNA) to stay with R48 prior to leaving the room to make calls). E22 stated that E19 told him/her that he/she called 911 and F2 (R48's spouse). E22 stated the next thing F2 arrived and E22 was trying to console F2, who was crying. E22 stated that F3 (R48's family member) arrived and was on the floor kissing R48 and crying. E22 stated that it took EMS personnel some time to arrive. E22 stated that EMS personnel asked about code status and E19 told them R48 was a DNR. E22 stated that F2 asked EMS Personnel to revive R48. [DATE] from 3:44 PM to 4:22 PM - A meeting was held with E16 (ED), E1 (NHA), E2 (former DON), E3 (acting DON) and the survey team. The survey team informed the facility that an Immediate Jeopardy was identified and involved R48 and the facility's failure to complete R48's code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility MD/NP failed to have a sit down discussion with R48's spouse (POA) to determine his/her code status wishes for R48, what the selected code status entailed and a written progress note of the code status discussion. [DATE] at 6:41 PM - A meeting was held with E1 (NHA), E2 (former DON), E3 (acting DON) and E6 (NP). The survey team identified 3 additional residents (R1, R8 and R14) currently in the facility that had incomplete code status documentation in their clinical records. The facility also conducted an audit of all the current residents and acknowledged that there were incomplete code status issues with some residents. [DATE] at 7:31 PM - The facility submitted a Plan of Correction to the survey team. The facility's NP, E6, was inserviced on the facility's DNR policy and procedure immediately. E6 then started working on the code status for the 3 residents identified by the survey team as having incomplete code status documentation. The facility started inservicing the nursing staff on the DNR policy and procedure. [DATE] from 7:37 PM to 8 PM - E6 (NP) spoke with either the resident/legal representative/POA to discuss each resident's advance directives. E6 wrote progress notes in each resident's clinical record documenting the discussion, the code status and then entered new physician's orders [REDACTED]. [DATE] at 12:35 PM - E5 (Physician) was inserviced on the facility's DNR policy and procedure as he/she signed and dated a copy of the facility's DNR policy and procedure. [DATE] at 2:30 PM - The facility completed the nursing staff inservices on the facility's DNR policy and procedure. The facility's Immediate Jeopardy was abated at this time. The facility failed to have an effective system to coordinate, document and implement DNR code status for R48 in accordance with the DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. [DATE] from 4:30 PM to 5:45 PM - A review of all current residents in the facility, totaling 43, revealed incomplete code status documentation in the following 3 residents' (R1, R8 and R14) clinical records: 2. R8's clinical record revealed a [DATE] History & Physical that noted R8 was a Full Code. A [DATE] physician progress notes [REDACTED]. A prescriber written physician's orders [REDACTED]. R8's clinical record lacked evidence of a [DATE] physician progress notes [REDACTED].patient .alert and coherent and quite articulate .plan .Patient is a DNR. Although R8 had a DNR physician's orders [REDACTED]. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. 3. R14's clinical record revealed a DMOST form signed by R14's POA and dated [DATE]. In Section B, R14's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R14 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. 4. R1's clinical record revealed a DMOST form signed by R1's POA and a Hospice Nurse on [DATE], which was the same day that R1 elected Hospice benefits. In Section B, R1's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R1 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference.

Based on observations and interviews, it was determined that the facility failed to properly prepare, store, and serve food in a sanitary manner. Findings include: During the kitchen inspection on 7/1/19 from 11:00 AM - 12:00 PM, it was observed that the floor tiles and grout throughout the facility were in disrepair. The holes in the corner of walls from the broken tiles will create opportunities for pests to infest the kitchen. Furthermore, it was observed that the ceiling tiles at the food service area were greasy and porous. The ceiling must be easily cleanable to reduce contamination from daily wear and tear. Findings were reviewed and confirmed with E18 (Food Service Director) on 7/1/19 at approximately 12:00 PM. Findings were reviewed with E1 (NHA) on 7/3/19 at approximately 3:00 PM.

