Every finding on record at Wilmington Nursing & Rehabilitation Center

Based on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for injuries, the facility failed to ensure that R1 received adequate care and treatment that met professional standards. R1, a cognitively impaired and dependent resident, was observed by a staff member with a visible head injury on 4/22/26 at approximately 6:00 AM and failed to inform the nursing staff at that time. The nurses were informed of the injury on 4/22/26 at approximately 8:30 AM, but failed to appropriately assess and provide care and treatment, including neurological checks. Each of the following shifts failed to identify and assess the injury, including failing to initiate neurological checks. As a result of this delay, R1 was found unresponsive in her bed on 4/23/26 at approximately 8:30 AM, more than 26 hours later, and was sent to the hospital, where emergency surgery was performed for a massive brain bleed. Due to this failure, an Immediate Jeopardy (IJ) was called at 1:30 PM on 4/30/26. For R11, the facility failed to ensure timely physician notification and follow-up of abnormal laboratory results. As a result, R11 experienced a delay in treatment and required emergent hospital transfer for acute kidney injury. Additionally, the facility failed to ensure that the physician's order for sodium chloride 0.9% intravenous infusion was administered when R11 developed signs and symptoms of dehydration on 3/18/26. The facility also failed to ensure R14 received timely care and services after a change in condition, and critical labs were identified, resulting in a hospital transfer requiring admission to the ICU for an acute kidney injury, resulting in harm. Findings include: 1. 1/29/24 – A facility document entitled, Neurological Assessment, included, A neurological assessment will be completed by a licensed nurse in order to detect potential early signs of brain injury. Complete the neurological checklist assessment in the medical record. Assess vital signs, orientation, level of consciousness, pupillary response, verbal response, pain, and movement and sensation of extremities. Complete assessment every 15 minutes for the first hour, every 30 minutes for the next two hours, and every hour for the next four hours. Notify provider and responsible party of any abnormal findings. Document in the medical record and follow provider recommendations. R1's clinical record revealed: 12/26/25 – R1 was admitted to the facility with diagnoses including, but not limited to, a stroke, deep vein thrombosis, heart failure, and dementia. 12/26/25 – R1's care plan (reviewed 3/24/26) included, . At risk for bleeding, hemorrhage, excessive bruising and complications related to anticoagulant use. The interventions included, .Monitor for signs/symptoms of bleeding, bruising, and complications and notify MD as indicated. 3/12/26 – R1's medications included aspirin 81 mg daily and Eliquis 5 mg, two times a day for deep vein thrombosis. 3/13/26 – R1's quarterly MDS assessment documented a BIMS score of 5, indicating a severe cognitive impairment. R1 required substantial to maximum assistance from staff for bed mobility and was totally dependent for all transfers between surfaces. 4/23/26 8:58 AM – R1's physician clinical record included, Right periorbital [tissues surrounding the eye socket, including the eyelid, skin and underlying soft tissue] bruising, right temporal hematoma, altered mental status. evaluated emergently at this a.m., nursing informed me that the aide had gone into her room and noticed that the resident was not communicating with her and [was] concerned for her level of responsiveness. The nurse was called, and upon examination, noted the patient had a right periorbital bruise and what appeared to be a right temporal sub-gluteal hematoma.No apparent reports of a fall.Patient is on Eliquis as well as a baby aspirin. Advised nursing to call 911 immediately to transport to the hospital for further evaluation .Patient was lying on her left side and also noticed a small area of what appeared to be vomitous on her sheet. I attempted to awaken the resident by calling her name but no response and I also attempted to touch her arm to see if she would respond and she did not.Patient with apparent fall, however no report of a fall at this time and I did speak to the assistant director of nursing to contact the night nurse to further discuss whether or the patient may have had a fall during the course of the evening hours. Sent to the emergency room for further evaluation as patient needs an emergent heat CT [scan].altered mental status.nonresponsive to verbal or stimulus. 4/23/26 9:36 AM – E12 (LPN) documented in R1's nursing clinical record, Resident discovered in bed sleeping not easily aroused in deep sleep not able to explain what happen. Observation hematoma to right [forehead] and right eye bruising. Fully dressed. [Name of doctor] assessed resident and ordered to send resident out to the hospital for further evaluation. 4/23/26 12:24 PM – A facility reported incident report submitted to the Division documented, On 4/23/26 at approximately 0830 [8:30 AM], CNA reported to the Unit Manager that resident [R1] has a hematoma to the right side of her forehead and a right periorbital bruising. 4/28/26 1:20 PM – During a telephone, FNE1 (Forensic Nurse Examiner) stated, [R1] was completely unconscious when she arrived at the hospital. She went immediately to surgery and did not regain coconsciousness. Approximately one quarter of her brain was filled with blood. She had a massive brain bleed and was dying. It did not look like she was going to recover, and her family decided to put her on end-of-life care because she would not want to live like that. 4/29/26 9:00 AM – During a telephone interview, E8 (CNA) stated, My shift started on 4/21/26 at 11:00 PM and ended at 4/22/26 at 7:00 AM. I provided care to the resident [R1] two or three times during the night. Around 6:00 AM, I saw a discoloration on the right side of her forehead, but I forgot to tell the nurse. The Surveyor asked E8 if R1 showed any signs of pain when care was provided was provided to her. E8 stated, No. The Surveyor then asked E8 about R1's status during the 11-7 shift of 4/22/26 to 4/23/26. E8 stated, I saw the bruise around 5:00 AM but I did not see any additional injuries. The resident was responsive when I provided care to her during the shift. The Surveyor asked E8 if he reported the bruise to the nurse on duty or the oncoming aide. R8 stated, No. E8 failed to notify the nurse despite observing the bruise on R1's face on two separate occasions. 4/29/26 9:15 AM – During a telephone interview, E16 (LPN) stated, I worked the 11:00 PM to 7:00 AM shift on 4/21/26 into 4/22/26. I did an initial round when I came on the shift, and the resident [R1] was in her bed. I did not observe anything unusual with her. I gave her the morning medication between 5:30 AM to 5:45 AM, but I did not turn on the light in the room. The Surveyor asked E16 how she was able to see to give the resident her medication and if the resident was awake enough to take the medication. E16 stated, There was some light in the room, so I was able to see. And the resident took the medication fine. The Surveyor asked E16 if E8 informed her about any bruising or other concerns with R1. E16 stated, No. 4/29/26 9:30 AM – During an interview, E7 (CNA) stated, I was helping to feed the residents breakfast in the dining/activity room around 8:30 AM on 4/22/26. I saw the bruising and swelling on the resident's [R1] right-side temple and forehead area. I asked if anyone saw this. I told E6 (UM) and she told me to tell the resident's nurse. I told the nurse [E15 LPN] and she stated, I will take a look at it. 4/29/26 9:45 AM – During an interview, the Surveyor asked E6 (UM) whether she was informed of the discoloration and swelling on R1's head. E6 stated, The aide told me, and I told him to tell her nurse. The Surveyor asked E6 whether she assessed R1, informed the ADON, DON, updated the provider or documented the change in the resident's status. E6 stated, No. 4/29/26 10:00 AM – During a telephone interview, E13 (AA) stated, [E7] and I were in the dining room around 8:30 AM to 9:00 AM on 4/22/26. We saw the bruise on the resident's face and the CNA went to tell the nurses. I stayed in the dining room to watch the residents. 4/29/26 10:30 AM – During a telephone interview, E14 (CNA) stated, This was my assignment on 4/22/26 on the 7-3 shift. I gave morning care to the resident and saw the bruise when I was washing her face. I dressed her and brought her into the hallway, and I asked her nurse [E15], Did you see this? What happened to her? The nurse replied, It happened overnight, and remained at the medication cart. I took the resident into the dining room for breakfast. 4/29/26 11:00 AM – During a telephone interview, E15 stated, The night nurse did not tell me anything about a bruise on this resident. It was around 8:30 AM to 9:00 AM on 4/22/26 when the aide [E7] told me that [R1] had a knot on her head. I was passing medications, and I stopped and checked on the resident. I took her vital signs and checked her neuros [neurological status]. I saw a mildly raised area on the right side of her forehead, but there was no discoloration and her eyes were clear. The Surveyor asked E15 if she reported her observations to the supervisor or the medical provider. E15 stated, No, I did not report it to anyone. I don't work with this resident very often and I thought it was an old bruise that was already addressed and did not need to be reported again. The Surveyor asked E15 if she documented the results of R1's neurological check and updated the 3-11 shift nurse about the bruise. E15 stated, No, I did not tell the 3-11 nurse, and I forgot to document the neuros. The facility lacked evidence that R1's neurological status was monitored, or the medical provider was notified of the swelling and discoloration on the right side of her face. R1's medication administration record revealed that E15 administered oral medications to R1 at 9:00 AM and oral supplements at 1:00 PM on 4/22/26 but failed to identify, assess or report the visible bruise on the right side of her head. 4/29/26 11:30 AM – During a telephone interview, E19 (CNA) stated, I was in the hallway around 8:30 AM or 9:00 AM on 4/22/26 when I heard the aide [E14] tell the nurse [E15] that the resident had a knot on her forehead. The nurse replied, It was not reported to me from the previous shift, and I saw the injury already. 4/29/26 1:30 PM – During a telephone interview, E17 (LPN) stated, I worked on the 3-11 shift on 4/22/26 but I did not see any bruising or swelling on the resident. R1's medication administration record revealed that E17 gave her oral medications at 4:00 PM and 8:00 PM but failed to identify the obvious bruise on the right side of her head. 4/29/26 2:00 PM – During a telephone interview, E21 (CNA) stated, I worked with the resident [R1] on the 3:00 PM to 11:00 PM shift of 2/22/26. I saw the bruise on the right side of her head. I don't usually work with her. When I saw the fall mat near her bed, I thought that she had a previous fall, and the nurses already knew about it. That is why I did not think the bruise was new and did not report it. E21 failed to report the bruise on R1's face despite the lack of a report of an injury from the previous shift. 4/30/26 9:00 AM – During a telephone interview, E20 (RN) stated, I worked with the resident [R1] on the 11:00 PM to 7:00 AM shift on 4/22/26 to 4/23/26. I checked on all the residents at the start of the shift. I did not turn on the lights because I didn't want them to wake up. [R1] slept all night and took her medication in the morning around 5:45 AM. The Surveyor asked R20 if R1 was awake and alert when she gave her the medication. R20 replied, I did not turn on the light when I gave her the medication with some applesauce. I did not give her water or anything else to drink. 4/30/2026 9:30 AM – During a telephone interview, E11 (CNA) stated, The resident [R1] was on my assignment on 4/22/26 on the 7:00 AM to 3:00 PM shift. I did a quick round when I came on the shift to check that none of the residents had fallen out of bed. [R1] appeared to be sleeping so I went and got a couple of other residents up and then went to get her up. She was breathing in and out but I could not wake her up. And I saw bruises on her forehead and right eye. I told the unit manager who was outside of the room. 4/30/26 11:30 AM – During a telephone interview, E5 (MD) stated, I was in the facility for a meeting on 4/23/26. At approximately 8:30 AM, I received a message that [R1] had a head injury and she was unresponsive. I told the staff to call 911 and went up to the unit. The emergency personnel were already there working on her. I saw that she was unresponsive and had a large, bruised area on the right side of her forehead/eye area. There was also some vomit on her bed sheet. I asked nurse if the resident had fallen, and she said, No. The Surveyor asked E5 what his expectation from the facility would be about a resident who was taking two blood thinning medications and had an obvious head injury. E5 stated, I would expect to be informed immediately, especially if she is on two blood thinners. And she should get medical treatment right away. The facility failed to ensure that R1 received medical care and treatment for more than 26 hours after the injury was identified by the staff. 4/30/26 1:15 PM – An Immediate Jeopardy was called due to the seriousness of this incident. 4/30/26 3:00 PM – The facility provided the Surveyor with the following action plan for the abatement for the Immediate Jeopardy: Education to CNA to notify nurse immediately up identifying and injury of unknown origin Nurse to notify supervisor and/or physician immediately upon identifying any injury of unknown origin Performing resident evaluation/assessments with change in condition and/or injury of unknown origin and completion of required documentation including risk management report as indicated Completion of incident reports to include any injury of unknown origin Neurological assessments Mandatory reporting requirements 1:1 education has been completed with staff that failed to follow the proper procedures Primary nurse that failed to report and document injury of unknown origin on 4/22/26 was suspended pending investigation Unit Manager was educated regarding following up with the primary nurse regarding change in condition of a resident ADHOC QAPI was held immediately which include department heads Head-to-toe skin assessments completed for all residents on the secured unit Any injuries of unknow origin will be reviewed to ensure that all proper documentation is completed Education was initiated on 4/23/26 for nurses and CNAs and reinforced through 4/29/26. Staff were educated via telephone and will be required to sign the education record upon next working shift. Director of Nursing/designee will conduct audits to include documentation compliance, physician notification and proper reporting procedures. Results will be reviewed through QAPI committee and acted upon immediately if concerns are identified. 4/30/26 5:15 PM – Based on the Surveyor's review of the facility's investigation, documented response, completion of audits from 4/23/26 to 4/29/26, staff interviews and no further injuries of unknow origins, the IJ was considered abated on 4/30/26 at 5:00 PM. 2. Cross refer F770 Review of R11's clinical record revealed: 1/17/26 – R11 was admitted to the facility with diagnoses including CKD (chronic kidney disease). 3/12/26 – R11 had a physician's order for CBC, CMP thyroid panel and A1C (blood test for diabetes) for chronic kidney disease. 3/13/26 – R11 had CBC, CMP thyroid panel and A1C labs drawn. 3/14/26 – R11 had a physician's order for BMP (basic metabolic panel) and Mg (magnesium) level. 3/16/26 2:14 PM – A medical note from P2 (PA) documented, labs drawn this morning and pending . 3/17/26 – R11 had BMP and Mg labs drawn. Despite the physician's order on 3/14/26, R11's BMP and Mg levels were not collected until 3/17/26. 3/17/26 2:33 PM – A medical note from P2 documented, . CKD (stage) 3 overall stable labs from 03/13 showing crt (creatinine) 1.6 BUN (blood urea nitrogen) 19 . this is in-line with pt's (patient's) prior labs with no notable acute changes . 3/18/26 5:12 PM – A medical note from P1 (physician) documented, . Acute on chronic renal failure worsened related to pre-renal azotemia (abnormally high levels of nitrogen – containing waste products in blood) . I reviewed BMP 3/17/2026. BUN/creatinine: 53/2.9 .Follow serial BMP. [R11] is at risk for deterioration, hospitalization. Despite laboratory values reviewed on 3/17/26, additional follow-up laboratory monitoring continued to be ordered due to ongoing concerns regarding R11's kidney function and risk for deterioration. P1's documentation identified concern for worsening renal function and specifically noted R11 was at risk for deterioration and hospitalization. 3/18/26 - An additional physician's order was written for a CBC, CMP, magnesium and phosphorous level for R11. 3/19/26 – A facility lab results report, with a collection date of 3/19/26 and reported on 3/23/26, documented R11's, . albumin please reschedule . difficult draw specimen not obtained . WBC please reschedule . difficult draw . CBC, CMP difficult stick . Although additional laboratory testing was ordered, portions of the ordered specimens were not obtained due to difficult venous access and required rescheduling. 3/20/26 8:43 AM – A medical note from P2 (PA) documented, . Hypokalemia/Hyponatremia/concern for Dehydration . labs from 03/13 showed potassium of 2.8, received supplementation over the weekend, repeat BMP from yesterday [3/19/26, although it was noted in the lab results report that R11's specimen was not obtained] showed improvement in potassium to 3.4 will continue with supplementation and continue to monitor – repeat labs also showed mild hyponatremia at 131 with acute drop in baseline kidney function . crt 2.9, BUN 53 . appear mildly dehydrated . mildly dry mucous membranes . repeat labs ordered for tomorrow . based on results of labs from today, will determine further need for supplementation. The medical note reflected continued concerns regarding dehydration, worsening kidney function, electrolyte imbalance, and the need for repeat laboratory monitoring. 3/20/26 – R11 had a physician's order for a stat CBC, CMP, magnesium, phosphate, B12, folate and Vitamin D for electrolyte derangement. 3/21/26 – R11 had CBC, CMP, magnesium, phosphate, B12, folate and Vitamin D labs drawn. Further review of R11's clinical record lacked evidence that the results of the stat laboratory testing collected on 3/21/26 were reviewed by P1 or P2 prior to 3/26/26. 3/24/26 2:47 PM – A medical note from P1 documented, . Acute on chronic renal failure worsened related to pre-renal azotemia . I reviewed BMP 3/17/2026. BUN/creatinine: 53/2.9 . awaiting follow up BMP. she is at risk for deterioration, hospitalization . 3/24/26 – R11 had a physician's order for CBC, CMP, magnesium and phosphate. Despite ongoing concerns regarding deterioration and hospitalization risk, the follow-up BMP referenced by P1 had not yet been reviewed. 3/25/26 – R11 had CBC, CMP, magnesium and phosphate labs drawn. 3/26/26 – 7:11 AM (another fax transmittal time stamped 7:14 AM) - A laboratory results of R11's labs drawn on 3/21/26 revealed the following results: elevated phosphorous 4.7 (2.6 – 4.5) BUN 44 (5-20) creatinine 2.6 (0.5 – 1.3) WBC 15.20 (4.5 – 11.00) and low hemoglobin 8.2 (11.7 – 16.1). Results of R11's physician order for stat lab work on 3/21/26 were not reported to the facility until five days later on 3/26/26. Results of R11's physician order for stat laboratory work collected on 3/21/26 were not reported to the facility until five days later, on 3/26/26. The laboratory results reflected continued worsening renal function and abnormal findings. Despite the stat laboratory order and documented concerns regarding worsening kidney function and hospitalization risk, the facility lacked evidence of timely follow-up regarding the pending laboratory results prior to 3/26/26. 3/26/26 9:35 AM – A laboratory results of R11's labs drawn on 3/25/26 revealed the following: elevated phosphorous 5.8 (2.6 – 4.5) BUN 56 (5-20) creatinine 4.6 (0.5 – 1.3) WBC 16.30 (4.5 – 11.00) low sodium 130 (133- 145) and low hemoglobin 7.6 (11.7 – 16.1). Results of R11's physician order for lab work on 3/25/26 were not reported to the facility until the next day, on 3/26/26. 3/26/26 2:46 PM – A nurse progress note documented, New labs received., pt (patient) in AKI (acute kidney injury) and also not eating and drinking more than 50% per meal for the least two days. New order to send pt to ED (Emergency Department) for further eval . 3/27/26 10:33 PM – A medical note from P1 documented, . Acute on chronic renal failure worsened related to pre-renal azotemia . I reviewed BMP 3/26/2026. BUN/creatinine: 56/4.6 . She is acutely ill and at high risk for further deterioration. Transfer the patient to hospital for further evaluation and management. 5/4/26 10:08 AM – In an interview, P1 (physician) confirmed that R11 was sent out to the hospital when the abnormal lab results came back indicating that R11 had an acute kidney injury. 5/8/26 9:05 AM – In an interview, P2 (PA) stated that he was not immediately notified of the results of R11's stat lab draw order. I think it was that weekend. We had a third-party lab issue that time. We didn't know whom to call for follow up results. 5/8/26 9:10 AM – During an interview, E47 (LPN) stated, . When there's a stat lab order, the nurses should call and follow up with the lab and notify the physician, especially if the results are critical and the resident is going through a change in condition. 5/5/26 4:00 PM – Findings were discussed with E1 (NHA), E2 (DON) and E3 (CRN). 3. Cross-refer F692 Review of R11's clinical record revealed: 3/18/26 5:12 PM – A medical note from P1 (physician) documented, . poor oral intake . optimize fluid intake . she is at risk for deterioration, hospitalization. 3/18/26 – R11 had a physician's order for Sodium Chloride 0.9 % (also known as normal saline solution) use 50 ml/hr intravenously every shift for hydration for 1 Day . for total of 1 Liter. 3/18/26 – A review of R11's eMAR lacked evidence that R11's sodium chloride intravenous solution was patent and infusing well on the 3-11 shift. 3/18/26 11:55 PM – A nurse progress note documented, IV access present: No. 3/19/26 12:48 AM – A nurse progress noted documented, IV site infiltrated, RN supervisor . notified. 3/20/26 8:49 AM – A medical note by P2 (NP) documented . pt refused IV fluids, . states . they were trying to stab her belly yesterday when they were attempting to place the hypodermoclysis . appears pt refused hypodermoclysis and NSS yesterday. 5/8/26 9:00 AM – During an interview, P2 (PA) confirmed that he did not receive any notification from the nursing staff that R11's IV site was infiltrated on 3/18/25 evening shift and that R11 refused the IV fluids until he learned about it on 3/20/26. 5/5/26 4 PM – Findings were discussed with E1 (NHA), E2 (DON) and E4 (CRN). 4. Review of R14's record revealed: 10/11/24 – R14 was admitted to the facility with diagnoses including psychosis, Alzheimer's Disease, cerebrovascular disease, bipolar disorder, hypertension, and aneurysm of the vertebral artery. 10/15/25 – Lab results include Sodium 142 (normal 135-145); BUN 22 (normal 10 – 26); Creatinine 0.8 (normal 0.5 – 1.5); WBC 7.6 (normal 4.8 – 10.8). 11/3/25 – R14's quarterly MDS documented a BIMS score of 0 (indicating severe cognitive impairment). The MDS further documented that the resident was able to ambulate at least 150 feet without assistance, was dependent for personal and oral hygiene, and was independent for eating. 12/29/25 6:00 PM – A progress note by P3 (Physician) documented History of Present Illness [R14] .will continue to be monitored and encouraged for oral hydration. Follow-up – Review CBC and CMP results when available. 1/6/26 8:32 PM – A progress note by P4 (Nurse Practitioner) documented .[R14] was noted to be lethargic this morning. CBC and CMP will be checked to monitor patient. The note further documented the plan was to continue to promote good p.o. [by mouth] intake with patient today and encourage fluids. 1/6/26 – CBC and CMP orders were listed with a status of completed in R14's EHR (Electronic Health Record). However, review of the clinical record lacked evidence of laboratory results between 10/15/25 and 1/9/26. 1/8/26 11:30 AM - A progress note by P3 documented .acute decline, altered mentation.[R14] . Staff report [R14] has not been participating well and appears more altered than at baseline.patient appears slightly altered. was noted to be lethargic the day prior.Exam – Frail, Lethargic, Altered, Declining status.No signs of distress or acute illness. Skin turgor normal. It should be noted that the lab results listed in the progress note were from 10/15/25, and vital signs were from 1/2/26. Assessment and Plan -.Altered mental status.Ordered CBC.BMP.urinalysis today. Follow up-Review CBC, BMP, and urinalysis when available. 1/8/26 – CBC and CMP orders were again listed as completed on 1/8/26 in R14's EHR; however, review of R14's clinical record lacked evidence of lab results between 10/15/25 and 1/9/26. 1/8/26 9:44 PM – A Nursing SBAR [Situation, Background, Assessment, Recommendation] Communication Form documented R14's mental status was better after encouraging fluids and assisting with meals. However, the note also documented that R14 required more assistance with ADL's, had decreased alertness, somnolence, and was spending a lot of time in bed. 1/9/26 8:39 AM – A nurse's progress note documented night shift nurse was unable to obtain the UA [urinalysis] specimen due to consistency. [P3] was made aware. 1/9/26 10:11 AM – A nurse's progress note documented – Specimen [urine] collected and labeled. 1/9/26 1:39 PM - A nurse's progress note documented – Resident assisted with ADLs and transfers, stayed in bed most of the shift, drowsy but easily arousable, decreased mobility and poor appetite noted, awaiting lab results. 1/9/26 1:51 PM – A Communication with Physician note documented critical laboratory findings, including WBC 22.0, were reported to P3. Recommendations: Ciprofloxacin (antibiotic), increase fluids, and repeat labs. 1/9/26 4:30 PM – The Facility's investigation records documented .[P3] was in the facility and was provided with a copy of the most recent lab results received today. 1/9/26 – [8:00 PM] A progress note by P3 documented .persistent confusion and marked lethargy. severe hypernatremia, and acute renal dysfunction. The following lab values from 1/9/26 are noted: WBC 22.0 BUN 100, creatinine 1.8, s[TRUNCATED]

Based on interview, record review, and review of other documentation as indicated, it was determined that for one (R11) out of four residents sampled for medication administration review, the facility failed to ensure that R11 was free from significant medication errors as evidenced by failing to check and monitor R11's blood sugars before meals, failing to administer ordered insulin and heparin injections. The facility's multiple failures to administer critical medications had the potential to cause a serious adverse outcome or death to R11. Due to the failures, an Immediate Jeopardy (IJ) was called on 5/8/26 at 1:24 PM. The IJ was abated on 5/9/26 at 11:59 PM. Findings include:The facility's policy titled, Medication Unavailability, effective 1/29/24, documented, . Procedure . 1. A licensed nurse will notify the provider of the unavailability of medication . 2. the licensed nurse will activate the backup pharmacy process and procedures. 3. A licensed nurse will document notification to the provider of the unavailability in the medical record . The facility's policy titled, Refusal of Medication/Treatment/Care, effective 1/29/24, documented that a licensed nurse is to document and notify the provider and responsible party when a patient refuses medication(s), treatment(s), and / or care.The facility's policy titled, Blood Glucose Monitoring, dated 3/17/25, documented, .Licensed nurses will complete blood glucose monitoring as ordered by the provider . Procedure.4. Blood glucose (sugar) checks will be documented in the medical record .Cross refer F865Review of R11's clinical record revealed: 1/17/26 - R11 was admitted to the facility with diagnoses including diabetes and stroke.1/17/26 - R11 had a physician's order for heparin sodium injection 1 mL subcutaneously every eight hours for blood clot prevention.1/19/26 - R11 had a physician's order for insulin Lispro injection subcutaneously for diabetes. Inject as per sliding scale:If 0-69 = 0 unit; call provider (physician) for BS (blood sugar) less than 70;70 - 100 = 0 unit;101 - 150 = 2 units;151 - 200 = 4 units;201 - 250 = 6 units;251 - 300 = 8 units;301 - 350 = 10 units;351 - 400 = 12 units Call provider for BS greater than 400.1/23/26 - R11 had a physician's order to check and record blood sugars before meals.A review of R11's insulin lispro administration from 2/1/26 through 2/14/26 revealed that R11 was administered insulin lispro coverages based of FSBS (finger stick blood sugar) on the following times:7:30 AM - 12 of 14 opportunities (86%); 2/1/26 went on LOA (leave of absence) and 2/2/26 refused12:00 PM - 13 of 14 opportunities (93%); 2/12/26 refused4:30 PM - 12 of 14 opportunities (86%); 2/1/26 went on LOA and 2/4/26 not given for blood sugar 79 mg/dlIt was noted that from 2/1/26 through 2/14/26, R11 was administered her insulin lispro coverages based on the results of her blood sugar checks 86% during breakfast and dinner times and 93% during lunch time.2/15/26 - Review of R11's eMAR revealed that E40 (LPN) administered R11's medications scheduled at 12:00 PM and 2:00 PM. Further review of R11's eMAR revealed that E40:- lacked evidence that R11's 12:00 PM blood sugar check was monitored;- lacked evidence that R11's 12:00 PM sliding scale insulin injection was administered nor did E40 document if insulin was not indicated; - lacked evidence that R11's 2:00 PM heparin injection was administered.2/16/26 - Review of R11's eMAR revealed that E40 (LPN) administered R11's medications scheduled at 7:30 AM, 12:00 PM and 2:00 PM. Further review of R11's eMAR revealed: - lacked evidence that R11's 7:30 AM blood sugar check was monitored;- lacked evidence that R11's 7:30 AM sliding scale insulin injection was administered nor did E40 document if insulin was not indicated;- lacked evidence that R11's 12:00 PM blood sugar check was monitored.- lacked evidence that R11's 12:00 PM sliding scale insulin injection was administered nor did E40 document if insulin was not indicated;- lacked evidence that R11's 2:00 PM heparin injection was administered.2/25/26 - Review of R11's eMAR revealed that E41 (LPN) administered R11's medications scheduled at 10:00 PM. E41 lacked that R11's 10:00 PM heparin injection was administered.3/11/26 - Review of R11's eMAR revealed that E42 (RN) administered R11's medications scheduled at 10:00 PM. E42 lacked evidence that R11's 10:00 PM heparin injection was administered.3/18/26 - Review of R11's eMAR revealed that E43 (LPN) administered R11's medications scheduled at 10:00 PM. E43 lacked evidence that R11's 10:00 PM heparin injection was administered.5/5/26 3:30 PM - In an interview, E4 (CRN) stated that she had another nurse review the missing entries in R11's February and March 2026 eMAR. E4 further stated and confirmed that the facility lacked evidence and documentation that R11's blood sugar checks were monitored and the insulin and heparin injections were administered on those dates in question.5/8/26 9:00 AM - In an interview, P2 (PA) stated, I don't think I remember receiving a call about [R11's] missing meds or unavailable meds particularly.5/8/26 10:20 AM - During an interview, E40 (LPN) stated, I don't remember what happened back then, I can't remember why I did not document on R11's eMAR on all those doses left blank.5/8/26 10:30 AM - In a telephone interview, E41 (LPN) stated, I don't remember anymore. I must have given the heparin but I forgot to sign in the eMAR.5/8/26 10:49 AM - In a telephone interview, E42 (RN) stated, If the heparin injection was not signed, I don't know. it must be held for a reason.for unavailable meds, we have a back up in our Omnicell machine (computer - controlled systems used to manage and dispense medications and supplies) . if it was not documented, I don't know. 5/8/26 11:25 AM - In an interview, E49 (LPN) stated that when meds are not available, she would call the pharmacy, notify the physician and document in the progress notes. E49 further stated that most medication back up supplies including insulin lispro and heparin injections are found in the Omnicell machine. 5/8/26 1:24 PM - During a meeting with facility management, the Survey Team notified E1 (NHA) and E4 (RDCS) of an Immediate Jeopardy for R11's significant medication errors that occurred from 2/15/26 through 3/18/26. 5/8/26 3:30 PM - E1 (NHA) submitted a signed, dated and timed written abatement plan to the State Agency.The facility's abatement included: Immediate Corrective Action for Identified ResidentNurses involved were identified and one on one education is in progress and with a scheduled completion date of 5/9/26 at 11:59 pm.Education for licensed nurses was initiated with a scheduled completion date of 5/9/26 at 11:59 pm.Identification of Other Residents at Risk On 5/8/26, the facility initiated a 100% audit of:All residents receiving insulinAll residents ordered blood sugar monitoringAll residents receiving anticoagulants including HeparinThe audit will include verification of:Medication administration completion and documentationCompletion of blood sugar checks as orderedPresence of any omitted doses and treatmentsAny identified concerns will be corrected, physician(s) notified as indicated, and residents assessed for adverse outcomes.Systemic Corrective ActionsThe facility immediately implemented the following systemic interventions to remove the likelihood of serious harm:Medication Administration Process ChangesA licensed nurse/designee will perform end - of - shift reconciliation ofInsulin administrationAnticoagulant administrationOrdered blood sugar checksAny omissions identified will be immediately escalated to the supervisor and Administrator/DON.Clinical Oversight EnhancementsDON/ADON, Unit Managers, and or/Clinical Consultants will initiate daily medication administration audits.Review of daily clinical meeting will include review if:Missed medicationsBlood sugar omissionsHigh - risk medication variancesFollow - up actions as requiredEducationEducation of licensed nursing staff was initiated with a scheduled completion date of 5/9/26 at 11:59 PM:Medication administration requirementsBlood sugar monitoring requirementsDocumentation accuracyProper follow - up for held/refused medicationsNotification expectations Ensure all documentation completed in medical recordMonitoring to Ensure Ongoing ComplianceNursing Leadership/Supervisors will audit medication administration compliance daily prior to end of each shift.Daily medication administration audits will be completed by Nursing Leadership in the scheduled Daily Clinical Meeting.Results of audits will be reviewed weekly by DON/AdministratorResults of audits will be reviewed Monthly in QAPI for ongoing compliance and identification of trendsAny identified concerns will result in immediate corrective action, re-education, and follow - up auditing.5/11/26 - Verification of facility's abatement plan included review of nursing staff education signed attestation. Interviews with nursing staff confirmed the facility's IJ was abated on 5/9/26 at 11:59 PM.5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on observation, interview, record review and review of other facility documentation, it was determined that for one (R2) out of three residents sampled for accidents, the facility failed to ensure that R2 received adequate supervision and assistive devices to prevent accidents to the extent possible. Findings include:1. R2's clinical record revealed:9/26/25 - R2 was admitted to the facility with diagnoses including but not limited to right hip pain and heart failure.9/26/25 - R2's fall care plan documented, At risk for falls related to cognitive impairment, poor memory and muscle weakness.9/28/25 - R2's admission MDS assessment documented a BIMS score of 00 indicating an inability to complete a cognitive assessment and required partial to moderate assistance from staff for wheelchair mobility.10/11/25 2:30 PM - R2's clinical record included, At 14:30 [2:30 PM], patient fell forward out of the wheelchair while staff member was wheeling her in the wheelchair in her room. Patient noted laceration to left eyebrow 2cm x 0.2 cm.Complained of pain to right hip.At 1535 [3:35 PM], patient heard yelling for help and found lying on the floor on her left side by her room.noted with hematoma below left eye.Send to the ER for evaluation.10/11/25 11:29 PM - A facility incident report submitted to the Division included, . At 1430 [2:30 PM] patient [R2] fell forward out of the wheelchair while staff member was wheeling her in the wheelchair in her room. Noted with a laceration to left eyebrow 2cm X 0.2 cm. Approximately 1530 [3:30 PM] resident was heard calling for help and was discovered on the left side of her room entrance. Noted with a hematoma below her left eye. Sent to the ER [emergency room] for evaluation.10/12/26 1:00 AM - R2's emergency room record included, . Laceration on left side of face . repaired with three stitches and steristrips.4/30/26 2:00 PM - A review of the facility's investigative document revealed that R2 asked E9 (Houskeeper) to wheel her to her room. E9 wheeled R2 and she fell forward to the floor. During an interview, the Surveyor asked E9 about the fall. E9 stated, [R2] asked me to push her into the room, and her feet got stuck and she fell out of the wheelchair.4/30/26 3:30 PM - During an interview, E2 (DON) stated, We provided education to [E9] that only nursing staff should push the wheelchair when the resident is in it. The nursing staff should be told if the resident asked to be pushed when they are in the wheelchair. We also educated the rest of the staff to ensure that the wheelchairs have foot pedals when they are wheeling the residents.4/30/26 4:00 PM - The facility's education and training entitled, Footrests on wheelchair, and dated 10/12/25 included, Before ambulating a resident on the wheelchair ensure footrests are attached to it. Footrests should be on all wcs [wheelchairs] during transport. Housekeeping staff should not transport residents in wheelchairs.The facility failed to ensure that R2 was free from accidents when she fell while she was transported in the wheelchair without footrests resulting in the injury. 5/6/26 4:10 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on interview and review of clinical and facility records, it was determined that for two (R13 and R16) out of seven residents reviewed for abuse, the facility failed to ensure each resident remained free from physical and emotional abuse. On the morning of [DATE], R13 was physically and emotionally abused by a staff person, resulting in dehumanization, a psychosocial harm. On [DATE], R16 was physically abused by another resident (R17) in the locked dementia unit. Findings include: 1. Review of R13 records revealed:[DATE] - R13 was admitted to the facility with diagnoses including, but were not limited to, end stage renal disease requiring renal dialysis, orthopedic aftercare following surgical amputations of the left leg below knee and toes on right foot and blindness in the right eyeXXX[DATE] - R13 had two physician orders for wound treatments in the perineal region, one requiring a dressing and the other a non-sting skin barrier film to protect against moisture-associated skin damageXXX[DATE] - The admission MDS assessment documented that R13 had a BIMS of 15 (cognitively intact), required substantial/maximal staff assistance for toileting hygiene and dependent on staff for transfersXXX[DATE] - A grievance form was completed and stated: Grievance Details: Resident reported that the night before a CNA came into his room to complete incontinence care. Resident asked CNA 'what was she doing' (sic) CNA then pulled his brief down to look for stool and/or urine. Summary of Findings: CNA report was obtained. The DON is currently completing an investigation. Summary of Actions Taken: The Director of Nursing met with the resident and obtained his statement. DON then reported the incident to the State Police and filed a report using Wellsky. When the police arrived, NHA went into the room with the resident and police. Resident had stated that he told the CNA that he didn't want care but she continued to proceed. He then slapped the bottle of spray out of her hand prior to being used as in the past it stung. CNA then left the room. Resolved Note: DON met with the resident to obtain his statement and reassured him that the matter would be looked into. DON will be completing an investigation into the incident. Police, NP [Nurse Practitioner] and a reportable completed. Satisfied at this time. No new concerns.[DATE] 10:02 AM - The facility reported the following to the State Agency: Resident stated CNA came into his room at approximately 0230-0300am to give care to resident in the A bed, then approached his bed. He asked her, 'what are you doing' and she said I am going to check your brief. Stated he told her he did not want care from her, but she continued to attempt to provide care. Resident stated, 'she reached and pulled the front of my brief open to see if brief was soiled.' [R13] told her I have not urinated in 6 years, and she said that is impossible. At that time, she turned the resident to the side using her 'leg' for support and turned him on his left side. Resident also stated she sprayed him with the skin cleanser and he asked her not to use it because it stings his skin. At this point, he stated he slapped the container from out of her hand. Resident did not report this to anyone else on the night shift and wasn't until the beginning of this shift did he report to his nurse and his therapist who were in the room. Resident is legally blind, but can visualize images. Unable to give a specific description of the CNA but stated he has had her before.[DATE] - The facility's investigation included the following statements:-E12 (OT) documented, Pt [Patient] made report to this therapist and RN [E13] in room. [R13] reported during therapy session a concern about PM aid (sic). Aid (sic) he did not know her name, but had a headband. Reports aid (sic) came in @ [at] 2:30 AM offering to clean [Room number beds A and B] up. [R13] reports aid (sic) then came to him to clean him up. Reports that aid (sic) ripped his diaper off moved his legs aggressively over, and used cleanser on his penis to clean aggressively. Pt noted having a. wound on his groin which is sensitive. Pt. told CNA that there is a wound and hurting him. [R13] reports throwing cleanser in CNA hand away from him asking her to stop. Patient did not report how the encounter ended.-E13 (RN) documented, . Resident [R13] stated over 11-7 shift a 'wide bodied CNA' entered his room & [and] attempted to give him care. Resident stated he did not need anything & to please leave, CNA stated she needed to see if he was wet & tried to open his brief. At some point, she (CNA) attempted to apply wound cleanser to pt . & pt stated he hit the wound cleanser out of her hand & told her to leave. CNA still attempted to change pt & then left. Identify any documentation you completed related to the incident: Wrote note & notified DON of pts accusation.-E8's (CNA) statement obtained on [DATE] via phone by E2 (DON): [E8] had the resident on 11-7AM. assisted him and gave incontinent care. He [R13] did not complain to me. [E8] did not put . leg on his bed or on his back . He didn't say anything to me. A facility Corrective Action form, signed by E1 (NHA) and E2 and dated [DATE], documented, CNA [E8] was suspended in regards to allegation from resident. Spoke with CNA over phone to inform her of the allegation and suspension.-E2's (DON) typed, undated statements: [R13]. made a complaint to the oncoming nurse and CNA (sic) that he had been abused overnight by his SNA (sic). [Name of E8] was the CNA on this assignment. I spoke with the resident and his [FM1, family member] in regard to the complaint of abuse. During the visit, [FM1] wanted me to see the resident was doubled briefed. She also took pictures of the briefs. Both briefs were in place and fastened. [R13] also made complaints of abuse related to. approach with him. He stated, '. came in and pulled his brief forward to see if it was wet. [R13] explained to [E8, CNA] that I have not made urine in 6 years, but she did not believe that was possible'. [E8] then turned me on my side and used her leg to hold me in a side position. Also explained he does not like the spray, and she used it anyway. Complains it stings his peri area. Resident stated he attempted to 'slap' the container out of her hand. Resident is visually impaired and can only go by who was assigned to him. He stated, 'I would know her voice'. E2 also documented, After receiving a complaint, I met with resident and [FM1]. After the meeting, I rounded with the CNAs and nurses and confirmed no other residents were doubled briefed at this time.[DATE] - The facility's Personnel Action Memo, signed by E1 (NHA) and E2 (DON), documented, CNA brought in to complete reinstatement documents. Investigation completed. CNA refused to sign Personnel Action Memo and left building. Administrator present for meeting.[DATE] 11:54 PM - The facility's 5-day follow-up investigation report to the State Agency submitted by E2 (DON) documented that there were no s/s [signs or symptoms] of abuse; no physical harm. Patient told CNA he didn't want care from her, but she continued to attempt to provide care. CNA denied putting two briefs on the resident or demanding he receive care after he asked her to stop. Patient is a 1 person assist with bed mobility, requires mechanical lift for transfers, and 1 person assist w/ [with] toileting. 6/16 approximately 0830 AM. Resident stated to his nurse and therapist who was in the room at this time, that he did not report this incident to anyone until now. Approximately 0915am, DON and Administrator met with patient. Approximately 0930am, DON again met with patient and a [FM1, family member]. He was in agreement that she was present. [FM1] informed the DON that she was a CNA and works in LTC [long term care] in Delaware, explaining she is aware of what abuse is, and then alerted the DON that resident was wearing two briefs at this time. Resident stated, CNA from day shift had not provided a brief change prior to this discovery. Resident is alert and oriented, but has poor vision, and was not aware he was wearing two briefs. Resident stated to DON and NHA he felt safe in his environment but did not want the CNA to provide care to him. [Name] PD [police department] was notified and officer responded and spoke with patient. After investigation was completed, the allegation of abuse could not be substantiated. CNA was reinstated and DON gave 1:1 education. r/t [related to] incontinent care and customer service along with understanding what abuse looks like. CNA verbalized understanding and denied she had placed two briefs on the resident at anytime during her shift.It should be noted that conflicting information was reported to the State Agency as E8 (CNA) was not reinstated according to the Personnel Action Memo where she refused to sign it and left the building on [DATE]. In addition, no evidence of E8's education was provided to the surveyor. [DATE] 9:55 AM - During an interview with the surveyor, R13 stated that he can see forms with his left eye and blind in the right eye. R13 stated that he had recent surgical amputations and was here for therapy and wound care. Surveyor asked R13 about the night shift incident where a CNA came in and pulled down his briefs. R13 stated it was a female, heavy set aide. R13 asked [E8, CNA] what she was doing, and she said she was checking his brief for urine. R13 stated that he told [E8] that he hasn't urinated in 6 years and didn't need care. [E8's] reply to him was that's the dumbest thing I ever heard. R13 stated that the aide was on one side of the bed and sprayed him in his wound area. R13 told E8 to stop because it stings. Then E8 came to the other side and sprayed him again and he knocked the cleanser spray away from him. During the interview, R13 was upset and angry when describing the incident. R13 stated that he felt the CNA was aggressive, did not listen to him and described the incident as an assault. R13 stated that his family member [FM1] called the police to report the incident. R13 stated that if he needs staff assistance, he will use the call bellXXX[DATE] 12:59 PM - Surveyor left a voicemail for E8 (CNA) and asked for a return call. No return call was received by the surveyor as of the exit conference on [DATE] at 4:50 PMXXX[DATE] 1:30 PM - During an interview, E12 (OT) stated that R13 was agitated and very angry when talking about the [DATE] incident with E8 (CNA). E12 stated that she immediately reported itXXX[DATE] 1:45 PM - During an interview, E13 (RN) confirmed that he was present with E12 (OT) in the room when R13 made the allegation of being treated aggressively by the CNA. E13 stated that R13 was initially calm at first, but then he became very upset recalling the details. E13 stated that R13 was getting irritated when they asked additional questions.The facility failed to ensure R13 was free from physical and emotional abuse on [DATE] during early morning care by E8 (CNA) when:- R13 told E8 that he did not need care and she continued anyway;- R13 told E8 that he hasn't urinated in 6 years and E8's response to R13 was that's the dumbest thing I ever heard;- E8 sprayed skin cleanser on R13's peri-area that had wounds despite R13 telling her to not use it because the cleanser stings; and- R13 was found double briefedXXX[DATE] 1:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (CRN). No further information was provided to the surveyor.2. Review of R16's and R17's clinical records revealed:[DATE] 8:30 PM - A facility incident report for R16 documented in the locked dementia unit, Physical Aggression Received. Resident's [R16] Room. Resident [R16] was resting in bed, when staff called that another resident was hitting the one that is laying in bed with a walker. Upon entering the room found the male resident [R17] standing by the bed side trying to fight staff that were trying to redirect him. This nurse [E16, LPN] tried to redirect, unsuccessful. Other staffs including a male came to our aid for resident to be removed from the room. Resident [R16] in bed was crying. saying 'he hit me'. RN supervisor [E18] called and assessed. Bruise noticed (sic) back of right hand. Tylenol PRN [as needed] administered for pain.XXX[DATE] 10:12 PM - A health status note by E10 (LPN) in R17's record documented, Called to another resident's room [number], and was notified by aide resident hit the female resident resting in bed with a walker, on entering the room, witnessed resident [R17] fighting with staff members who were trying to redirect and yelling in [specific language] holding his walker and refusing to leave the room, managed to redirect him back to his room and he laid in bed.[DATE] 11:40 AM - A psych progress note in R17's record documented, . oriented to person. no verbal aggression, yes physical aggression. yes tangential thought process. yes delusions. behavioral symptoms (checked) restless. Severity of behaviors (checked) mild. Frequency of behaviors (checked) intermittent. Requested by staff due to recent physical aggression toward another resident and staff. Patient AAOX1, seen at bedside with staff present for monitoring. Hx [History] significant for chronic depression, anxiety, mood irritability, agitation, and exit-seeking behaviors. Patient unable to recall recent behavioral incident. Thought process tangential; thought content notable for delusional ideation. Insight and judgment severely impaired. Given recent escalation in aggression and mood dysregulation, recommendation made to restart Celexa to target depressive symptoms, irritability, and behavioral disturbance. Advanced major neurocognitive d/o [disorder] with behavioral disturbance continues to place patient at high risk for. aggression, impaired safety awareness. requiring ongoing supervision and behavioral monitoring. Continued psychiatric oversight remains medically necessary for medication management, behavioral stabilization, safety monitoring, and prevention of further decline. dementia-related behavioral disturbance with recent physical aggression, psych med management, and ongoing risk for harm to self/others requiring close mo (sic).[DATE] - The facility's 5-day follow-up report to the State Agency documented:-R16's x-ray of right wrist was negative for acute fracture;- Approximately 10:12 PM [[DATE]], CNA was giving care in another resident's room. when she heard a woman say ouch and raised her voice. CNA exited room and saw [R17] in room. [R16] was lying in her bed. when [R17] raised his walker and struck her with his walker as witnessed by CNA. [R17] was confused, yelling at [R16] to get 'out of his bed'.-Actions taken by the facility: For R16, assess resident's emotional and mental health needs and update care plan accordingly; include resident in quarterly care plan meetings; maintain communication w/ [with] resident's RP [responsible party] to support emotional well-being; monitor for signs of depression or anxiety and refer to psychiatry/psychology as needed. For R17, Psych consult; 1:1 observation until cleared by Psych; and medication review.-Conclusion: Verified. [R17] has a history of wandering in other resident's rooms requiring redirection from staff back to his room and his surroundings. [R17] also has a history of being combative with staff. [R17] wandered into another resident's [R16] room, became disoriented and struck [R16] with his walker. CNA witnessed [R17] yelling. to [R16] to get out of his bed, then lifted his walker in the air and hit [R16] with the walker before the CNA could reach him.Review of the facility's investigation revealed written statements from E10 (LPN), E16 (LPN) and E18 (RN Supervisor). The facility lacked evidence of a statement from E17 (CNA) who witnessed R17 hit R16XXX[DATE] 10:55 AM - During an interview, E10 (LPN) stated that R16 looked scared after the incident with R17. E10 stated that R16 had redness on her wrist. E10 stated that the CNAs told her that R16 was hit with R17's walker. E10 stated that on the following day, R16 was back to her normal baselineXXX[DATE] 11:08 AM - During an interview, E11 (CNA) stated that she was on break and she was told about the incident when she returnedXXX[DATE] 4:50 PM - Findings were reviewed during the exit conference with E1, E2 and E3.