Based on interviews and review of facility documentation, it was determined that the facility failed to have sufficient nursing staff with the appropriate skills to ensure that all residents received needed care and services. Findings include: 1. Resident Council Meeting minutes reviewed from (MONTH) 2019 through (MONTH) 2019 stated: 1/21/19 - .Old Business: Medicines not being given on time. Weekends are not good, some miss breakfast since they are the last to get up . 2/19/19 - .Nursing: Call light time is still ongoing for all three shifts. The water is not being filled on a regular basis. Beds are not being made in the am shift . 3/18/19 - .New Business: .[NAME] Beds are still not being made. B. The water is being filled. This concern is resolved. C. Call light response time is improving .improved to 20 minutes and all shifts improved. This concern is resolved . 5/30/19 - .Nursing .Resident sat 40 minutes before call bell got answered .Several residents are waiting for their aide to come and put them to bed after resident lunch . 6/6/19 - .Nursing .Various residents discussed concern about call bell response time and shower preference . 6/24/19 - .Call [NAME] response time still seems to be a general area of concern with most residents. The weekends tend to be worse than the week time . 2. A surveyor conducted Resident Council Meeting was held on 7/3/19 at approximately 10:30 AM. There were 17 (A4 through A20) residents present. When asked Do you get the help and care you need without waiting a long time? Does staff respond to your call light timely? Eleven (A4 through A8, A10, A13, and A15 through A19) out of the 17 residents stated that they do not always get the help and care they need without waiting a long time. They stated that they have had to wait 20 to 60 minutes at times. 3. The facility's Alarm (call bell) Response Report was reviewed for 6/30/19, 7/1/19, 7/5/19, and 7/6/19. The report revealed the following: 6/30/19 - The response time to R12's call bell was 22 minutes and 2 seconds; 6/30/19 - The response time to R37's call bell was 24 minutes and 17 seconds; 6/30/19 - The response time to R42's call bell was 21 minutes and 28 seconds; 6/30/19 - The response time to R248's call bell was 25 minutes and 51 seconds; 7/1/19 - The response time to R42's call bell was 37 minutes and 50 seconds; 7/5/19 - The response time to R7's call bell was 21 minutes and 5 seconds; 7/5/19 - The response time to R6's call bell was 21 minutes and 15 seconds; 7/6/19 - The response time to R37's call bell was 21 minutes and 37 seconds. 4. Interviews during the survey with five (A1, A2, A3, A4, and A5) residents and one family member (F4), all who wished to remain anonymous, revealed the following: [NAME] 7/1/19 10:00 AM - During an interview, A1 stated that he/she waits a long time. A1 stated that yesterday (Sunday) I sat for one hour and 15 minutes waiting to go to the bathroom. A1 stated this occurred around 1 PM to 2:15 PM. A1 stated that he/she was very wet, that weekends are the worst. A1 stated he/she spoke with a nurse (did not identify who), who ended up toileting him/her and changing his/her clothes. A1 also stated that the nurse responded, you know there are problems here. B. 7/1/19 10:39 - During an interview, A2 stated that he/she has had to wait approximately 30-45 minutes for staff to respond on the 11 PM to 7 AM shift. C. 7/2/19 10:52 AM - During an interview, A3 and F4 (family member) stated that A3 has had to wait 45 minutes for staff to respond to the call bell for assistance to go to the bathroom. A3 and F4 stated that this occurred yesterday (Monday) at approximately 3:50 PM. A3 and F4 stated that it took staff approximately 40 minutes to respond. F4 was angry and stated, this is not acceptable. D. 7/3/19 11:05 AM - During an interview, A4 stated that there have been times during the 11 PM to 7 AM shift when he/she has had to wait an hour before their call bell was answered. E. 7/2/19 10:00 AM - During an interview, A5 stated that the facility was understaffed and that it takes 20 to 25 minutes for staff to respond to call lights. A5 stated it was especially bad on weekends across all three (3) shifts. The facility failed to have sufficient nursing staff to meet the needs of all residents. 7/15/19 approximately 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).

Based on reviews of one (R48) death record and 43 current residents' records, interviews and review of facility documentation as indicated, it was determined that the facility's Quality Assessment and Assurance Committee failed to identify a system failure to follow the facility's DNR policy and procedure that was in place since ,[DATE] to ensure completion of 7 (R1, R3, R8, R14, R17, R33 and R48) residents' code status. Findings include: Cross refer to F678 Review of R48's clinical record revealed that on [DATE], R48 had an acute medical event and was found on the bedroom floor at 4:56 AM. Facility staff did not initiate CPR as R48 was a DNR according to what was listed in R48's clinical record. E19 (RN) called 911 emergency services at 5:13 AM and EMS personnel responded. Despite E19 stating that R48 was a DNR and showing multiple documents to EMS personnel, the facility failed to have the proper DNR paperwork on hand for EMS personnel. The facility's failure to complete R48's code status according to the facility's DNR policy and procedure was identified as immediate jeopardy (IJ) on [DATE] at 3:44 PM. Review of all current residents' clinical records in the facility, as of [DATE], revealed that 6 (R1, R3, R8, R14, R17 and R33) out of 43 residents had incomplete code status documentation. [DATE] at 6:41 PM - A meeting was held with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The survey team identified 6 additional residents currently in the facility that had incomplete code status documentation in their clinical records. The facility also conducted an audit of all the current residents and acknowledged that there were incomplete code status issues with some residents. [DATE] at 11:10 AM - During a combined interview with E1 (NHA), E2 (former DON) and E3 (interim DON), when asked if the facility identified a system failure with respect to code status, E1 stated that the QAA Committee talked about having a code status for each resident during QAA meetings. However, E1 stated that the QAA Committee never identified an issue with code status, specifically the failure to follow the facility's DNR policy and procedure. E1 stated that the QAA Committee never developed an official performance improvement plan for code status. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP) during the Exit Conference. The facility's Quality Assessment and Assurance Committee failed to identify a system failure to follow the facility's DNR policy and procedure that was in place since ,[DATE] to ensure completion of code status' for 7 residents.

Based on observations, record review and interview, it was determined that the facility failed to ensure that one (R44) out of two residents reviewed for the care area of urinary catheter/urinary tract infection was treated with respect and dignity. Findings include: Review of R44's clinical record revealed the following: 6/5/19 - A care plan was developed for indwelling Foley catheter use. Interventions included, .position catheter bag and tubing below the level of the bladder and away from entrance room door for my dignity . The following observations were made of R44: 7/2/19 8:58 AM - R44 was observed seated in a recliner in his/her room watching TV. The Foley catheter drainage bag was hanging on the wheel of a wheelchair next to R44 and was visible from the doorway of R44's room. The drainage bag was not covered and the urine was very bloody. 7/2/19 10:16 AM - R44 remained seated in a recliner in his/her room with the urinary drainage bag still hanging on the wheelchair containing bloody urine visible from the doorway. 7/3/19 9:39 AM - R44 was seated in a recliner in his/her room asleep. The urinary drainage bag was hanging on a rollator next to the resident. The drainage bag was currently empty, but not covered and visible from the doorway. 7/8/19 10:40 AM - R44 was seated in a recliner in his/her room with eyes closed. The urinary drainage bag was hanging on a rollator next to him/her, not covered and visible from hallway. The facility failed to ensure that R44 was treated with respect and dignity when his/her catheter drainage bag was left uncovered and visible to anyone in the hallway and/or entering the room. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).

Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for 1 out of 1 death record sampled, the facility failed to notify the resident's physician when R48 did not receive 2 doses of Lacosamide medication and R48 had a new [DIAGNOSES REDACTED]. The facility's policy entitled Physician Notification, last revised in 6/2014, stated, . Procedure: 1. The licensed nurse is responsible for notifying the resident's physician at a minimum when there is: . j. The inability to obtain or administer on a prompt and timely basis prescribed medications . 5. Record the following in the resident's health record: a. All attempts to notify the physician or on-call physician, method of attempted contact, time and individuals contacted . b. Reported assessment findings. c. Additional information provided. d. Physician's response. e. physician's orders [REDACTED]. Resident's status and response to the treatment ordered. g. Notification of family or legal representative provided and the family or legal representative response. Review of R48's clinical record revealed: 5/28/19 - The hospital's Medication Orders Upon Discharge stated to administer the next dose of Lacosamide to R48 at 10 PM tonight (5/28/19). 5/28/19 at approximately 12 Noon - R48 was admitted to the facility with a [DIAGNOSES REDACTED]. 5/28/19 - A physician's orders [REDACTED]. 5/28/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Note at 10:33 PM revealed that R48 did not receive Lacosamide at 8 PM because they were waiting for the pharmacy to deliver the medication. Review of R48's clinical record lacked evidence that the physician was notified of the inability to obtain and administer the above medication to R48 on 5/28/19 at 8 PM. 5/29/19 at 1:27 AM - The pharmacy's Proof of Delivery report for R48 revealed that Lacosamide was delivered to the facility at this time. 5/29/19 at 8 AM - Review of R48's eMAR revealed that he/she received the 8 AM dose of Lacosamide. 5/29/19 at 8:45 PM - An Order-Administration Note, written by E24 (RN), for R48's Lacosamide stated, .Not delivered yet from (name) pharmacy. Despite having received the Lacosamide medication from pharmacy on 5/29/19 at 1:27 AM and R48 receiving the 8 AM dose, R48 was not administered the medication at 8 PM. Review of R48's clinical record lacked evidence that R48's physician was notified that R48's anti-[MEDICAL CONDITION] medication was not administered. 7/10/19 at 2:36 PM - During a combined interview with E2 (former DON) and E4 (ADON), E2 stated that when a physician was contacted, nurses should be documenting this information in the progress notes. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to notify the physician when R48's Lacosamide medication was not available and/or administered.

Based on clinical record review and interview, it was determined that for one (R47) out of one Admission, Transfer, Discharge sampled resident, the facility failed to ensure that appropriate information was communicated to the receiving health care provider to ensure a safe and effective transition of care for R47. Findings include: Review of R47's clinical record revealed: 3/13/19 - R47 was admitted to the facility for skilled nursing and rehabilitation. 4/16/19 - A physician's orders [REDACTED]. Review of R47's clinical record lacked evidence that the facility provided the following information to the receiving health care provider: - lab results dated 4/16/19; - an accurate ADL status of R47 and current vital signs on the interagency nursing communication record; - updated comprehensive care plan; - special instructions/precautions for ongoing care, including adaptive equipment needs; and - a copy of the resident's discharge summary. 7/9/19 at 11:38 AM - During an interview, E17 (SW) stated that he/she did not send R47's care plan to the receiving provider. 7/15/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to ensure that appropriate information was communicated to the receiving health care provider to ensure a safe and effective transition of care for R47.

Based on clinical record review and interview, it was determined that for one (R47) out of one Admission, Transfer, Discharge sampled resident, the facility failed to develop R47's discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions. Findings include: Review of R47's clinical record revealed: 3/13/19 - R47 was admitted to the facility for skilled nursing and rehabilitation. 4/16/19 - A physician's orders [REDACTED]. Review of R47's clinical record lacked evidence of a complete discharge summary that included: - a recapitulation of R47's stay at the facility that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results; and - a post-discharge plan of care that was developed with the participation of the resident, including any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services. 7/9/19 at 11:27 AM - During a combined interview, findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E17 (SW) and E4 (ADON). The facility failed to develop a discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions.