Based on interview and record review, it was determined that for three (R11, R13 and R26) out of eight residents reviewed for activities of daily living (ADLs), the facility failed to provide necessary services for personal hygiene care of dependent residents. R13, who had a perineal wound, returned from dialysis incontinent of bowel and requested to be changed. As a result of R13's toileting hygiene care request being deferred by staff until after dinner, R13 sat in a soiled incontinence brief for an additional two hours, resulting in dehumanization, a psychosocial harm. R26 was left soiled for four hours after requesting staff assistance. In addition, the facility failed to ensure that R11, a dependent resident, received the necessary services to maintain grooming and personal hygiene. Findings include: 1. Cross refer F609 Review of R13's record revealed: 5/21/26 – R13 was admitted to the facility for short-term rehabilitation with diagnoses including, but were not limited to, end stage renal disease requiring renal dialysis, orthopedic aftercare following surgical amputation of the left leg below knee and toes on right foot and blindness in the right eye. 5/27/26 – The admission MDS assessment documented that R13 had a BIMS of 15 (cognitively intact), required substantial/maximal staff assistance for toileting hygiene and dependent on staff for transfers. 6/22/26 – A wound assessment report revealed that R13 had an abrasion in the perineal region that was receiving daily and PRN Santyl ointment treatment with no dressing. 7/1/26 – A grievance form was completed and stated: Grievance Details: Resident upset with the timeliness of being changed. Summary of Findings: Resident reported that he had a bowel movement while at dialysis. He returned approximately 5:10 [PM]. Trays for dinner started to come out and resident then pressed call bell. CNA attempted to explain to resident that she will be back to [NAME] (sic) him once the trays are passed. Resident became angry and stated he should be able to be changed whenever he needs to be. Summary of Actions Taken: Director of Nursing [DON] attempted to explain the (sic) due to infection control, the CNA will pass out all meal trays then return to provide care. CNA who had resident did report to DON that she did try to explain to resident, but he became angry. Resident stated that once he was changed the stool was dry and hard to get off, so the CNA was a (sic) rough. A PRN [as needed] shower was offered but was declined. Resolved Note: DON, NHA and evening supervisor met with resident and [family member]. Educated resident on the process of passing meals. Resident not satisfied. 7/1/26 6:59 PM – The facility's Documentation Survey Report revealed that E6 (CNA) documented that R13 ate 0-25% of meal intake for dinner. 7/9/26 9:55 AM – During an interview with the surveyor, R13 stated that he can see forms with his left eye, while he was blind in the right eye. R13 stated that he had a bowel movement when he was at dialysis on Wednesday, 7/1/26. R13 explained that he was unable to use the bathroom at dialysis because of his inability to walk due to recent surgical amputations. R13 stated that he arrived back to the facility around 4:45 PM. R13 stated that he was told by staff upon arrival back to the facility that they do not change residents during mealtimes. During the interview with the surveyor, R13 became very emotional from being tearful to becoming angry as he recalled what occurred on 7/1/26. R13 stated that he was not changed until after 7:00 PM despite having had a bowel movement at dialysis earlier that day. When asked about the time he was changed, R13 stated he remembered that Jeopardy was on the TV at the time. R13 stated that the staff need more training because they keep saying, I'll be back and they never come back. R13 stated that he knows there are other residents who have needs and he understands that, but he felt ignored and did not understand why he could not get changed when he asked during a mealtime. 7/9/26 11:10 AM – During an interview, the surveyor asked E5 (SSD) about R13. E5 stated that R13 has a BIMS of 15 (cognitively intact), receiving short-term rehabilitation, a man of good faith, and cares about his family. E5 stated that she spoke to R13 several times, including on 7/2/26. When asked about R13's return from dialysis on 7/1/26 and his request to be changed, E5 stated that she was aware of the delay in changing. When asked how would she feel if she was told that she had to wait for toileting care, she responded frustrated. Surveyor asked E5 for a copy of the facility's policy and procedure that stated staff were not to provide toileting care for residents during mealtimes. 7/9/26 11:46 AM – During a follow-up interview, E1 (NHA) and E5 (SSD) stated that the facility does not have a policy about not changing a resident during meals. E1 stated it is a resident's right to be changed at any time. E1 stated that they will educate all staff that residents have a right to be changed at any time. 7/10/26 9:35 AM – During an interview, E6 (CNA) confirmed that she was R13's assigned CNA on 7/1/26 from 3 PM to 11 PM, and it was her first time she provided care to R13. E6 stated that R13 returned from dialysis, and he rang his call bell and asked to be changed. E6 stated that she told him that she would change him after dinner. E6 stated that during the meal she had to pass the meal trays in the hallway, retrieve missing meal items for residents from the kitchen, feed another resident across the hall from R13, and then she was asked at the end of dinner to supervise another resident, R27, in the nursing station as E7 (RN Supervisor) was called to the 1st floor for a resident who fell. E6 stated about 30-40 minutes after dinner, R13 started yelling to be changed to the nurse, E9 (LPN). E6 stated that she explained to the nurse that she would change R13 after dinner. E6 was asked by the surveyor if E9 (LPN) offered to change R13, E6 stated, no. E6 stated that after she changed R13, a family member and E2 (DON) were present in his room. When asked by the surveyor if R13 ate dinner on 7/1/26, E6 stated no. E6 stated that she was told in orientation to not change residents during mealtimes and that pretty much everyone does that. When asked who told her not to change residents during mealtimes, E6 could not recall. When asked if the facility was short-staffed on that shift, she replied I can't say short-staffed. 7/10/26 8:30 AM – During a follow-up interview, R13 stated that E2 (DON) and E5 (SSD) came back into his room recently and E2 told him that she was wrong and he can get changed during meals. R13 stated in an upset and angry tone that E2 lied to me and that he did not receive an apology for sitting soiled after using his call bell and asking to be changed on 7/1/26. 7/10/26 9:45 AM – During an interview, E9 (LPN) stated that she could not remember R13 asking to be changed on 7/1/26. However, E9 said if he needs to be changed, then we will change him. 7/10/26 1:24 PM – During an interview, E7 (RN Supervisor) stated that the CNA [E6] was assisting with dinner and she went in to change R13 after dinner. E7 stated that he apologized to R13 that all CNAs were in the process of dinner and no one was available. E7 confirmed that R13 was upset. 7/10/26 1:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (CRN). No further information was provided to the surveyor. 1. Cross refer F550 Review of R11's clinical record revealed: 9/25/19 - R11 was admitted to the facility with diagnosis including stroke and dementia. 2/20/23 – R11 was care planned for requiring assistance with ADLS related to physical limitation. weakness with interventions including one person staff assist with bed mobility. 6/8/23 (revised 12/20/23) – R11 was care planned for bowel and bladder incontinence and interventions included one person staff assist with. toileting hygiene as needed for incontinent episodes and providing toileting hygiene with brief exchanges. 5/18/26 – R11's quarterly MDS assessment revealed R11's cognition was severely impaired and was totally dependent with toileting, and personal hygiene. R11 required partial to moderate assistance with bed mobility and was always incontinent with bladder and bowel. R11 was also receiving hospice services during the review period. 6/24/26 1:04 PM – A facility incident report submitted to the state reporting agency documented that on 6/24/26 at 11:15 AM, .During rounds at approximately 1100 (11:00 AM), [P1 Hospice RN] and [E29 CNA] were giving care to [R11]. During care, it was discovered [R11] was briefed, with another brief under him and also a plastic trash can liner was underneath a drawsheet. 6/24/26 – A written statement by P1 documented, . [R11] was observed to be briefed with another brief inside of it. [R11] was lying on drawsheet with a trash bag smoothed out under the draw sheet. [R11] was saturated in urine, significant loos (sic) stool noted and redness to sacral area and down to left leg. 6/25/26 – A written statement by E29 (CNA) documented, I arrived late for my shift, then I started passing trays. I was checking my residents for safety and took care of immediate care. [P1] asked me to help her with [R11's] care. When we moved sheet (sic) we saw two briefs & the plastic liner. 7/1/26 – A facility 5 Day Follow Up Report documented, . CNA from the 11p-7a [E30 CNA] and 7a-3p shift [E29] were interviewed and denied knowledge of the 2nd brief and/or liner. 7/9/26 11:39 AM – In an interview, P1 stated, . Both incontinence briefs were soaked with significant amount of urine and loose stools. it looked like it's been there for quite some time. longer than that of morning start of shift. 7/9/26 12:21 PM – During an interview, E2 stated that E30 was the CNA who worked the previous night shift and she just came off from orientation. E2 stated that E30 was suspended along with E29 at that time when investigation was ongoing. 7/9/26 4:35 PM – In a telephone interview, E29 stated that on 6/24/26, she reported late for work and at around 10 or close to 11 AM she and P1 went to R11's room to do R11's incontinent care. P1 pulled the blanket and found trash bag underneath the blanket. E29 stated, We took off two adult briefs that were on [R11] and it was soaked with urine and stool. The facility failed to ensure R11, a dependent resident, received hygiene/toileting care on 6/24/26. Care was not provided to R11 until 11:00 AM. 7/10/26 10:35 PM – Findings were discussed with E1 (NHA) and E2 (DON). 7/10/26 10:40 PM – Findings were reviewed with E2 and E2 during the Exit Conference. 3. Cross refer F610 Review of R26's clinical record revealed: 5/2/26 – R26 was admitted to the facility with diagnoses including polyneuropathy. 5/2/26 – A care plan documented that R26 required the assistance of one staff member for toileting, toileting hygiene and brief changes. 5/8/26 – An admission MDS assessment for R26 documented a BIMS score of 15, indicating intact cognition. The assessment also documented that R26 was frequently incontinent of bowels, was dependent for transferring to the toilet and required supervision or touching assistance for toileting hygiene. 6/7/26 8:23 PM- A facility document entitled, Documentation Survey Report E14 (CNA) documented that R26 did not have a bowel movement and was assisted after being incontinent of urine. 6/8/26 3:28 AM – A facility document entitled, Documentation Survey Report E25 (CNA) documented that R26 was incontinent of bowels and was dependent for assistance after having a large bowel movement. 6/8/26 – A facility document entitled, Grievance Summaries documented, .Grievance Details: [R26] complained that she did not receive adequate care over the weekend. [R26] stated she stayed in bed all weekend and that she turned on her call light at 10:10 pm [6/7/26 10:10 PM]; an aide came and said she will be back but did not return after being informed that she needed to be changed.Summary of Investigation.[R26] reported a delay in being care [sic].aide came in but didn't return to change her until hours later. The grievance summary also documented that a CNA and Nursing Supervisor on duty received education. 7/9/26 10:35 AM – During an interview, E14 stated that she did not know of any incident where R26 was not changed after a bowel movement. E14 also denied receiving any education regarding this incident. 7/6/26 3:36 PM – During an interview, R26 stated, Three or four weeks ago I put on my call bell. I had a BM [bowel movement] and needed to be changed. It was 10:30 [PM] and I did not get help until 2:30 [AM]. I was told there were no aides. At 11:30 [PM], I told the aide I needed to be changed and was told, 'I'll be back'. One hour later, another aide came with wipes and a brief and said, 'I'll be back'.I filed a report.I sat there for hours in feces.I reported it to [E1, NHA], [E2, DON] and [E4 RN, UM]. 7/7/26 10:52 AM – During an observation, R26's call light was on. E26 (CNA) entered R26's room turned off the call light and stated, I will get your aide. 7/7/26 1:35 PM – During an interview, E26 stated, If a resident puts on their call light I will help them. The Surveyor asked E26 why R26 was not assisted when entering room. E26 stated, I did not help [R26] because I was busy. 7/7/26 2:30 PM – During an interview, E27 (CNA) stated, I told [R26] I would her get up at 10:00 AM. My assignment got changed at 9:00 AM and I had to give two other residents showers. The Surveyor asked E27 if anyone informed her that R26 needed assistance. E27 stated, The nurse (E23, RN) told me when I was finished that [R26] was waiting for me. [R26] needed to be changed; she had a massive bowel movement. I assist with other CNAs' residents and I helped other CNAs' residents this morning. They don't help with other CNAs' residents here. 7/7/26 4:16 PM – During an interview, R26 stated, I told the aide [E26] I needed to be changed. She told me that I have [E27] and that she would go get her. I was sitting here for over an hour. 7/10/26 2:00 PM – Findings were reviewed with E1 (NHA) and E2 (DON). 7/10/26 4:50 PM – Findings were reviewed with E1, E2 and E3 (CRN) during the exit conference.

Based on record review, interview, and review of other facility documentation, it was determined for four (R1, R18, R27 and R28) out of five residents sampled for reporting of injuries, injuries of unknown origin, abuse and activities of daily living, the facility failed to ensure that all injuries, including injuries of unknown source were reported to the State Survey Agency within the guidelines. R1, a dependent resident was observed with visible head injury on 4/22/26 at 6:00 AM and was not reported to the State Survey Agency until 4/23/26 at 8:30 AM, more than 26 hours later. For R18, R27, and R28, the facility failed to report incidents of abuse and alleged neglect and to submit a follow-up report within the required timeframe. Findings include:1. R1's clinical record revealed: 12/26/25 – R1 was admitted to the facility with diagnoses including, but not limited to, a stroke, deep vein thrombosis, heart failure, and dementia. 3/13/26 – R1's quarterly MDS assessment documented a BIMS score of 5, indicating a severe cognitive impairment. R1 required substantial to maximum assistance from staff for bed mobility and was totally dependent for all transfers between surfaces. 4/23/26 9:36 AM – E12 (LPN) documented in R1's nursing clinical record, Resident discovered in bed sleeping not easily aroused in deep sleep not able to explain what happen. Observation hematoma to right [forehead] and right eye bruising. Fully dressed. [Name of doctor] assessed resident and ordered to send resident out to the hospital for further evaluation. 4/23/26 12:24 PM – A facility reported incident report submitted to the Division documented, On 4/23/26 at approximately 0830 [8:30 AM], CNA reported to the Unit Manager that resident [R1] has a hematoma to the right side of her forehead and a right periorbital bruising. 4/29/26 9:00 AM – During a telephone interview, E8 (CNA) stated, My shift started on 4/21/26 at 11:00 PM and ended at 4/22/26 at 7:00 AM. I provided care to the resident [R1] two or three times during the night. Around 6:00 AM, I saw a discoloration on the right side of her forehead, but I forgot to tell the nurse. The Surveyor asked E8 if R1 showed any signs of pain when care was provided was provided to her. E8 stated, No. The Surveyor then asked E8 about R1's status during the 11-7 shift of 4/22/26 to 4/23/26. E8 stated, I saw the bruise around 5:00 AM but I did not see any additional injuries. The resident was responsive when I provided care to her during the shift. The Surveyor asked E8 if he reported the bruise to the nurse on duty or the oncoming aide. R8 stated, No. E8 failed to notify the nurse despite observing the bruise on R1's face on two separate occasions. 4/29/26 9:15 AM – During a telephone interview, E16 (LPN) stated, I worked the 11:00 PM to 7:00 AM shift on 4/21/26 into 4/22/26. I did an initial round when I came on the shift, and the resident [R1] was in her bed. I did not observe anything unusual with her. I gave her the morning medication between 5:30 AM to 5:45 AM, but I did not turn on the light in the room. The Surveyor asked E16 how she was able to see to give the resident her medication and if the resident was awake enough to take the medication. E16 stated, There was some light in the room, so I was able to see. And the resident took the medication fine. The Surveyor asked E16 if E8 informed her about any bruising or other concerns with R1. E16 stated, No. 4/29/26 9:30 AM – During an interview, E7 (CNA) stated, I was helping to feed the residents breakfast in the dining/activity room around 8:30 AM on 4/22/26. I saw the bruising and swelling on the resident's [R1] right-side temple and forehead area. I asked if anyone saw this. I told E6 (UM) and she told me to tell the resident's nurse. I told the nurse [E15 LPN] and she stated, I will take a look at it. 4/29/26 9:45 AM – During an interview, the Surveyor asked E6 (UM) whether she was informed of the discoloration and swelling on R1's head. E6 stated, The aide told me, and I told him to tell her nurse. The Surveyor asked E6 whether she assessed R1, informed the ADON, DON, updated the provider or documented the change in the resident's status. E6 stated, No. 4/29/26 10:00 AM – During a telephone interview, E13 (AA) stated, [E7] and I were in the dining room around 8:30 AM to 9:00 AM on 4/22/26. We saw the bruise on the resident's face and the CNA went to tell the nurses. I stayed in the dining room to watch the residents. 4/29/26 10:30 AM – During a telephone interview, E14 (CNA) stated, This was my assignment on 4/22/26 on the 7-3 shift. I gave morning care to the resident and saw the bruise when I was washing her face. I dressed her and brought her into the hallway, and I asked her nurse [E15], Did you see this? What happened to her? The nurse replied, It happened overnight, and remained at the medication cart. I took the resident into the dining room for breakfast. 4/29/26 11:00 AM – During a telephone interview, E15 stated, The night nurse did not tell me anything about a bruise on this resident. It was around 8:30 AM to 9:00 AM on 4/22/26 when the aide [E7] told me that [R1] had a knot on her head. I was passing medications, and I stopped and checked on the resident. I took her vital signs and checked her neuros [neurological status]. I saw a mildly raised area on the right side of her forehead, but there was no discoloration and her eyes were clear. The Surveyor asked E15 if she reported her observations to the supervisor or the medical provider. E15 stated, No, I did not report it to anyone. I don't work with this resident very often and I thought it was an old bruise that was already addressed and did not need to be reported again. The Surveyor asked E15 if she documented the results of R1's neurological check and updated the 3-11 shift nurse about the bruise. E15 stated, No, I did not tell the 3-11 nurse, and I forgot to document the neuros. R1's medication administration record revealed that E15 administered oral medications to R1 at 9:00 AM and oral supplements at 1:00 PM on 4/22/26 but failed to identify, assess or report the visible bruise on the right side of her head. 4/29/26 11:30 AM – During a telephone interview, E19 (CNA) stated, I was in the hallway around 8:30 AM or 9:00 AM on 4/22/26 when I heard the aide [E14] tell the nurse [E15] that the resident had a knot on her forehead. The nurse replied, It was not reported to me from the previous shift, and I saw the injury already. 4/29/26 1:30 PM – During a telephone interview, E17 (LPN) stated, I worked on the 3-11 shift on 4/22/26 but I did not see any bruising or swelling on the resident. R1's medication administration record revealed that E17 gave her oral medications at 4:00 PM and 8:00 PM but failed to identify the obvious bruise on the right side of her head. 4/29/26 2:00 PM – During a telephone interview, E21 (CNA) stated, I worked with the resident [R1] on the 3:00 PM to 11:00 PM shift of 2/22/26. I saw the bruise on the right side of her head. I don't usually work with her. When I saw the fall mat near her bed, I thought that she had a previous fall, and the nurses already knew about it. That is why I did not think the bruise was new and did not report it. E21 failed to report the bruise on R1's face despite the lack of a report of an injury from the previous shift. 4/30/26 9:00 AM – During a telephone interview, E20 (RN) stated, I worked with the resident [R1] on the 1:00 PM to 7:00 AM shift on 4/22/26 to 4/23/26. I checked on all the residents at the start of the shift. I did not turn on the lights because I didn't want them to wake up. [R1] slept all night and took her medication in the morning around 5:45 AM. The Surveyor asked R20 if R1 was awake and alert when she gave her the medication. R20 replied, I did not turn on the light when I gave her the medication with some applesauce. I did not give her water or anything else to drink. 4/30/2026 9:30 AM – During a telephone interview, E11 (CNA) stated, The resident [R1] was on my assignment on the 7:00 AM to 3:00 PM shift. I did a quick round when I came on the shift to check that none of the residents had fallen out of bed. [R1] appeared to be sleeping so I went and got a couple of other residents up and then went to get her up. She was breathing in and out but I could not wake her up. And I saw bruises on her forehead and right eye. I told the unit manager who was outside of the room. The facility failed to ensure that R1's injury of unknown origin was reported to the State Survey Agency for more than 26 hours after the injury was identified by the staff. 2. 4/3/26 2:30 PM – A facility report documented an incident of resident-to-resident abuse between R18 and R12. 4/3/26 11:06 PM- The facility submitted an incident report to the State Agency over six hours after the two-hour reporting requirement for alleged resident abuse. 4/13/26 – A facility 5 Day Follow-Up Report was submitted to the State Agency. The 5 Day Follow-Up Report was submitted three days after the required due date. 3. 4/22/26 – A facility investigation statement signed by E22 (RN Supervisor, UM) and E23 (LPN) documented, [E24] was scheduled to work on [unit] 4/21/26 for 3-11 PM shift. [R27] complained that [E24] assisted him in using the toilet at approximately 3:45 PM. [R27] stated that [E24] did not return to assist him with care for the rest of the shift. [E22] called [E24] on the staffing phone, but [E24] did not pick up. This was approximately 10:30 PM. [E22] did not see [E24] for the rest of the shift. 4/22/26 - A facility investigation statement signed by E22 and E23 documented, [R27] had his call bell on, but [E24] never went back to assist him with care.[E24] was not on the floor at this time and did not return to the floor. [R27] was finally assisted by the overnight nurse when she came on duty at 11PM. 4/23/26 3:41 PM – A facility incident report submitted to the State Agency documented that R27 and R28 reported to E22 an allegation of neglect by E24 on 4/21/26 during the 3:00 PM to 11:00 PM shift. The incident report also documented that E23 reported to E22 that she completed care for residents assigned to E24 and that E22 was not aware of the need to report the allegation of neglect. The incident report was submitted to the State Agency forty (40) hours after the required timeframe for reporting alleged neglect. 5/5/26 1:09 PM – During a telephone interview, E23 stated, I saw the call lights on in the hallway. I went in [R27]'s room.[R27] was very upset.I told him I would get someone to help him .[E24] did not pass hydration or get any snacks during the shift. I took care of the residents. At 8:00 PM or 8:30 PM, I helped [R27] change into his night clothes. I reported it to [E22]. 4. 4/22/26 – A facility investigation document signed by E22 and E23 documented, .[R28] complained [E24] assisted her with a shower and then to bed around 4:30 PM.Care was given by the nurse when called.[R28] stated that [E24] did not return to her room the remainder of the shift. 4/22/26 – A facility investigation document signed by E22 and E23 documented, .[R28] also stated [E24] did not assist with her care for the rest of the shift despite [R28] calling for help.Most of the patients on [R28]'s assignment complained to the night nurse that they did not get care on the evening shift. 4/23/26 3:41 PM – A facility incident report was submitted to the State Agency documenting an allegation of neglect when E24 assisted R28 to bed at 4:30 PM on 4/21/26 and did not assist R28 again for the rest of the shift. The incident report was submitted to the State Agency forty hours after required timeframe for reporting alleged neglect. 5/5/26 - During a telephone interview, E23 stated, .I saw [E24] in [R28]'s room around dinner time. I did not see [E24] after that. 5/5/26 3:30 PM – Findings were reviewed with E1 (NHA) and E4 (CRN). 5/11/26 12:30 PM – Findings were reviewed with E1, E2 (DON) and E4 during the exit conference.