Based on record review and interview, it was determined that for two (R42 and R44) out of six (6) residents sampled for medication review, and for one (R48) out of one (1) resident sampled for death review, the facility failed to administer medications as ordered and/or transcribe physician's orders [REDACTED]. 1. Review of R42's clinical record revealed: 6/14/19 - A physician's orders [REDACTED]. 6/28/19 - A physician's orders [REDACTED]. Review of the eMAR revealed R42 received the [MEDICATION NAME] 2.5 mg on 6/28/19, 6/30/19, 7/2/19, and 7/4/19 for a total of four (4) doses. The facility failed to administer the fifth dose of [MEDICATION NAME] on 7/6/19 as per physician's orders [REDACTED]. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 2. Review of R44's clinical record revealed the following: 6/5/19 - A physician's orders [REDACTED]. According to the (MONTH) 2019 MAR, the Eliquis was timed to be administered at 9:00 AM and 6:00 PM. 7/2/19 10:35 AM - A physician's orders [REDACTED]. Review of the eMAR revealed that the 7/2/19 9:00 AM Eliquis dose had already been given prior to the order being written. Review of the eMAR revealed that the Eliquis was held on: - 7/2/19 at 6:00 PM; - 7/3/19 at 9:00 AM and 6:00 PM; - 7/4/19 at 9:00 AM and 6:00 PM; - 7/5/19 at 9:00 AM. This was a total of three (3) days or six (6) doses held. According to the physician's orders [REDACTED]. 7/8/19 2:29 PM - During an interview with E6 (NP) regarding the order to hold Eliquis for 2 days, written on 7/2/19, E6 confirmed that he/she would have expected it to be resumed on 7/4/19 with the 6:00 PM dose. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 3. Review of R48's clinical record revealed: A facility policy and procedure entitled Physician order [REDACTED].To strive to ensure that physician orders [REDACTED]. Procedure: 1. The licensed nurse receiving a hand-written physician order [REDACTED]. b. Enter the physician order [REDACTED]. 2. In order to double check that orders were not overlooked and are accurate in the electronic application order entry process, within twenty-four (24) hours, a second licensed nurse shall review the hand-written transcribed and newly entered physician orders [REDACTED]. Notify the physician as to the physician order [REDACTED]. Transcribe the correct order on the electronic health record application. 5/28/19 - R48 was admitted to the facility. 5/30/19 - A handwritten physician's orders [REDACTED]. The facility failed to transcribe the 5/30/19 physician's orders [REDACTED]. 5/31/19 - Review of R48's 24 Hour Chart Check form, performed on the 11 PM to 7 AM shift, revealed a blank space in the Initials column on 5/31/19 where a nurse signs off that it was completed. The facility failed to perform a 24 hour chart check on 5/31/19. 6/1/19 - The handwritten 5/30/19 physician's orders [REDACTED]. Although the 24 Hour Chart Check wasn't completed on 5/31/19, a nurse documented under the written order that he/she reviewed it on 6/1/19, but still did not identify the omission. Review of R48's (MONTH) 2019 and (MONTH) 2019 eMARs and Physician order [REDACTED]. 7/15/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to transcribe the 5/30/19 physician's orders [REDACTED].

Based on clinical record reviews, interviews, and review of facility documentation as indicated, it was determined that for two (R26 and R43) out of four (4) residents sampled for accidents, the facility failed to ensure that adequate supervision and assistance was provided to prevent accidents. For R43, the facility failed to complete a Physical Therapy (PT) evaluation post fall on 10/22/18 and failed to ensure that R43 was not left alone while toileting on 4/9/19. R43 fell when left alone in the bathroom and sustained a skin tear to the top of his/her right hand. For R26, despite a care plan for 2 - person transfer assist, an unsafe 1-person stand/pivot transfer was performed when R26 fell from the bed to the wheelchair on 2 occasions. R26 had another fall when R26's bed was not in the lowest position. Additionally, the facility failed to ensure adequate supervision and failed to follow R26's toileting plan when R26 fell while being assisted by his/her spouse off the toilet in the bathroom. R26 had 11 falls in 4 months from (MONTH) through (MONTH) 2019. Findings include: 1. Review of R43's clinical record and facility documents revealed the following: 10/22/18 - The facility's Incident Report stated, .in gym with fitness instructor. While transferring from w/c (wheelchair) .lost his/her balance and hit his/her head . The facility's Quality Assurance Report, dated 10/23/18, stated that as part of the corrective action, a PT evaluation would be completed. Review of the clinical record, including PT notes, lack evidence of a therapy evaluation being completed after R43's 10/22/18 fall. 4/3/19 through 4/6/19 - R43 was hospitalized . 4/6/19 approximately 3:00 PM - R43 was readmitted to the facility. 4/7/19 3:19 PM - A Rehabilitation Note stated, DOR (Director of Rehabilitation) asked by charge nurse to assist in establishing transfer status for resident. Current recommendation is for resident to use Hoyer lift with all transfers at this time. Resident is unsafe to perform standing transfers or ambulate until further assessment is completed. Resident and CNA agreeable to recommendation. 4/9/19 7:30 AM - A Rehabilitation Note stated, PT eval (evaluation) completed 4/8/19, recommend continuing with Hoyer lift at this time and having resident use WC for all mobility on and off unit. 4/9/19 6:40 PM - A progress note stated, Writer was called .to find resident sitting on his/her bottom with back towards wall facing toilet .Resident noted with skin tear to top of right hand measure (sic) at 1.5 cm . 4/9/19 - A written statement, completed by E21 (CNA), stated R43 was transferred to the toilet and R43 stated he/she wanted to sit for a few minutes to have a bowel movement. E21 wrote that he/she left the resident and went down the hall to get some wipes. E21 wrote that by the time he/she returned, R43 had attempted to get up even after I had told him/her to wait for me and not to get up before leaving the room, he/she had agreed. 