Based on interview and record review, it was determined that for one (R26) out of eight residents reviewed for activities of daily living, the facility failed to have evidence of a thorough investigation of a neglect allegation when R26 complained to staff that she had been left incontinent of feces for four hours after requesting assistance. Findings include:Cross refer F677Review of R26's clinical record revealed:5/2/26 - R26 was admitted to the facility with diagnoses including polyneuropathy.5/2/26 - A care plan documented that R26 required the assistance of one staff member for toileting, toileting hygiene and brief changes.5/8/26 - An admission MDS assessment for R26 documented a BIMS score of 15, indicating an intact cognition. The assessment also documented that R26 was frequently incontinent of bowels, was dependent for transferring to the toilet and required supervision or touching assistance for toileting hygiene.6/7/26 - A facility document entitled, Daily Nurse Assignment, documented that E7 (RN Supervisor) and E14 (CNA) were assigned to R26 during the 3:00 PM to 11:00 PM shift on 6/7/26.6/7/26 - A facility document entitled, Daily Nurse Assignment, documented that E28 (RN Supervisor) and E25 (CNA) were assigned to R26 during the 11:00 PM to 7:00 AM shift from 6/7/26 to 6/8/26.6/8/26 3:28 AM - A facility document entitled, Documentation Survey Report documented that between 11:00 PM on 6/7/26 and 7:00 AM on 6/8/26, R26 was assisted by staff after having a large bowel movement.6/8/26 - A facility document entitled, Grievance Summaries documented, .Reported Date: 6/8/26.Reported By: [R26].Reported To: [R26].Resolved Date - Resolved By: 6/8/26 - [E1, NHA].Grievance Details:.[R26] stated she remained in bed all weekend. [R26] turned her light on at 10:10 [6/7/26 10:10 PM], an aide came and said she will be back but did not return after being informed that [R26] needed to be changed. [R26] stated she did not get changed until 2 am [2:00 AM].Summary of Investigation: [R26] reported a delay in being care [sic].aide came in and did not return to change her until hours later.Summary of Findings: [R26] reported a delay.Summary of Actions Taken:.Education completed with CNA and supervisor on duty. The grievance summary did not indicate who R26 reported her concern to or a result of the findings. The grievance summary also documented that E1 resolved R26's grievance on 6/8/26 and a CNA and Nursing Supervisor on duty received education following the incident.7/6/26 3:36 PM - During an interview, R26 stated, .Three or four weeks ago I put on my call bell. I had a BM [bowel movement] and needed to be changed. It was 10:30 [PM] and did not get help until 2:30 [AM]. I was told there were no aides. At 11:30 [PM], I told the aide I needed to be changed and was told, 'I'll be back'. One hour later, another aide came with wipes and a brief and said, 'I'll be back'. I filed a report.7/7/26 11:00 AM - During a joint interview, the Surveyor requested all facility investigation documents and evidence of education provided to staff that were involved in the incident resulting in R26's grievance from E1(NHA), E2 (DON) and E3 (CRN).7/8/26 12:10 PM - During an interview, E2 stated, E1 [NHA] just updated the grievance status to resolved. [E4, RN UM] did the investigation and education for the CNA and Nursing Supervisor on duty. The Surveyor again requested all investigation documents. E2 stated, I don't know where those documents are. [E4] is out of the country. I cannot reach her. The Surveyor asked, What are the names the CNA and the supervisor that were educated as stated on the grievance? E2 stated, I do not know who the CNA or supervisor was. It is either [E7] and [E14] or [E28] or [E25].7/9/26 10:35 AM - During an interview, E14 stated, I don't know of any incident when [R26] did not get changed. I know when [R26]'s light goes on, she needs to be changed. The Surveyor asked E14 if education was provided on responding to residents requesting assistance or providing timely incontinence care. E14 stated, No.7/9/26 4:23 PM - During an interview, E7 stated that he did not remember any incidents where R26 was not changed after requesting assistance. The Surveyor asked E7 if education was provided or was made aware of R26's complaint. E7 stated, No one talked to me about it.7/10/26 2:00 PM - Findings were confirmed with E1 (NHA) and E2 (DON).7/10/26 4:50 PM - Findings were reviewed with E1, E2 and E3 (CRN) during the exit conference.

Based on observation, interview and record review, it was determined that for two (R4 and R13) out of 27 sampled residents, the facility failed to respect each residents' right to personal privacy and confidentiality of personal care. Findings include: 1. 7/9/26 9:14 AM - An observation in the hallway outside of R13's room revealed a ripped piece of white paper thumbtacked on top of the enhanced barrier precaution sign with the following handwritten: NOT WET @ 5:55 AM 07/09/26. 7/9/26 9:20 AM - During an interview, E24 (RN/IC) confirmed the observation and removed the piece of ripped paper. 2. 7/9/26 9:15 AM - An observation in the hallway outside of R4's room revealed a ripped piece of white paper thumbtacked on top of the enhanced barrier precaution sign with the following handwritten: CHANGED @ 4:50 CHECKED AGAIN @ 6:03 AM NOT WET 07/09/26. 7/9/26 9:20 AM - During an interview, E24 confirmed the observation and removed the piece of ripped paper. 7/9/26 9:25 AM - During a combined interview, surveyor was present when E24 reviewed the two observations with E2 (DON) and E3 (CRN). 7/10/26 4:50 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E3.

Based on observation, interview and record review, it was determined that the facility failed to ensure that one (R10) of 31 sampled residents, was given the right to self-determination when the resident was not provided an early lunch tray or a bagged lunch prior to his afternoon neurosurgeon appointment until the surveyor intervened. Findings include: Review of R10's clinical record revealed:12/5/25 - R10 was re-admitted to the facility with diagnoses including neck fracture. 4/14/26 - R10's quarterly MDS assessment documented a BIMS score of 5 indicating a severe cognition impairment, had adequate hearing and vision, usually makes self understood and understands others with clear speech. R10 ambulates with a wheelchair and is independent of eating. 4/22/26 10:23 - A nurse progress noted documented, . [R10's] appt (appointment) is 4/29/26 @ (at) 130pm 4/29/26 12:00 PM - During an observation in (unit dining room), R10, sitting on his wheelchair, was looking at the nursing staff taking out food trays from the food truck and passing the trays to the residents seated in the dining room. 4/29/26 12:20 PM - E50 (CNA) was heard talking to R10 and told him, Your food tray is not in here, it's on the next truck. Since you will be going out now for your appointment, you will just have your lunch later when you come back. R11 and his companion, FM3 (father) both nodded in agreement.4/29/26 12:25 PM - E27 (LPN) was heard instructing R11 and FM3 to go up to the 2nd (second) floor lobby and wait for the transportation to come and pick them up for R11's neurosurgeon appointment.4/29/26 12:30 PM - As instructed, FM3 was observed wheeling R11 out of the dining room heading up to the lobby on the 2nd floor.4/29/26 12:32 PM - When asked if R10 had his early lunch? E27 stated that R10 would eat his lunch when he returns from his 1:30 PM appointment. When asked if R11 brought a bagged lunch with him, E27 stated, No. When surveyor told E27 that it would be way past lunch time when E27 would return from the appointment. E27 replied to the surveyor that she will try to ask for bagged lunch from the kitchen.4/29/26 12:40 PM - During an observation, E27 was heard asking R10 if he wanted to take a quick lunch in the dining room or bring a bagged lunch with him to the appointment. R10 was heard saying, a bagged lunch is good, make sure you have soda in it.4/29/26 12:42 PM - In an interview, FM3 stated that he was appreciative that E27 offered to send a bagged lunch for R10. FM3 further stated, There's nothing much we can do. We don't want to miss this appointment even if lunch will be served late.5/4/26 4:00 PM - Findings were reviewed with E2 (DON) and E4(CRN). 5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on record review and interview, it was determined that for two (R11 and R26) out of eight residents reviewed for activities of daily living, the facility failed to ensure that the residents were treated with dignity. For R11, the facility failed to promote respect and dignity when he was found lying in bed on top of a plastic trash bag wearing two incontinence briefs. R26 was left unchanged and soiled after requesting assistance from staff. Findings include:1. Cross refer F677 Review of R11's clinical record revealed: 9/25/19 - R11 was admitted to the facility with diagnosis including stroke and dementia. 6/24/26 1:04 PM – A facility incident report submitted to the state reporting agency documented that on 6/24/26 at 11:15 AM, .During rounds at approximately 1100 (11:00 AM), [P1 Hospice RN] and [E29 CNA] were giving care to [R11]. During care, it was discovered [R11] was briefed, with another brief under him and also a plastic trash can liner was underneath a drawsheet. 7/9/26 11:08 AM – In an interview, E21 (LPN, UM) stated that she was notified by E20 regarding R11 and E21 notified E2 (DON). E21 stated, I went and checked the other residents in the unit to make sure no other residents where double briefed. I spoke with aids and nurse about proper care, dignity and safety of residents. 7/9/26 11:13 AM – During an interview, E20 (LPN) stated that she didn't have R11 on the assignment on that day (6/24/26). E20 stated she was called by P1 to check on R11 in his room. E20 stated, I went in there and saw a plastic trash bag. when I walked in I saw [R11] with two incontinent briefs on and was fastened. I reported this to [R11's] nurse, [E10 LPN ] and [E21, LPN UM] . skin check was done. 7/9/26 11:39 AM – In an interview, P1 stated, . I checked in with [E29] and we helped clean [R11] up. We saw two briefs on [R11] one was fastened, I can't remember if the inner brief was fastened as well. we turned [R11] to his side of the bed facing [E29], I saw a large trash bag underneath the folded blanket which served as a drawsheet. 7/10/26 10:35 PM – Findings were discussed with E1 (NHA) and E2 (DON). 2. Review of R26's clinical record revealed: 5/2/26 – R26 was admitted to the facility with diagnoses including polyneuropathy. 5/2/26 – A care plan documented that R26 required the assistance of one staff member for toileting hygiene, including incontinence care. 5/8/26 – An admission MDS assessment for R26 documented a BIMS score of 15, indicating an intact cognition. The assessment also documented that R26 was frequently incontinent of bowels, was dependent for transferring to the toilet and required supervision or touching assistance for toileting hygiene. 6/8/26 3:28 AM – A facility document entitled, Documentation Survey Report documented that R26 was incontinent of bowels and was dependent on the assistance of one staff member after having a large bowel movement. 6/8/26 – A facility document entitled, Grievance Summaries, documented, .Summary of Investigation.[R26] reported a delay in being care [sic] as she initiated the call bell at 10:10 [6/7/26 10:10 PM], aide came in but didn't return to change her until hours later. The grievance summary also documented that a CNA and Nursing Supervisor on duty received education. 7/6/26 3:36 PM – During an interview, R26 stated, Three or four weeks ago I put on my call bell. I had a BM [bowel movement] and needed to be changed. It was 10:30 [PM] and did not get help until 2:30 [AM]. I was told there were no aides. At 11:30 [PM], I told the aide I needed to be changed and was told 'I'll be back'. One hour later another aide came with wipes and a brief and said 'I'll be back'. I filed a report. I sat there for hours in feces. It really affected my self-esteem to be left there like that. The facility failed to ensure R26 was treated with dignity when requested incontinence care was not provided, leaving the resident soiled for four hours. 7/10/26 2:00 PM – Findings were confirmed with E1 (NHA) and E2 (DON). 7/10/26 4:50 PM – Findings were reviewed with E1, E2 and E3 (CRN) during the exit conference.

Based on observation, interview and record review, it was determined that for three (R14, R15 and R24) out of three residents sampled for medication storage, the facility failed to ensure each resident's medications were safely stored in a secured area and under direct observation of authorized staff. Additionally, the facility failed to properly dispose of each residents' expired medications. Findings include: 1. 7/6/26 10:32 AM – An observation of an unlocked and unlabeled closet door at the end of the locked dementia unit revealed a large brown box on the bottom shelf filled with blister packs of residents' medication. 7/6/26 10:39 AM – Surveyor asked the two nurses, E10 (LPN) and E20 (LPN), in the locked dementia dining/activity room around the corner to have E21 (LPN/UM) to meet the surveyor in the hallway. 7/6/26 10:47 AM – Surveyor and E21 observed the unlocked closet and E21 stated that they do not use this closet. Further observation revealed a brown box on the bottom shelf filled with residents' blister packs of medications with the following handwritten on the top of the box Backup meds Arcadia Front. E21 could not explain why there were medications stored in the closet. The following residents' medications were in the box and immediately confirmed with E21: -R24's medication labels stated, Spironolactone 25mg tab. Give 50mg by mouth one time a day related to hypertension. 2 tablets = 50mg. Hazardous Group 2 Drug. HD Caution: Hazardous Drug. Observe Special Handling, Administration and Disposal Requirements. Out of twenty-nine (29) blister packs accounted and prescribed to R24, twenty-four (24) blister packs containing either 7 tablets or 14 tablets had expired use by dates. -R15's medication labels stated, Diltiazem 60mg tab. Give 1 tablet by mouth every 8 hrs [hours] for HTN [hypertension]. Recommend monitor BP [blood pressure] & [and] pulse wkly [weekly] or per policy. May cause photosensitivity or dizziness. Out of forty (40) blister packs accounted and prescribed to R15, twenty-seven (27) blister packs containing 14 tablets had expired use by dates with one blister pack missing 2 tablets. 7/6/26 12:05 PM – During an interview, E21 stated that R24 and R15's medications are kept in the front medication cart. A follow-up interview after reviewing the contents of the box with E21 confirmed the following: -the residents' medications should not be stored in an unlocked, unsupervised closet; and -expired medications should have been properly disposed. 2. 7/6/26 – Observations of the front medication cart assigned to E10 (LPN) revealed the following: -at 12:12 PM, R24 had two Aldactone 25mg medication blister packs containing 14 tablets with expired use by dates of 10/8/25 and 2/4/26. -at 12:19 PM, R15 had one Diltiazem 60mg medication blister pack containing 14 tablets with expired use by date of 12/14/25. Observations immediately confirmed with E10 and in the presence of E21 (LPN/UM). 7/6/26 2:00 PM – Findings were reviewed with E1 (NHA) and E3 (CRN). 3. Review of R14's clinical record revealed: 6/27/25 – R14 was admitted to the facility with diagnoses including dementia. 4/5/26 – R14's quarterly MDS assessment revealed that R14's cognition was severely impaired. 7/7/26 2:02 PM – During an interview, FM4 (friend) stated that she visits R14 in the facility regularly. FM4 indicated stated that she noticed a bottle of medicated powder left inside the drawer of R14 bedside table. FM4 motioned the surveyor to examine the contents of the drawer. 7/7/26 2:20 PM – An observation in R14's drawer revealed an unused bottle of nystatin powder prescribed for R14 on 6/11/26 with directions to apply to groin topically two times a day for rash for 10 days. 7/7/26 2:25 PM - When interviewed, R14 stated, They (nursing staff) never put them on me. 7/7/26 2:34 PM – E21 (LPN UM) entered R14's room to deliver incontinence briefs. Surveyor showed E21 the bottle of nystatin powder inside R14's drawer. 7/7/26 2:36 PM – In an interview, E21 confirmed that the nystatin powder should be kept in the treatment cart and not inside R14's drawer. E21 further stated that the nurses apply the powder on R14 and that she will check R14's treatment orders if R14 was to continue using it or to discontinue. 7/10/26 10:35 PM – Findings were discussed with E1 (NHA) and E2 (DON). 7/10/26 10:40 PM – Findings were reviewed with E1 and E2 during the Exit Conference.

Based on interview, record review, and review of other facility documentation, it was determined that for one (R11) out of 31 sampled residents, the facility failed to provide laboratory services to R11 when lab work ordered was not followed up after a failed specimen collection. In addition, the facility failed to ensure that a stat (at once) ordered lab draw result was reported to the physician in a timely manner. Findings include: Cross refer F684 example 2Review of R11's clinical record revealed:a. 3/18/26 - R11 had a physician's order for CBC and CMP for hyponatremia.3/23/26 - A labs result report from C6 (contracted laboratory vendor) with a specimen collection date of 3/19/26 documented . albumin . please reschedule . difficult draw specimen not obtained . WBC . please reschedule . difficult draw . specimen not obtained . a handwritten note also documented, CBC, CMP difficult stick.5/4/26 2:00 PM - A review of R11's nurse progress notes lacked evidence that the physician was notified of R11's lab draw for CBC and CMP was not completed due to difficulty in drawing R11's blood specimen.5/4/26 3:00 PM - In an interview, E4 (CRN) stated, That was approximately the time when we encountered change of service provider issues with between our laboratory [C6] and [C7, the lab vendor contracted by C6 to temporarily provide lab services to the facility while in transition]. A phlebotomist did come in on 3/19/26 and made an attempt to draw [R11's] blood specimen, but it was a hard stick and was not able to collect R11's specimen. Somebody else was supposed to follow up, come in and do [R11] again the next night (3/20/26) but nobody came. We did not know if it was supposed to come from [C6] or from [C7]. 5/5/26 4:00 PM Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN).b. 3/20/26 - R11 had a stat (at once) physician's order for CBC, CMP, magnesium, phosphate, B12, folate, Vitamin D for electrolyte derangements. 3/24/26 - A medical note by P1 (physician) documented . I reviewed BMP 3/17/26 . BUN/creatinine 53/2.9 . 3/25/26 - R11 had CBC, CMP, magnesium, phosphate, B12, folate, Vitamin D labs drawn.3/26/26 - 7:11 AM (another fax transmittal time stamped 7:14 AM) - Transmitted via fax by C7, R11's calcium, magnesium phosphorus, CMP, Vit B12 folate, CBC with diff profile lab results report revealed the following: elevated phosphorous 4.7 (2.6 - 4.5) BUN 44 (5-20) creatinine 2.6 (0.5 - 1.3) WBC 15.20 (4.5 - 11.00) and low hemoglobin 8.2 (11.7 - 16.1).3/26/26 9:35 AM - Transmitted via fax by C7, R11's magnesium, phosphorus, CMP and CBC profile lab results report revealed the following: elevated phosphorous 5.8 (2.6 - 4.5) BUN 56 (5-20) creatinine 4.6 (0.5 - 1.3) WBC 16.30 (4.5 - 11.00) low sodium 130 (133- 145) and low hemoglobin 7.6 (11.7 - 16.1).5/4/26 4:10 PM - A review of R11's progress notes lacked evidence that results of R11's 3/20/26 stat lab draw order for CBC, CMP, magnesium, phosphate, B12, folate, Vitamin D for electrolyte derangements was followed up by the nursing staff.5/5/26 10:40 AM - In an interview, E4 (CRN) stated that C7's reporting system was not connected to the facility's EHR (electronic health record system). E4 further stated, Unlike [EHR], we could not access the lab results from [C7]. They didn't call us, they only sent the results by fax. In the case of [R11], her lab results were only faxed on 3/26/26 in the morning. We had a contract with another laboratory vendor [C8] starting April 2026. 5/8/26 9:05 AM - In an interview, P2 (PA) stated that he was not immediately notified of the results of R11's stat lab draw order. I think it was that weekend. We had a third-party lab issue that time. We didn't know whom to call for follow up results. 5/8/26 9:10 AM - During an interview, E47 (LPN) stated, . When there's a stat lab order, the nurses should call and follow up with the lab and notify the physician, especially if the results are critical and the resident is going through a change in condition.5/8/26 4:00 PM - Findings were discussed with E1 (NHA), E2 (DON) and E3 (CRN). 5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on interview, record review and review of other facility documentation, it was determined that for one (R9) out of four residents reviewed for change in condition, the facility failed to ensure that a stat (at once) ordered chest x-ray was completed until 31 hours after it was ordered. In addition, the facility failed to ensure that R9's STAT chest x-ray result was reported to the physician in a timely manner. Findings include: Cross refer F580 and F684 Review of R9's clinical record revealed:6/5/26 9:21 AM - A nurse progress note documented, . [P2 NP] made aware (sic) she went to see [R9] . gave verbal order for STAT chest x-ray.6/5/26 3:00 PM - R9 had a physician's order for chest x-ray two views for cough and congestion.6/6/25 4:54 PM - A radiology results report documented R9's chest x-ray examination was done on this date and time.6/6/26 9:07 PM - A radiology results report documented R9's chest x-ray result with significant findings. 6/7/26 6:13 AM - A nurse progress note documented, .CXR (chest x-ray) results are back and MD (physician) will review them and give further instructions.6/7/26 9:43 AM - A nurse progress note documented that R9's chest x-ray result was reported to the on-call physician.7/10/26 6:29 PM - In an interview, E2 (DON) confirmed that R9's stat chest x-ray ordered on 6/5/26 at 9:21 AM was not done until the next day, 6/6/26 after 4:00 PM. E2 also confirmed that the nurse who received the report from the x-ray company that evening or night shift did not immediately call the physician but left it in the MD (physician's) book. 7/10/26 7:51 PM - In a telephone interview, E31 (LPN) stated . The evening nurse told me it was just a regular chest x-ray order, and not stat. When asked if she received the report of R9's chest x-ray result on Saturday evening, E31 stated that she did not see the actual copy of the report.7/10/26 8:17 PM - During a telephone interview, E32 (LPN) stated that he worked on 6/6/26 on the 3-11 shift. E32 further stated, . I was told by the outgoing day nurse of R9's delayed chest x-ray. The nurse working before my shift should have notified the on call NP or MD when R9's chest x-ray was not completed right away. 7/10/26 10:35 PM - Findings were discussed with E1 (NHA) and E2 (DON).7/10/26 10:40 PM - Findings were reviewed with E2 and E2 during the Exit Conference.

Based on interviews and record reviews, it was determined that for one (R11) out of 4 residents reviewed for nutrition, the facility failed to maintain clinical records that meet professional standards of practice when R11's missing nutrition assessments were completed and signed by another Registered Dietitian on 5/5/26, one month after R11 was discharged from the facility on 3/26/26. Findings include:Review of R11's clinical record revealed: 1/17/26 - R11 was admitted to the facility.1/19/26 - R11's nutrition assessment was completed by C1 (contract RD/ Registered Dietitian).3/26/26 2:00 PM - A nurse progress note documented that R11 was transferred to the hospital.5/4/26 - A review of R11's electronic health record under the evaluation/assessment tab revealed only one nutrition assessment completed by C1 on 1/19/26.5/4/26 3:00 PM - In an interview, E2 (DON) confirmed that R11 was discharged from the facility on 3/26/27. E2 further stated that R11 did not return to the facility after she was transferred to the hospital on 3/26/26. 5/5/26 3:25 PM - E2 presented to the surveyor copies of R11's nutrition assessment for 2/19/26 and 3/17/26 completed by another RD (C5) and signed on the same day, 5/5/26. 5/5/26 3:30 PM - E2 informed this surveyor that C1 was on leave and they have an interim RD (C2) who fills in and sees patients in C1's absence. E2 provided C2's contact information.5/5/26 3:38 PM - During an interview, C2 told this surveyor that she has never met R11 and never completed a nutritional assessment for R11. When asked if C2 was familiar with C5, C2 stated, Yes, she is my boss and the owner of our contract dietary agency. I can call her for you now to get clarification on why [R11's] nutrition assessments were dated back in 2/19/26 and 3/17/26 and she's only signing them with her name today.5/5/26 3:46 PM - In an interview, C5 (Owner of contract RD company) stated that C1 (contract RD) was on leave and was not available to answer this surveyor's questions regarding R11's assessments. C5 further stated, The facility called me today and asked about these nutrition assessments. I went over C1's risk management notes and since I can't find any assessments, I just typed the information in the template, signed it and dated it today. When asked if C5 had personally met R11 for a nutrition assessment in the past, C5 replied, No.5/4/26 4:00 PM - Findings were discussed with E1 (NHA), E2 (DON) and E4 (CRN).5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on interview and review of facility documents, it was determined that the facility failed to identify and correct R11's significant medication errors involving blood sugar checks, heparin and insulin injections. Findings include:Cross refer 7605/8/26 3:15 PM - During QAPI interview, E1 (NHA) confirmed that the facility failed to identify and correct quality issues for R11's nutrition and hydration status requiring emergent hospitalization on 3/26/26.5/8/26 3:50 AM - In a follow up interview, E1 further confirmed that facility failed to identify and correct R11's significant medication errors involving blood sugar checks, heparin and insulin injections from 2/15/26 to 3/18/26. 5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on observations, interviews and review of records and the facility's policy and procedure, it was determined that for two (R29 and R30) out of 31 residents sampled during the survey, the facility failed to ensure infection control and prevention practices were followed. Findings include:According to the Center for Disease Control's (CDC) website, the Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities, dated 6/27/25, stated, . The prevention of MRSA infections is a priority for CDC . Based on the current evidence, CDC recommends the use of Contact Precautions for MRSA-colonized or infected patients . The facility's policy and procedure entitled Transmission Based Precautions, effective 2/6/2020, stated, . Transmission based precautions are designed for patients documented as suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission . 3. Contact precautions (e.g., MRSA . C. difficile .). In addition to standard precautions, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment . 1.Review of R29's clinical record revealed: 4/28/29 - An active physician's order for R29 documented, CONTACT PRECAUTIONS every shift for MRSA . 4/29/26 9:57 AM - Observation by the surveyor revealed a contact precautions sign and an isolation cart with personal protective equipment available outside R29's room. Further observation with the door opened revealed E38 (RN) only wearing gloves while in R29's room administering an injection in the resident's right arm. Interview upon exit of R29's room, E38 confirmed that that he should have applied a gown on before entering R29's room. 2. Review of R30's clinical record revealed: 5/2/26 - A physician's order for R30 documented contact precautions for diagnosis of C-Diff. 5/3/26 10:41 AM - A telehealth note documented that R30 was evaluated by C9 (contracted telehealth APN) with E39 (LPN) present for vomiting. 5/3/26 approximately 1:00 PM - Observation by the surveyor revealed C2 (contracted dietician) ask E39 (LPN) at the medication cart if she needed to apply personal protective equipment before entering R30's room if she was only going to be asking her questions. E39 replied no if only you are asking questions. Further observation revealed that outside of the R30's room there was a contact precautions sign posted with instructions to apply gown and gloves before entering the room and an isolation cart was present with personal protective equipment (PPE) available. C2 entered the R30's room without applying PPE. 5/3/26 approximately 1:10 PM - Surveyor reported observation to E2 (DON) and E4 (CRN). 5/4/26 - An individual inservice record for C2 was provided to the surveyor by E2 (DON), which stated Isolation Requirements - Before entering any room that has a posted isolation sign, stop, read the instructions before entering. The information on the signage will direct you to the proper PPE. 5/6/26 4:10 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E4 (CRN).

Based on record review, interview and observation, it was determined that for one (R10) out of five residents sampled for resident records, the facility lacked evidence that oxygen therapy was administered as stated in the care plan and as ordered by the provider. Findings include:Cross refer F656Review of R10's clinical record revealed: 5/28/26 - R10 was admitted to the facility with diagnoses including COPD (Chronic Obstructive Pulmonary Disease) and acute respiratory failure.5/28/26 - R10's care plan documented, [R10] is at risk for respiratory complications secondary to COPD, lung cancer and respiratory failure.Interventions: administer oxygen as ordered.pulse ox [oximeter] and alert clinician per parameters.6/4/26 - A facility document entitled Order Summary Report, documented, O2 [oxygen] at 2 LPM [liters per minute] via NC [nasal cannula] every shift for COPD.monitor O2 sat [saturation] to maintain oxygen at or above 92% .6/29/26 9:43 AM - E15 (LPN) documented in R10's clinical record an O2 reading of 78% on RA (room air).6/29/26 11:58 AM - E15 documented in R10's clinical record an O2 reading of 78% on RA.7/9/26 10:18 AM - During an interview, the surveyor asked E15 if the physician was notified of R10's consecutive low oxygen readings on 6/29/26. E15 stated, .if I entered 78% for R10's oxygen readings it was a mistake. The surveyor asked E15 if these oxygen readings were errors, how would that be documented. E15 stated, I would have entered a note. The surveyor asked E15 what you would do if a resident has a pulse oximeter reading of 78%. E15 stated, I would've called the provider, put on a non-rebreather, called 911 to send her out to the hospital, but [R11] was never at 78%. The surveyor asked E15 why it was documented that R11 was on room air if she is ordered to receive oxygen therapy every shift. E15 stated, I can't remember if [R10] was on room air or not. That was the first day I worked with [R10]. It might have been an error.7/9/26 11:00 AM - Review of R10's clinical record revealed no documentation that the two oxygen readings of 78% on 6/29/26 were entered in error or documentation of physician notification of R10's low oxygen reading levels. Review of R10's oxygen reading levels entered in the vitals section of the clinical record from 6/1/26 to 6/30/26 revealed eleven oxygen saturation readings that documented room air as the method of oxygen delivery.7/9/26 10:39 AM - During an observation, R10 was lying in bed not wearing an O2 nasal cannula. The surveyor asked R10 if she could place the nasal cannula back into her nostrils. R11 was unable to replace the nasal cannula. The surveyor notified E23 (LPN) that R10 was not wearing an O2 nasal cannula. 7/9/26 10:40 AM - During an interview, E23 stated, I just put it [nasal cannula] on R10 when I gave her meds [medications]. The surveyor observed E23 place R10's nasal cannula onto her nostrils. The surveyor then requested E23 to obtain R10's oxygen level. R10's oxygen saturation reading was 82%.7/9/26 10:41 AM - During an observation, E23 left R10's room to get another pulse oximeter. E23 placed the new pulse oximeter onto R10's finger, which gave a reading of 95%. The surveyor then requested that E23 obtain R10's oxygen level with the first pulse oximeter used, which gave a reading of 98%.R10's oxygen level reading at 82% was accurate at the time it was taken.7/10/26 2:00 PM - Findings were reviewed with E1 (NHA) and E2 (DON).7/10/26 4:50 PM - Findings were reviewed with E1, E2 and E3 (CRN) during the exit conference.

Based on interview and record review, it was determined that for one (R9) out of four residents reviewed for change in condition, the facility failed to ensure that the physician was immediately consulted when R9's stat chest x-ray report revealed significant results. Findings include: Cross refer F684, F695 and F777Review of R9's clinical record revealed:6/5/26 - A physician note by P2 (NP) documented that per nursing report, R9 had increased congestion and, . will check stat (at once) chest x-ray .6/5/26 9:21 AM - A nurse progress note documented, . [P2] made aware (sic) she went to see [R9] . gave verbal order for STAT chest x-ray.6/5/26 3:00 PM - R9 had a physician's order for chest x-ray two views for cough and congestion.6/6/26 9:07 PM - A radiology results report documented R9's chest x-ray result was reported on this date and time revealing, moderate congestive heart failure.moderate interstitial edema, cardiomegaly and pulmonary vascular redistribution. There is peri bronchial cuffing (hazy appearance around the airways which occurs when excess fluid, mucus, or inflammation builds up in the surrounding lung tissue) . There is (sic) bibasilar infiltrates (shadows or haziness in the lowest sections of both lungs) right greater than left. The record lacked evidence that the physician was consulted about the abnormal chest x-ray result.6/6/26 10:31 PM - A nurse progress note documented that R9's chest x-ray was done with pending result. R9 was noted with occasional dry, non-productive cough. 6/7/26 6:13 AM - A nurse progress note documented, .CXR (chest x-ray) results are back and MD (physician) will review them and give further instructions.6/7/26 9:43 AM - A nurse progress note documented that R9's chest x-ray result was reported to the on-call physician.This was two days after the STAT chest x-ray order.7/9/26 12:39 PM - During interview, E16 (LPN) stated that R9's chest x-ray result was reported to the on-call physician on the morning of 6/7/26. E16 stated that R9 had new orders including guaifenesin for cough, azithromycin for pneumonia and Lasix (water pill). 7/10/26 6:29 PM - In an interview, E2 (DON) confirmed that the nurse who received the report from the x-ray company that evening or night shift did not immediately call the physician but left it in the MD (physician's) book. 7/10/26 7:51 PM - In a telephone interview, E31 (LPN) stated I can't remember exactly what [E28 RN Supervisor] told me that night when she received [R9's] results. she must have said, '.done and reviewed' and put in the box for the MD (physician) to read. Attempts to contact E28 were unsuccessful. 7/10/26 10:35 PM - Findings were discussed with E1 (NHA) and E2 (DON).7/10/26 10:40 PM - Findings were reviewed with E1 and E2 during the Exit Conference.

Based on observations, interviews and record reviews, it was determined that in one (R10) out of 31 sampled residents, the facility failed to develop a person centered care plan to address an identified need when R10 refused to wear his neck brace when out of bed. Findings include:Review of R10's clinical record revealed:12/5/25 - R10 was re-admitted to the facility with diagnoses including neck fracture. 4/14/26 - R10's quarterly MDS assessment documented a BIMS score of 5 indicating a severe cognition impairment, had adequate hearing and vision, usually makes self understood and understands others with clear speech. R10 ambulates with a wheelchair and is independent of eating.4/21/26 - R10 had a physician's order for neck collar to be worn when out of bed every shift and for monitoring.4/25/26 10:49 AM - A nurse progress notes documented Neck collar . frequently remove.4/27/26 12:53 PM - A nurse progress notes documented, Neck collar . removes.4/28/26 2:57 PM - A nurse progress notes documented, Neck collar . removes.4/29/26 11:50 AM - R10 was observed out of bed and sitting on his wheelchair watching TV in his room. R10's neck collar was not in use.4/29/26 11:55 AM - In an interview, E50 (CNA) stated that R10 was supposed to wear his neck collar when not in bed but he likes to take it off.4/29/26 11:58 AM - E27 (LPN) entered the room and asked R10 if he wanted to put the neck collar on. R10 stated, It's uncomfortable. E27 was looking at this surveyor and said, Sometimes [R10] likes to put it on, sometimes he likes it off him. 4/29/26 1:53 PM - A nurse progress notes documented, . resident frequently removes neck brace.encouraged not to remove leave on when OOB (out of bed).4/30/26 12:43 PM - R10 was observed sitting in the dining room. R10's neck collar was not in use.4/30/25 12:45 PM - In an interview, E28 (LPN) confirmed that multiple nurse progress notes documented that R10 refused to wear his neck collar. E28 further stated that it was not documented in the care plan as an identified behavior problem of refusal. 5/4/26 4:00 PM - Finding was discussed with E3 (DON) and E4 (CRN)5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on observation and interview, it was determined that the facility failed to ensure residents' rights to a dignified existence and self-determination when the facility failed to develop a system that notified residents of the daily menu. Findings include:9/18/25 8:53 AM - During resident screening R50 stated, They don't give us menus. We never know what we having until it gets here. Then, if you don't want it you have to wait cause you ordering something else. I said something to them, and they said they don't have to give us a menu. 9/18/25 9:46 AM - During resident screening, R83 stated, It's great here, only complaint I have is there's no menu or calendar of what's being served, but if you get it and don't like it, they will bring something else.9/18/25 11:40 AM - During a tour of the facility, the surveyor observed that the facility's common room for dining and activities displayed a posting of the daily menu at the entrance on both the first and second floors. 9/18/25 12:48 PM - During an interview, E36 (CNA) confirmed that residents were not provided a menu or made aware of the daily meals until they were served to the residents. 9/18/25 12:51 PM - During an interview, E37 (CNA) confirmed that residents were not provided a menu or other means of knowing the meals prior to being served. E37 stated, I do try to go look at the posting so I can tell them if they ask. 9/22/25 10:13 AM During an interview, E35 (FSD) confirmed that residents are not distributed/made aware of the daily menu. E35 stated, Activities is supposed to be implementing a new process to do that in the next few weeks. All residents do receive a copy of the always available options. 9/22/25 11:55 AM - During an interview, R108, the resident council president, confirmed that residents do not receive a menu of the daily meals served. R108 stated, We used to but now we don't.9/22/25 11:58 AM - During an interview, E12 (DOR) reported that presently the activities department staff does not distribute menus to residents.9/29/25 1:25 PM - Finding was reviewed with E1 (NHA), E2 (DON) and E3 (Corporate Nurse) during the exit conference.