4/10/19 - The facility's investigation stated, .Resident was transferred to the toilet using the full mechanical lift (Hoyer lift) and 2 person assist. Lift was removed from in front of the resident to give more space to provide care. New CNA left resident to get wipes in the hall, when he/she returned the resident was on the floor. The resident appears to have attempted to self transfer and lost his/her balance and fell to the floor .The CNA was given extensive education on not leaving a resident in the bathroom without supervision and to make sure he/she has all necessary supplies prior to toileting/transferring a resident. 7/8/19 approximately 4:45 PM - Findings were reviewed with E2 (former DON). 7/8/19 4:53 PM - During an interview, E15 (OT) stated that anyone requiring a Hoyer lift transfer usually had poor standing and/or sitting balance. E15 agreed that R43 should not have been left unsupervised on the toilet on 4/9/19. The facility failed to ensure that a PT evaluation was completed post fall on 10/22/18, and failed to ensure that R43 had adequate supervision on 4/9/19. Instead, facility staff left the resident alone in the bathroom when he/she attempted to self transfer resulting in a fall and a skin tear. 7/9/19 approximately 8:15 AM - During an interview, E1 (NHA) and E2 (former DON) provided documentation of a PIP (Performance Improvement Plan) and stated that they self identified having issues with falls in the facility. They stated that although they continue to have resident falls, they have not had a fall due to a resident being left alone in the bathroom since R43's 4/9/19 fall. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 2. Review of R26's clinical record revealed the following: R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk care plan was initiated on 1/27/18 identifying that R26 was a fall risk related to a history of falls, leg pain and weakness. Interventions included: - Anticipate and meet the resident's needs. - Be sure the call light is within reach and encourage the resident to use it for assistance as needed .Prompt response to all requests for assistance. - Ensure that the resident is wearing appropriate footwear when ambulating (walking) or mobilizing in wheelchair. - Needs a safe environment with even floors, free from spills and/or clutter; adequate glare-free light; a working and reachable call light, the bed in a safe position for transfers with wheels locked, personal items within reach. - Remind the resident to request assistance for all transfers and mobility. - Ensure bed height is lowered to appropriate level for safe exit/entry and not too high to reduce risk of serious injury. 2/1/18 - The admission MDS assessment stated that R26 was moderately cognitively impaired (decisions poor; cues/supervision required), required extensive assist of one staff person for transfers, and had no falls since admission. 2/12/18 - R26's care plan for bladder incontinence was developed related to dementia and impaired mobility with interventions including staff should supervise and offer toileting every 2 hours during waking hours and check and change as needed due to occasional incontinence. 1/22/19 - A Nursing fall risk evaluation score was high risk at 16. 1/23/19 - A Significant change MDS assessment revealed that R26 was severely impaired and exhibited rejection of care with worsening verbal and physical behaviors. R26 required two+ staff person extensive assist for transfers and had 2 falls without injury. 2/1/19 - A care plan intervention on the problem ADL (Activities of Daily Living) self care performance deficit was added indicating the need for 2 person assist at times to transfer and move in bed. Review of R26's fall incident/investigation reports, nursing progress notes, physician orders [REDACTED]. Fall # 1 2/24/19 at 12:00 PM - R26 fell during a transfer from the bed to a chair with assist from his/her CNA and obtained an abrasion on the left knee. The IDT (Interdisciplinary Team) who reviews falls, noted for PT to screen the amount of assistance appropriate for safe transfers for R26. R26 required 2+ persons for transfers according to his/her significant change MDS, dated [DATE]. There was no evidence that PT screened R26 after his/her fall on 2/24/19. The facility failed to follow the care plan for 2 person transfer. Fall # 2 3/10/19 at 8:45 PM - R26 stated he/she fell out of bed. R26 was trying to transfer himself/herself and was found on the floor on his/her left side. R26's bed was not in the lowest position. R26 was last observed at 8:30 PM resting in bed. Interventions added after the fall included adhering to R26's toileting schedule every 2 hours, offer hipsters, fall mats beside the bed and a pharmacy review. The facility failed to follow R26's care plan for appropriate lowered bed height for safe exit/entry. 3/11/19 - A PT screen status [REDACTED]. 4/15/19 - A PT quarterly screen indicated no skilled services were warranted at this time .continue to recommend 2 person transfers. Anti rollbacks were recently applied on the wheelchair and the wheelchair brakes were tightened. 4/17/19 - A quarterly MDS assessment stated that R26 remained severely cognitively impaired and he/she continued to exhibit rejection of care. R26 required two+ staff person extensive assist for transfers. Since the prior assessment on 1/23/19, R26 had three falls, two falls without injury and one fall with minor injury. 4/18/19 - The following care plan interventions were initiated, .staff to toilet and offer to return to bed for nap at mid - morning, continues to be insistent on performing own tasks and adhering to his/her preferences and self propels in wheelchair back to his/her room regardless of staff redirection. 4/19/19 - A Nursing fall risk evaluation score remained high risk at 14. Fall # 3 5/1/19 at 11:07 AM - R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 had sock on only. A CNA (E25) witness statement summary documented that the last time R26 was cared for or toileted was on the 11-7 shift. E25 stated, Resident was in bed prior to shift change and during rounds. Was with another resident when spouse stopped me in the hall stating that resident was on the floor. Did not witness fall but notified the nurse .he/she was in the bathroom on the floor in front of the toilet. The fall investigation worksheet documented safety education to spouse and footwear - non skid socks to be in place. There was no evidence indicating that R26 was asleep during E25's rounds. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for occasional incontinence. 5/1/19 at 4:15 PM - A PT screen post fall recommended when staff were assisting that the arm rest of the wheel chair be removed and the bed leveled to the chair to minimize the loss of R26's center of gravity and minimize muscular demand as opposed to the bathroom where a railing was available and R26's stability was greater. 5/1/19 - The following care plan interventions were initiated, .continue toileting schedule, monitor for non skids socks when not wearing shoes, 2 person transfer and staff to remove arm rest when able for stand pivot transfer. 5/1/19 - The CNA Kardex documented 2 person transfers - and staff to remove arm rest when able for stand pivot transfer .ensure proper footwear when out of bed and gripper socks when in bed .staff to provide more assistance with dressing, personal hygiene and toileting needs now .keep bed at lowest setting when in bed .obtain and encourage use or wear hip savers. 5/5/19 - The care plan intervention Offer to lay resident down after meals was initiated. 5/7/19 - The care plan intervention Request labs check to r/o (rule out) clinical issue that may add to fall risk was initiated. 5/28/19 - The care plan interventions Keep bed at lowest setting when in bed and obtain and encourage the wear of hip savers were initiated. Fall # 4 6/9/19 at 7:30 AM - R26 was being transferred from the bed into the wheelchair with stand/pivot transfer when R26 slid to the floor from the wheelchair. Predisposing factor included staff handling and gait imbalance. A witness statement was obtained from the CNA who performed the transfer. The facility fall investigation worksheet revealed that the actual transfer when the fall happened was with one staff person (required two). The CNA ADL flowsheet dated 6/9/19 at 11:23 AM documented extensive assist of one person. There was no evidence that two staff person assist was performed during the transfer. Interventions included the Nurse Practitioner was to evaluate for possible labs and a PT evaluation. The facility failed to transfer R26 according to the plan of care. 6/17/19 - A Physician ordered a PT evaluation for the recent fall (6/9/19). 6/21/19 at 6:13 PM - A PT note documented that R26 required extensive assistance of two persons for transfers with a gait belt to help secure R26's safety and stability. 7/9/19 at 2:21 PM - During an interview, E7 (RN) stated that R26 used to ambulate with a walker before his/her increasing left leg pain that caused a decline. R26's increased weakness and agitated behavior made it very difficult for staff during transfers and care. He/She was seen by rehab and had a transfer status change from one person assist stand pivot turn (stand pivot transfer), to two person extensive assist. Sometimes we use the total hoyer lift or the stand up lift to transfer him from bed to wheelchair or whenever we pick him up from the floor. He/She has a lot of falls. The amount of help needed is very inconsistent depending on his/her mental status and his/her ability to help himself/herself on that particular shift or day. 7/9/19 at 2:46 PM - During an interview, E9 (PT) stated that R26 had multiple falls mostly occurring in his/her room recently. When asked if R26 was a hoyer lift or a stand up lift transfer candidate based on feedback from nursing staff, E9 replied that resident is not a lift (Hoyer and/or Stand Up lift) transfer candidate and that resident can display transfers from wheelchair to bed a low (sic) pivot with intermittent trouble clearing armrest and needs 1-2 person maximum assistance for transfers. E9 also added that the wheelchair armrest be removed and the bed leveled to chair to minimize the loss of his/her center of gravity. 7/9/19 at 3:10 PM - In an interview, E10 (CNA) stated that R26 does not use the call bell and does not ask for help when needing assistance with transfers to the bed or to the bathroom. E10 further stated that another aide would have to come with her when she does morning care because of R26's combative behavior. 7/11/19 at 9:59 AM - E10 (CNA) revealed to the surveyor that, We use the total hoyer lift when we transfer him/her from bed to the wheelchair because he/she is very heavy. I think it is in our CNA task. That's how we transfer him/her every time I am assigned to take care of him. When asked about monitoring R26 for safety, E10 stated that R26 frequently stays in the activity room or self propels his/her wheelchair in the hallways. Furthermore, E10 stated, When I see him/her in the hallway, I would ask him/her if he/she wants to use the bathroom, and most of the time he/she would answer, 'No.' If I smell him/her of BM (bowel movement) or urine I will take him/her back to his/her room to change. The facility failed to ensure that the environment was free from accident hazards when: - On 2/24/19 at 12:00 PM, R26 had an unsafe transfer from the bed to the wheelchair when one CNA was providing assistance, instead of two staff that were required, which resulted in a fall with a left knee abrasion. - On 3/10/19 at 8:45 PM, R26 fell out of bed and the bed was not in the lowest position, despite R26 being at high risk for falls. - On 5/1/19 at 11:00 AM, R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 was last toileted by the 11-7 shift. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for incontinence. - On 6/9/19 at 7:30 AM, R26 had a fall due to an unsafe transfer from the bed into the wheelchair with 1 staff person extensive assist, despite the care plan and rehab recommendation for 2 person extensive assist with transfers. Findings were reviewed with E1 (NHA), E2 (former DON), E3 (Acting DON), E6 (NP), and E16 (ED) during the Exit Conference on 7/15/19 at approximately 12:30 PM.

Based on facility document review and interview, it was determined that the facility failed to complete an annual performance review for one (E20) out of five (5) CNAs reviewed. Findings include: Review of E20's employee documents revealed: 3/8/18 - E20's date of hire. There was no annual performance review provided by the facility for E20. 7/15/19 8:55 AM - During an interview, E4 (ADON) confirmed there was no performance review for E20. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).

Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for one out of one death record review, the facility failed to provide routine pharmaceutical services to meet the needs of R48. Findings include: The facility pharmacy's policy entitled LTC Facilities: Receiving Pharmacy Products and Services from Pharmacy, last revised on 1/2/13, stated, .Procedure . 3. The pharmacy will provide new routine and PRN medication orders the same day, unless the medication would be started until the next day. 5/28/19 - The hospital's Medication Orders Upon Discharge stated to administer to R48 the following medications: [REDACTED] - [MEDICATION NAME] (inhaler) twice a day, Next Dose Due: tonight 5/28; - Lacosamide (anti-[MEDICAL CONDITION]) twice a day, Next Dose Due: tonight 10 PM 5/28; - [MEDICATION NAME] (antipsychotic) at bedtime, Next Dose Due: tonight 5/28 10 PM. 5/28/19 at approximately 12:00 Noon - R48 was admitted to the facility. 5/28/19 - R48's physician Order Recap Report also stated that Calcium-Vitamin D (dietary supplement) and a nasal spray were ordered. 5/28/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Notes revealed: - R48 did not receive [MEDICATION NAME], Lacosamide, [MEDICATION NAME], Calcium-Vitamin D and nasal spray at 8 PM as the facility was waiting for the pharmacy to deliver the medications. - At 8:58 PM, R48's [MEDICATION NAME] was discontinued by E6 (NP) for a generic equivalent medication, Breo Ellipta (inhaler), for a [DIAGNOSES REDACTED]. It was unclear in R48's clinical record why the Breo medication was ordered to start on 5/30/19 and not 5/29/19. 5/29/19 at 1:27 AM - The pharmacy's Proof of Delivery report for R48 revealed that Lacosamide, [MEDICATION NAME], nasal spray, Breo Ellipta, and Calcium with Vitamin D were delivered to the facility at this time. 5/29/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Notes revealed: - At 8:45 PM - An Order-Administration Note, written by E24 (RN), for R48's Lacosamide stated, .Not delivered yet from (name) pharmacy. Despite having received the Lacosamide medication from the pharmacy on 5/29/19 at 1:27 AM and R48 receiving her 8 AM dose, R48 was not administered the medication at 8 PM. 7/11/19 at 9:26 AM - During an interview, E5 (Physician) stated he/she was told about R48's missing doses of his/her [MEDICAL CONDITION] medication at a later time. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The facility failed to provide routine pharmaceutical services to meet the needs of R48.

Based on clinical record reviews and interviews, it was determined that for one (R42) out of six (6) residents sampled for medication review the facility failed to ensure R42's PRN [MEDICATION NAME] (anti-anxiety medication) physician's orders [REDACTED]. Findings include: Review of R42's clinical record revealed the following: 6/11/19 - The original physician's orders [REDACTED]. 6/24/19 - An order was written to renew R42's PRN [MEDICATION NAME] for seven (7) days. 7/2/19 - An order was written to renew R42's PRN [MEDICATION NAME] for 14 days. The facility failed to ensure that when the PRN [MEDICATION NAME] orders were renewed on 6/24/19 and 7/2/19 for R42, a corresponding note documenting the rationale to extend the medication was not completed by the prescribing practitioner. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).

Based on clinical record review, interviews and review of facility documentation as indicated, it was determined that for one out of one death record review, the facility failed to ensure that R48 was free of any significant medication errors. R48 missed an 8 AM dose of an intravenous (IV) antibiotic, [MEDICATION NAME], on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat (immediately) IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered. Findings include: The facility's pharmacy policy entitled LTC Facilities: Receiving Pharmacy Products and Services from Pharmacy, last revised on 1/2/13, stated, .Procedure .4. The pharmacy will provide stat medication orders that are not available in the facility's emergency drug supply within one hour of the time ordered during normal pharmacy hours . Review of R48's clinical record revealed: 5/28/19 - The hospital's Medication Orders Upon Discharge for R48 stated to administer [MEDICATION NAME] intravenously every 12 hours. 5/28/19 at approximately 12 Noon - R48 was admitted to the facility for IV antibiotic therapy status [REDACTED]. 5/28/19 - A physician's orders [REDACTED]. 5/30/19 at 8 AM - Review of R48's (MONTH) 2019 eMAR revealed that the resident's IV antibiotic, [MEDICATION NAME], was not administered at 8 AM. 5/30/19 at 8:56 AM - A nurse's note stated, NP (E6) made aware of missing IV tubing. Pharmacy called and new IV tubing to be sent out STAT. 5/30/19 at 12:38 PM - The pharmacy's Proof of Delivery record revealed that R48's IV tubing was received by the facility at 12:38 PM. 5/30/19 at 2:08 PM - An Order-Administration Note for R48's IV antibiotic [MEDICATION NAME] stated, .Waiting for pharmacy. 5/30/19 at 2:41 PM - A nurse's note stated, .Unable to give 0900 (9 AM) abt. (antibiotic) DR (doctor) made aware. Tubing arrived. Dosage schedule has changed . Despite the delivery of the Stat IV tubing at 12:38 PM according to the pharmacy's record, the facility did not administer R48's IV antibiotic. 5/30/19 at 6 PM - R48's (MONTH) 2019 eMAR revealed that the timing of the resident's IV antibiotic was changed from 8 AM and 8 PM to 6 AM and 6 PM. 5/30/19 at 6:30 PM - An Order-Administration Note revealed that R48 received the IV antibiotic. The facility delayed R48's IV antibiotic treatment 6 additional hours after the Stat IV tubing was delivered to the facility. 7/10/19 at 9:03 AM - During an interview, E2 (former DON) stated that the hospital sent R48's discharge information to the facility on Friday, 5/24/19. E2 stated that E4 (ADON) reviewed everything to ensure the facility had everything in place for R48 before he/she was admitted on Tuesday, 5/28/19. E2 stated that the pharmacy provided all IV equipment, including the IV pump, IV tubing and IV medication. 7/10/19 at 2:36 PM - During a combined interview with E2 (former DON) and E4 (ADON), when asked about the missing IV antibiotic dose due to the lack of IV tubing available, E2 confirmed that the facility should have had an emergency backup of IV tubing and he/she had addressed this with the pharmacy. E4 stated that the pharmacy told her the delivery would be in 4 hours for the Stat request. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The facility failed to ensure that R48 was free of any significant medication errors when R48 missed an 8 AM dose of an IV antibiotic on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered.