Based on interview and review of clinical record and other documentation as indicated, it was determined that for one (R116) out of two residents sampled for hospitalization , the facility failed to ensure that R116 was free from a significant medication error. R116 was prescribed and administered Metformin and Ibuprofen at 8:00 AM every day from 9/10/24 through 9/15/24 despite two pharmacy warnings. In the setting of poor oral intake and the facility initiating hypodermoclysis during this timeframe, R116's creatinine increased from 0.8 baseline to 4.2 and BUN increased from 23 to 87 prior to being sent emergently to the hospital, requiring treatment with intravenous fluids and the discontinuation of the Ibuprofen. R116 was harmed. Findings include: R116's clinical record revealed: 8/20/24 - The hospital records included a Nephrology consultation, dated 8/20/24 at 10:20 AM, that stated, . Acute kidney injury-due to intravascular volume depletion . creatinine has already improved from 2.5 to 1.7 . continue hydration with normal saline . baseline . creatinine 0.9 . on 6/5/24 . 8/20/24 - R116 was admitted to the facility with diagnoses that included, but were not limited to, acute kidney injury. 8/21/24 at 11:28 AM - R116's lab results revealed: -Creatinine = 0.8 (normal range 0.5-1.5) -BUN = 23 (normal range 10-26) -Calcium = 10.4 (normal range 8.5-10.5). 8/22/24 - A progress note by E4 (MD) documented, . Diagnoses, Assessment and Plan . Acute kidney injury. Follow-up labs reviewed and BUN/creatinine are at baseline at this time and continue to monitor clinically and encourage p.o. (oral) intake and maintain hydration . 8/22/24 at 5:10 PM - A nutrition note documented, . Resident received IVF (intravenous fluids) while in the hospital . admitted to the hospital with generalized weakness and an episode of hypotension. Resident also experienced AKI (acute kidney injury), acute metabolic encephalopathy, UTI (urinary tract infection), hypoglycemia (low blood sugar) and hyponatremia (low sodium) which per hospital records were affecting her mental status and PO intake. These issues have resolved and resident is now alert with improved energy levels and improved PO intake per resident's [family member] report . 9/6/24 at 12:23 PM (Late Entry) - A Physical Medicine and Rehabilitation Follow Up Note by C6 (NP) documented, . Chief Complaint: Weakness . PMHx (past medical history) reviewed . seen this am while working in the PT (physical therapy) gym. She reports lower back right-sided non-radiating muscle pain . A&P (Assessment and Plan) . Ibuprofen 600 mg q (every) 6 PRN (as needed) for muscle pain. 9/6/24 at 4:09 PM - An Order Note automatically populated and stated, The order you have entered Ibuprofen Oral Tablet 600 MG . Give 1 tablet by mouth every 6 hours as needed for low back muscle pain Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The System has identified a possible drug interaction with the following orders: Metformin HCl Oral Tablet 1000 MG. Give 1 tablet by mouth two times a day for DM. Severity: Moderate. Interaction: Coadministration of Metformin and Ibuprofen Oral Tablet 600 MG may increase the risk of acute renal failure . This warning was acknowledged by E54 (LPN). 9/9/24 - A progress note documented by E4 (MD) documented, . Medication List: . Ibuprofen Oral Tablet 400 MG, Give 1 tablet by mouth one time a day for (sic) pain . ACTIVE, 9/10/2024 . Chief Complaint/Nature of Presenting Problem: Acute metabolic encephalopathy, diabetes type 2, hypertension . Patient this a.m. resting comfortably and appears (sic) no acute distress. Patient also with a history of acute kidney injury and I will repeat Chem-7 this week. P.o. intake has been stable and patient agrees to continued rehab services secondary to debility . Diagnosis, Assessment and Plan . Acute metabolic encephalopathy. Clinically patient has been stable and again reinforced safety and use of call bell and patient for rehab services secondary to debility . Diabetes mellitus type 2 with neurological manifestations. Patient continues with diabetic diet and metformin 1000 mg twice a day and sugars have been managed . continue to monitor . Acute kidney injury. Patient for follow-up Chem-7 this week . Measures . I have utilized all available immediate resources to obtain, update, or review the patient's current medications (including all prescriptions, over-the-counter products . 9/9/24 at 12:41 PM (Late Entry) - A progress note by C6 (NP) documented, . seen for today . PMHx (Past Medical History) reviewed . seen this am while sitting in the therapy gym. She tells me that she has been comfortable and has not had any knee pain all weekend. She did tell me that she took Ibuprofen this morning. We will continue to monitor her knee pain to see if we need to make adjustments . 9/10/24 at 12:22 AM - An Order Note automatically populated and stated, The order you have entered Ibuprofen Oral Tablet 400 MG . Give 1 tablet by mouth one time a day for (sic) pain Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The System has identified a possible drug interaction with the following orders: Metformin HCl Oral Tablet 1000 MG. Give 1 tablet by mouth two times a day for DM. Severity: Moderate. Interaction: Coadministration of Metformin and Ibuprofen Oral Tablet 400 MG may increase the risk of acute renal failure . This warning was acknowledged by E55 (RN). 9/11/24 at 12:42 PM (Late Entry) - A progress note by C6 (NP) documented, . Chief Complaint: Weakness . seen for today . did well today while in PT (physical therapy) and speech group . no changes to plan. 9/11/24 - R116's lab results received at 5:36 PM revealed: -Creatinine = 1.1, up from 0.8 on 8/21/24; -BUN = 49, up from 23 on 8/21/24. The BUN doubled; and -Calcium = 11.7, up from 10.4 on 8/21/24. 9/12/24 - A progress note by E4 (MD) documented under the . Medication List: . Ibuprofen Oral Tablet 400, Give 1 tablet by mouth one time a day for pain . ACTIVE, 9/10/2024 . Chief Complaint/Nature of Presenting Problem: Acute metabolic encephalopathy, hypercalcemia, diabetes type 1, hypertension, acute kidney injury . Patient with follow-up laboratory studies and I note that she has an elevated calcium of 11.7 and this is new as previous laboratories demonstrated a normal calcium level. My immediate concern is that patient with volume depletion and I will initiate hypodermoclysis D5W . for 2 L (liters) and repeat a Chem-7 (labs) in the a.m. Patient this a.m. resting comfortably and appears in no acute distress and I reinforced with the resident the importance of maintaining hydration. If elevated calcium persists will consider further workup especially in the setting of metastatic breast disease . Labs . BUN 49, creatinine 1.1, calcium 11.7 . Diagnosis, Assessment and Plan . Hypercalcemia. Most recent calcium with normal limits and concerns for current elevation due to volume depletion and will initiate D5W (sugar in water fluid) . for 2 L and will repeat a calcium level in the a.m. If remains elevated and/or increases and/or changes in mentation may need to send to the emergency room for further treatment . Acute kidney injury. I do note slight increase in the BUN and creatinine from most previous and again encourage fluids and will initiate hypodermoclysis and repeat a Chem-7 in the a.m . Acute metabolic encephalopathy. Patient currently appears at her baseline and I again reinforced safety and use of call bell and encourage p.o. intake to maintain hydration . Measures . I have utilized all available immediate resources to obtain, update, or review the patient's current medications (including all prescriptions, over-the-counter products . 9/12/24 on 3-11 PM shift - R116 started to receive fluids by hypodermoclysis. 9/13/24 at 5:45 AM (LATE ENTRY) - A note by C6 (NP) documented that R116 was seen today and resident was on . fluids for elevated calcium levels. R116's major rehabilitation goals: improve functional level and pain. Under Assessment and Plan section, C6 documented, . Deconditioning/ gait instability: Secondary to Weakness, the patient is at high risk for functional impairment without therapy as needed, and adequate pain control . no changes to plan. 9/13/24 - A progress note by E4 (MD) documented under the . Medication List . Ibuprofen Oral Tablet 400 MG, Give 1 tablet by mouth one time a day for pain . ACTIVE, 9/10/2024 . Chief Complaint/Nature of Presenting Problem: Hypercalcemia, acute metabolic encephalopathy, acute kidney injury . past medical history of metastatic breast cancer . admitted to our facility for rehab services status post hospitalization for acute metabolic encephalopathy. Patient with follow-up labs and was found to have an elevated calcium of 11.7 and I initiated hypodermoclysis and patient appears to be tolerating at this time. I again reinforced the importance of hydration and proper nutrition with the resident (sic) staff working with the resident in this regard as well and if persist patient may need to be sent to the emergency room for further evaluation . Labs: . BUN 67, creatinine 1.7 . Diagnosis, Assessment and Plan . Acute kidney injury - Most likely due to hypovolemia as discussed earlier and patient is continuing with hypoderclysis (sic) staff working to encourage p.o. intake to maintain hydration and patient for follow-up labs which are pending at this time. As I stated before if persist patient may need to go to the emergency room . Hypercalcemia. Slight improvement of the calcium level and continue with the hypodermoclysis (sic) patient for follow-up (labs) . Acute metabolic encephalopathy. Patient hospitalized previously and resting comfortably this a.m. and I again reinforced the importance of nutrition and proper hydration . Measures . I have utilized all available immediate resources to obtain, update, or review the patient's current medications (including all prescriptions, over-the-counter products . E4 documented that he reviewed R116's medications, but made no mention of the metformin and ibuprofen interaction having the potential to cause renal failure. 9/13/24 at 2:01 PM - R116's lab results revealed: -creatinine = 1.7, up from 1.1 on 9/11/24; -BUN = 67, up from 49 on 9/11/24; -Calcium = 11.5, down from 11.7 on 9/11/24. Despite initiating fluids by hypodermoclysis, both creatinine and BUN continued to elevate. Review of the nurse's notes and the CNA Documentation Survey Report during this timeframe lacked evidence that R116's oral intake was being encouraged and monitored by nursing staff. 9/14/24 at 9:30 AM (collected time) - R116's lab results revealed: -creatinine = 2.8, up from 1.7 on 9/13/24; -BUN = 76, up from 67 on 9/13/24; -calcium = 11.1, down from 11.5 on 9/13/24. R116's BUN and creatinine continued to elevate despite receiving fluids by hypodermoclysis. 9/14/24 at 3:45 PM - An Orders - Administration Note documented that 2 liters of . fluids were administered subcutaneously for elevated calcium level were completed. 9/14/24 at 10:08 PM - A lab note documented, Lab results received, Cr 2.8, BUN 76. Patient completed ordered Hypodermoclysis fluids today. Oncall NP [E56] notified and new orders given to repeat BMP in AM. Orders noted, patient and family aware. 9/15/24 at 6:26 AM - A nurse's note documented, STAT order called in for blood draw this morning d/t (due to) abnormal lab results . 9/15/24 at 11:09 AM - R116's lab results revealed: -creatinine = 4.2, up from 2.8 on 9/14/24; -BUN = 87, up from 76 on 9/14/24; -calcium = 11.0, down from 11.1 on 9/14/24. Despite the pharmacy's black box warnings, review of the September 2024 EMAR revealed that R116 was administered Ibuprofen medication daily from 9/10/24 through 9/15/24 at 8:00 AM, at the same time as Metformin medication. Six doses of Ibuprofen 600 mg were given to R116 from 9/10/24 to 9/15/24. Review of the September 2024 CNA Documentation Survey Report revealed R116's daily fluid intake during meals, including the Ensure drink, as: -9/10/24 = 770 mls; -9/11/24 = 770 mls; -9/12/24 = 720 mls; -9/13/24 = 577 mls; -9/14/24 = 837 mls; and -9/15/24 = 142 mls. 9/15/24 (Sunday) at 12:08 PM - A change of condition note documented, Lab results received, Cr 4.2, BUN 87. Oncall NP . notified and gave new order to send patient to . ER for evaluation and treatment. Dx. Acute Kidney Failure . [F1, R116's family member] present and notified in person. Patient sent to . ER via 911 ambulance at 11:30 AM. 9/15/24 at 1:12 PM - The hospital ER record documented that R116's creatinine was 5.19, BUN of 86 . calcium 11.2 . continue with fluid resuscitation . 9/18/24 at 3:12 PM - The hospital record documented that . AKI (acute kidney injury) suspected due to decreased oral intake/dehydration. Also receiving ibuprofen at rehab facility. Nephrology is following. On IV fluids for prerenal AKI . 10/1/24 at 11:25 AM - During an interview, C6 (NP) stated that she prescribed Ibuprofen prior to Physicial Therapy to help R116 do better in therapy. C6 stated that R116 wasn't taking the PRN dose due to her cognitive deficit, so C6 ordered the scheduled Ibuprofen dose prior to therapy. C6 requested a BMP lab to monitor R116's renal function after ordering Ibuprofen. C6 stated that there were other contributing factors that may have played a part in her renal injury/hospitalization : metastatic cancer and poor oral intake. C6 stated that she spoke to E50 (NP) when she was prescribing the Ibuprofen. 10/2/24 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E46 (VPO) and a representative from the Ombudsman's Office.