Based on record review, interview and review of other facility documents and hospital records, it was determined that the facility failed to ensure that one (R53) out of 20 sampled residents received adequate supervision to prevent accidents. R53, assessed as a high risk for falls, was left unattended on 7/24/10 while seated on the toilet in the bathroom, fell and sustained a laceration to the back of her head, requiring transportation to the emergency room and the placement of ten (10) staples. Findings include: R53 was originally admitted to the facility on [DATE] post hospitalization after a fall. Her [DIAGNOSES REDACTED]. Review of R53's Quarterly MDS (Minimum Data Set) Assessment, dated 5/12/10, indicated that R53 was coded "1" (modified independence) for cognitive skills for daily decision making and required limited assistance of one person for toilet use. R53's Fall Risk Assessment, dated 6/21/10, indicated a score of "7" (Score equal to or greater than 6 equals "high risk" for falls). Review of the clinical record revealed that R53 had a history of [REDACTED]. R53's "ADL Plan of Care," dated 7/6/10 which the CNAs can access via their headphones from "AccuNurse," revealed "Cautions: Assistance needed for toileting transfer; Do not leave unattended in bathroom; and "High risk for falls." Review of R53's nurse's notes, dated 7/24/10 and timed 1600 (4 PM) stated, "Resident found on bathroom floor with head against the wall. Laceration on back of head, bleeding frank red blood..." The physician was called and ordered R53 to be sent to the hospital for evaluation. The daughter was notified and requested that her mother be assessed by the Hospice nurse before going to the hospital. Meanwhile, the wound was cleaned and a compression dressing and ice were applied. Another nurse's note, dated 7/24/10 and timed 1730 (5:30 PM) stated, "On call RN vs (visited) from... Hospice. Pt (Patient) with large laceration on back of head bleeding uncontrolled. .." R53 was sent to the hospital emergency room after the nurse from Hospice visited. A nurse's note dated 7/24/10 and timed 2345 (11:45 PM) stated, "Resident returned from (name) Hospital c sutures & dsg to back of head..." The "Facility Internal Incident Report," dated 7/24/10 and timed 1600 (4 PM), revealed that R53 was "alert/oriented," and stated that the resident was "found on bathroom floor with head against the wall. Laceration noted on back of head, bleeding frank red blood. Compression dsg applied. Ice pak applied." Review of E4's, the CNA (certified nurse's aide), assigned to R53, witness statement stated that "While passing ice & water, R53 rang her call light. She wanted to go to the bathroom about 3:30 PM. I assisted her in her wheelchair and into the bathroom. I locked the wheelchair and said to R53, 'I'll give you a few moments.' I passed out ice & water to R2's room, and came back to R53. She was on the bathroom floor, I called for the nurse, (E5) to help. Blood from R53's head was noticed - I got the lift and E5 & I helped her into her wheelchair - R53 faced into the bathroom with her head at the wall near the door, the wheelchair was still locked & facing the toilet." The hospital "Emergency Physician Record," dated 7/24/10, revealed R53 was seen at 21:15 (9:15 PM) for a head injury from a fall with "mild"... pain, "dazed", with "headache". The scalp wound was described as "3.0 cm (centimeter)" in length, and was closed with "10 staples." The Clinical Impression revealed a "contusion" to the head and a "laceration" to the scalp. Review of the facility's report entitled, "SWIF"(report used to track "Skin, Weight, Infection, Falls"), dated "7-20 to 7-27-10," regarding R53 stated, " 7/24/10 @ (at) 1600 (4 PM) Left in bathroom unattended ---ER 10 staples (abrasion head --- CNA terminated.)" Review of E4's employee file on 8/9/10, revealed that a "Conduct/Performance" review was conducted on 8/2/10 with E2, the ADON (Assistant Director of Nursing), and resulted in E4's "Termination" because she "... failed to follow resident plan of care which resulted directly with resident safety and injury..." During an interview on 8/9/10 at 4:30 PM, E2 was questioned regarding what part of the plan of care was not followed. E2 stated, "specifically, that the CNA left the resident unattended in the bathroom." E2 and E3 (Registered Nurse) stated that R53 was "not to be left alone in the bathroom since at least the 6/19/10 fall, possibly even the 4/14/10 fall." Both confirmed that R53 should not have been left alone in the bathroom and stated that was the reason for E4's termination on 8/2/10. The facility failed to provide adequate supervision to prevent an accident for R53 on 7/24/10 when R53 was left unattended in the bathroom, fell and was injured. Subsequently, R53 was sent to ER and received 10 staples to a laceration on her head. Findings of "Harm" were acknowledged by E1 (Administrator), E2, and E3.