Based on observation, interview and review of clinical record and other documentation as indicated, it was determined that for three (R26, R105, R228 and R533) out five residents sampled for pressure ulcer, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing. For R26, the facility failed to initiate and implement a sacral pressure ulcer care plan with appropriate interventions and hospice involvement and appropriately Stage her sacral pressure ulcer that started as MASD. As a result of multiple failures, R26 was harmed. For R105, R228 and R533, the facility failed to provide pressure ulcer wound care as ordered. In addition, the facility failed to complete weekly skin audits. Findings include: A facility policy entitled, Pressure Ulcer Monitoring & Documentation (initiated 11/1/2019) included, A licensed nurse will assess patients for the presence of pressure ulcers/injuries. A facility policy entitled, Skin Assessments (initiated 11/1/2019) included, A licensed nurse will ensure that the skin risk assessment is done upon admission and quarterly thereafter. The weekly skin assessment will be completed thereafter. 1. Cross refer to F641, F656, F657, F697, F849 R26's clinical record revealed: 12/23/23 - R26 was care planned for requiring assistance with ADLs (activities of daily living) related to physical limitations with an intervention for one person assist for bed mobility and transfers. 1/1/24 - R26 was readmitted to the facility from the hospital and remained on hospice services. 1/2/24 - R26 was care planned for at risk for pressure ulcers related to chronic diseases, PVD, incontinence episodes and decreased mobility. The approaches included: -assess resident for risk of skin breakdown; -assist the resident to turn and reposition often; -encourage to turn and reposition often; -keep skin clean and dry as possible; -offload heels while in bed as tolerated; -skin assessments as indicated; -Treatment per TAR (Treatment Administration Record). From 1/1/24 through 3/17/24, R26's nurse's notes documented that that she was being turned and repositioned every 2 hours and oral intake monitored. From 2/15/24 through 2/29/24, R26 was diagnosed and treated for a Stage 2 pressure ulcer on the sacrum. Per C1's (WCC) progress note on 2/29/24, the sacral pressure ulcer was resolved. 3/9/24 at 3:09 PM - E8 (LPN, Wound Nurse) documented that R26's Braden scale for predicting pressure sore risk was 13, a moderate risk. 3/18/24 at 11:48 PM - A nurse's note documented that R26's room was changed to another floor. 4/19/24 - A hospice nurse's note documented that a Stage 1 pressure ulcer on the sacrum, painful. Review of the facility's nurse's notes lacked evidence that R26's sacrum pressure ulcer was being assessed and monitored. 4/28/24 - A facility Skin Assessment documented no issues. Review of R26's clinical record lacked evidence that weekly skin assessments were completed by nursing staff from 4/29/24 through 6/5/24. 5/20/24 - The quarterly MDS assessment documented that R26 was moderately impaired for daily decision making; no rejection of care; required supervision or touching assistance for eating and toileting hygiene; required partial/moderate assist with rolling left to right in bed; always incontinent of bladder and bowel; active diagnoses but were not limited to, coronary artery disease, dementia, adult failure to thrive, malnutrition; weight loss; at risk for pressure ulcers; no unhealed pressure ulcers at the present time; no other skin problems; and current skin treatments were pressure reducing device for bed and applications of ointments/medications. 5/22/24 at 12:09 PM - A nutrition note documented, . significant weight loss . Resident is on comfort care so wt (weight) loss is anticipated. PO (oral) intake is variable 25-75%. Pt (Patient) receives Magic cup q (every) day which she accepts. Family is aware and NP made aware . Monitor . po intake . 5/28/24 at 2:45 PM - E8 (LPN, Wound Nurse) documented that R26's Braden scale for predicting pressure sore risk was 13, a moderate risk. 5/30/24 at 11:04 AM - A skin note by C1 (WCC) documented, . new skin and wound consult . location: sacrum primary etiology: MASD stage/severity: partial thickness . size: 2cm x 2 cm x 0.1 cm . treatment: apply collagen, zinc oxide paste to base of the wound, leave open to air, BID (twice a day) . Recommend washing area with soap and water and pat dry thoroughly . 5/31/24 - R26 was care planned for MASD to the sacrum with interventions to: -notify MD as indicated; -observe for signs and symptoms of worsening or improvement; -supplement to aid in wound healing; and -treatments as ordered. 6/5/24 at 2:43 PM - A skin note by C1 (WCC) documented, .Location: sacrum . Stage/severity: partial thickness . size: 1 cm x 2 cm x 0.2 cm, stable . treatment . medical grade honey fiber to base of the wound . bordered gauze. Change daily, and prn . The patient was noted to have incontinence associated dermatitis . Recommend washing area with soap and water and pat dry thoroughly . 6/5/24 at 9:43 PM - E8 (LPN, Wound Nurse) documented that R26's Braden scale for predicting pressure sore risk was 13, a moderate risk. 6/13/24 at 9:51 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: partial thickness . improving without complications, Size: 1 cm x 1.5 cm x 0.2 cm . Treatment .medical grade honey fiber to base of the wound . bordered gauze. Change daily, and prn . reviewed treatment plan with nursing staff. 6/20/24 at 8:15 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: partial thickness . stable . Size: 1.5 cm x 2.2 cm x 0.1 cm . moderate amount of serosanguineous exudate . Treatment . Apply calcium alginate to base of the wound . Change daily and PRN . noted to have incontinence associated dermatitis . Continue with turning and repositioning schedule per protocol for pressure prevention. Position patient side to side as tolerated. Recommend an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. 6/25/24 at 2:30 PM - A nutrition note documented, . hospice . magic cup q day . po intake: variable, typically 50-75% . weight loss is anticipated with decline and advanced age/hospice status . Recommend: continue with Magic Cup q day, honor pt preferences, comfort over satiety . 6/27/24 at 7:06 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable, Size: 3 cm x 1 cm x 0.1 cm, periwound fragile, moderate amount of serosanguineous exudate . debrided 100% removal of biofilm causing delayed wound closure. Removal of necrotic tissue . topical lidocaine . Treatment . Apply medical grade honey fiber to base of the wound . bordered gauze . Change daily, and PRN . Continue with turning and repositioning schedule . The facility lacked evidence of R26's pressure ulcer stage as the severity increased to full thickness and removal of necrotic tissue was completed by debridement. In addition, there was no evidence in the clinical record of turning and repositioning R26. 7/2/24 at 7:14 AM - A skin note by C2 (WCC #2) documented, . Location: sacrum . Stage/severity: full thickness, improving without complications . Size: 2.5 cm x 1.2 cm x 0.1 cm, wound base 100% epithelial, attached wound edges, periwound fragile, intact, moderate amount of serosanguineous exudate . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily, and prn . continue with turning and positioning schedule per protocol for pressure prevention. Position patient side to side as tolerated . Review of R26's clinical record lacked evidence that R26 sacral pressure ulcer was staged and R26 was being turned and repositioned. 7/11/24 at 10:13 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness . stable . Size: 1.5 cm x 2 cm x 0.3 cm, 75-99% granulation, 1-24% slough, attached wound edges, fragile/intact periwound, moderate amount of serosanguineous exudate . debrided 100% removal of biofilm causing delayed wound closure, removal of necrotic tissue, topical lidocaine . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change BID and PRN . continue with turning and repositioning . The facility lacked evidence of R26's pressure ulcer stage as the severity was full thickness and removal of necrotic tissue was completed by debridement. In addition, there was no evidence in the clinical record of turning and repositioning R26. 7/18/24 at 6:23 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable . Size: 1.5 cm x 2.5 cm x 0.2 cm, 75-99% granulation, 75-99% slough . moderate amount of serosanguineous exudate . A sharp debridement was not performed today due to patient is palliative and/or under hospice care and debridement is not recommended at this time . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change BID and PRN . continue with turning and repositioning. The facility lacked evidence of the sacral PU stage and turning and repositioning of R26 in the clinical record. 7/24/24 at 11:18 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness . Size: 1.5 cm x 2 cm x 0.4 cm, 1-24% epithelial, 75-99% granulation . moderate amount of serosanguineous exudate. A sharp debridement was not performed today due to patient is palliative and/or under hospice care and debridement is not recommended at this time . Treatment . calcium alginate to base of wound . bordered gauze . Change daily, and prn . Continue with turning and repositioning schedule . The facility lacked evidence of the sacral PU stage and turning and repositioning of R26 in the clinical record. 7/26/24 - A progress note by E4 (MD) documented, . po intake has been relatively stable . 7/30/24 - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable . Size: 1.5 cm x 2 cm x 0.4 cm, 1-24 % epithelial, 75-99% granulation . moderate amount of serosanguineous exudate . A sharp debridement was not performed today due to patient is palliative and/or under hospice care and debridement is not recommended at this time . Treatment . calcium alginate to base of the wound . bordered gauze . Change daily, and PRN . Continue with turning and repositioning . for pressure prevention. Position patient side to side as tolerated . The patient was seen today for evaluation and management of a chronic ulcer. Despite individual interventions in place in accordance with the standards of care for patient's needs and goals . It is this provider's opinion that the ulcer is unavoidable due to the patient's chronic medical/comorbid conditions . The patient has the following risk factors and/or co-morbities that delay, impair, or impede wound healing: age, bladder incontinence, bowel incontinence, fragile skin. The facility lacked evidence of the sacral PU stage and turning and repositioning of R26 in the clinical record. 7/31/24 at 5:15 PM - A nutrition note documented, .She often refuses wts (weights), but past month was agreeable to obtaining wt . has gained significant amount of wt which is favorable considering her underweight status . Some wt loss and decline may be unavoidable due to medical condition. PO (oral intake) appears to be stable with most meals at 50-100% and good acceptance of supplements. Per wound notes, sacral wound is stable . 8/9/24 at 1:53 PM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, improving without complications . Size: 2 cm x 2 cm x 0.1 cm, 100% epithelial, no exudate . Treatment . zinc oxide paste to base of the wound . leave open to air . (every) shift . continuing turning and repositioning . The facility lacked evidence of the sacral PU stage and turning and repositioning of R26 in the clinical record. 8/13/24 at 7:37 AM - A skin noted by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable . Size: 1 cm x 2 cm x 0.3 cm, 50% epithelial, 30% granulation, 20% slough, moderate amount of serosanguineous exudate . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily . continue with turning and repositioning . The patient is currently under hospice services. Goals of care remain to minimize pain and risk of infection. Continue palliative wound management. The facility lacked evidence of R26's sacral PU stage and turning/repositioning in the clinical record. 8/14/24 at 1:24 PM - E8 (LPN, Wound Nurse) documented that R26's Braden scale for predicting pressure sore risk was 14, a moderate risk. Despite having a full thickness, unstaged sacral PU, the facility assessed R26's pressure sore risk as moderate. 8/18/24 - The annual MDS assessment documented that R26 was moderately impaired for daily decision making; no rejection of care; required supervision or touching assistance for eating and was dependent for toileting hygiene; required substantial/maximal assist with rolling left to right in bed; always incontinent of bladder and bowel; active diagnoses but were not limited to, coronary artery disease, peripheral vascular disease, dementia, adult failure to thrive, malnutrition; at risk for pressure ulcers; no unhealed pressure ulcers at the present time; other skin problem was MASD; and current skin treatments were pressure reducing device for bed and applications of nonsurgical dressing and ointments/medications. Despite R26 having a full thickness, unstaged sacral PU with 20% slough on 8/13/24, the MDS assessment was coded that R26 had MASD and no pressure ulcer. In addition, under current skin treatments, turning and repositioning was not checked as being completed nor was the nutrition or hydration intervention. 8/20/24 at 12:27 PM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable . Size: 2 cm x 2 cm x 0.3 cm, 50% epithelial, 30% granulation, 20% slough, moderate amount of serosanguineous exudate . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily . continue with turning and repositioning . 8/23/24 - A nutrition note documented, . Supplements: magic cup .daily . active liquid protein . BID (twice a day) . Supplements in place to assist w/ (with) weight gain and also for healing of MASD to sacrum which is stable per recent wound report . MD notified of significant weight gain . Despite R26 having a full thickness, unstaged sacral PU with 20% slough, the facility's dietician documented MASD on the sacrum. 8/28/24 at 10:55 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, stable, Size: 1 cm x 3 cm x 0.3 cm, 100 % granulation, moderate amount of serosanguineous exudate . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily . continue with turning and repositioning . 9/6/24 at 10:24 AM - A skin note by C2 (WCC #2) documented, . Location: sacrum . Stage/severity: full thickness, worsening . Size: 4 cm x 5 cm x 0.3 cm, 50% granulation, 50% slough, periwound evolving DTI, moderate amount of serosanguineous exudate . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily . continue with turning and repositioning . Patient with worsening sacral wound to sacrum due to decreased PO intake, failure to thrive and end of life skin changes. Wound etiology changed to disorder of the skin: Kennedy ulcer. 9/11/24 at 10:45 AM - A skin noted by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness, worsening . Size: 4 cm x 5 cm x 0.3 cm, 10% epithelial, 50% slough, 40% eschar, evolving DTI periwound, moderate amount of serosanguineous exudate . continue turning and repositioning . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily . Patient with worsening sacral wound to sacrum due to decreased PO intake, failure to thrive and end of life skin changes. Wound etiology changed to disorder of the skin to Kennedy ulcer. 9/17/24 at 11:02 AM - A nutrition note documented, . wound sacral . presenting with a favorable weight gain . Per wound records, pt wound has worsening. Will increase pro liquid from BID to TID for optimal wound healing. Continue with magic cup QD (every day) . 9/17/24 - A physician's orders documented, Active Liquid protein three times a day for wound healing 30ml . po, supplement . 9/18/24 at 9:37 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/Severity: Full Thickness . worsening . Size: 4 cm x 7.5 cm x 0.2 cm . 10% epithelial, 50% granulation, 40% eschar . Periwound: Fragile, intact, evolving DTI. Exudate: Moderate amount of serosanguineous . A sharp debridement was not performed today due to patient is palliative and/or under hospice care and debridement is not recommended at this time . Treatment . medical grade honey fiber to base of the wound . bordered gauze . Change daily, and PRN . Continue with turning and repositioning . Position patient side to side as tolerated. The patient has the following risk factors that delay, impair, or impede wound healing: age, bladder incontinence, bowel incontinence, fragile skin. NEW RECOMMENDATIONS: The patient is currently under hospice services. Patient with worsening sacral wound to sacrum due to decreased PO intake, failure to thrive and end of life skin changes. Wound etiology changed to disorder of the skin to Kennedy ulcer. Goals of care remain to minimize pain and risk of infection. Continue palliative wound management. 9/24/24 - Observations of R26 revealed: -at 9:00 AM, R26 laying on her left side facing doorway; -at 10:31 AM, R26 laying on her left side facing doorway; -at 12:02 PM, R26 sitting up in bed eating lunch with assistance of staff; -at 2:07 PM, R26 laying on her left side facing doorway. 9/25/24 at 8:11 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness . worsening . Size: 4.2 cm x 6.5 cm x 0.2 cm . 10% epithelial, 50% granulation, 40% slough . Periwound: fragile, intact, evolving DTI Exudate: moderate amount of serosanguineous . Treatment . medical grade honey fiber to base of the wound . bordered gauze . change daily, and PRN . continue with turning and repositioning . position patient side to side as tolerated . Patient with worsening sacral wound . due to decreased PO intake, failure to thrive and end of life skin changes. Wound etiology changed to disorder of the skin to Kennedy terminal ulcer . can be present up to 6 weeks . 9/25/24 at 8:00 AM - An observation of wound care with C1 (WCC) and E8 (LPN) revealed the following: -observed R16 moaning when R26 was being repositioned in bed and during the dressing change; -observed the saturated wound dressing dated 9/23 in black ink on R26's sacrum. The Surveyor asked if this was a daily dressing and E8 confirmed that it was and the dressing was not changed yesterday. -no enhanced barrier precautions were in place for R26's chronic wound and thus no gowns were worn during the dressing change; -observed that the low air loss mattress device at the foot of the bed was on standby; -observed C1 state 6 cm x 4 cm as she measured and took a picture of the wound; Immediately following the wound dressing change, the Surveyor asked C1 if she believed that the area was a Kennedy ulcer, which C1 replied no. C1 stated that her colleague, C2, filled in for her once about two weeks ago and believed it to be a Kennedy ulcer, but it has gone on too long. C1 stated that she believes R26 has rebounded. When the Surveyor asked about the black area on the sacrum, C1 stated that it was slough and that slough can be black in color. When the Surveyor asked about debridement, C1 stated that she does not do debridement because the resident was on hospice. When the Surveyor asked if she spoke to R26's hospice nurse, C1 stated no and that she would only talk to them if he/she are here in the facility when she was present. It should be noted that R26's daily sacral wound treatment was signed off on the September 2024 eTAR as completed on 9/24/25. 9/25/24 at 8:17 AM - During an interview, E26 (LPN) stated that she did not administer any medications to R26 this morning. 9/25/24 at 8:45 AM - Observed E26 administer two Tylenol tablets for pain to R26. 9/25/24 at 11:00 AM - During an interview, the Surveyor asked C3 (Hospice Nurse) if hospice would prohibit debridement of a wound. C3 replied no, being on hospice does not prevent debridement. 9/25/24 at 12:26 PM - Observed R26's low air loss mattress device on the footboard still on Standby. 9/25/24 at 12:34 PM - During an interview, E52 (Maintenance) was asked if he could confirm if the low air loss mattress device on the footboard was working as the Standby green light was on. E52 stated no, it was not on and then he pushed the On button and the device turned on. Review of the September eTAR lacked evidence that R26's prescribed daily wound treatment to her sacrum was completed on 9/11/24, 9/16/24 and 9/18/24. 10/1/24 at 1:48 PM - Reviewed findings with E1 (NHA), E2 (DON), E3 (ADON), E53 (Regional), E46 (VPO). No further information was provided to the Surveyor. 10/2/24 at 9:44 AM - A skin note by C1 (WCC) documented, . Location: sacrum . Stage/severity: full thickness . worsening . Size: 4 cm x 6.7 cm x 0.2 cm . 10% epithelial, 40% slough 50% eschar . Periwound: fragile, intact, evolving DTI Exudate: moderate amount of serosanguineous . Treatment . medical grade honey fiber to base of the wound . bordered gauze . change daily, and PRN . continue with turning and repositioning . position patient side to side as tolerated . Patient with worsening sacral wound . due to decreased PO intake, failure to thrive and end of life skin changes. Wound etiology changed to disorder of the skin to Kennedy terminal ulcer . Review of R26's progress notes from 5/31/24 through 9/25/24 lacked evidence of any documentation of turning and repositioning R26 or monitoring her pressure ulcer on the sacrum by the nursing staff. With respect to R26's sacral pressure ulcer, the facility failed to do the following: - failed to develop a pressure ulcer care plan with appropriate interventions as of 6/27/24; - failed to implement turning and repositioning from 5/31/24 through 9/25/24; - failed to complete weekly skin assessments during the month of May 2024, August 2024 and September 2024; - failed to complete four daily sacral wound treatments on 9/11/24, 9/16/24, 9/18/24 and 9/24/24; - failed to ensure that wound care was not signed off on the eTAR as completed on 9/24/24 when it wasn't done; - failed to ensure that on 9/25/24 R26's air loss mattress device on the footboard was turned on; - failed to collaborate with R26's hospice provider from 6/27/24 through 9/25/24 on sacral wound care and treatment; and - failed to Stage R26's sacral PU from 6/27/24 through 10/2/24 on weekly wound assessments. 46134 2. Review of R533's clinical record revealed: 9/10/24 - R533 was admitted to the facility with multiple diagnoses including CVA, right sided paralysis, aspiration pneumonia, aphasia and dysphagia. R533 had a PEG tube for nutrition. 9/10/24 11:30 PM - A nursing admission progress note revealed that R533's skin assessment included that he had a scar on his sacrum. 9/10/24 - A Braden Scale Assessment revealed R533 had a moderate risk for pressure ulcer development. 9/11/24 - A nursing skin assessment was completed on R533 that revealed that he had no skin impairments. 9/16/24 - MDS Assessment, section M Skin Conditions: R533 had no unhealed pressure ulcers/injuries. 9/17/24 - A Braden Scale Assessment for R533 revealed a high risk for pressure ulcer development. 9/18/24 - A progress note was written by E10 (Nurse Practitioner) that R533 had a new wound to the sacrum: Wound: 1 Location: sacrum Primary Etiology: Incontinence Associated Dermatitis (IAD) Stage/Severity: Partial Thickness Wound Status: New Size: 2.7 cm x 5 cm x 0.1 cm. Calculated area is 13.5 sq cm. Wound Edges: Attached. 9/18/24 - A physician order was written to apply collagen particles/zinc oxide paste to sacrum incontinence associated dermatitis (IAD) twice a day and as needed for incontinence care. 9/23/24 - A Braden Scale Assessment revealed a very high risk for pressure ulcer development. 09/24/24 10:33 AM - During an observation, wound care was performed on R533 by E8 (LPN wound care). The wound on R533's sacrum was observed to be a stage II pressure ulcer wound. The following electronic medical record documents were reviewed on 9/24/24: -9/11/24 care plan revealed: The resident is at risk for pressure ulcers related to chronic health conditions, cognitive impairment, inability to turn and reposition independently, incontinence. - The kardex aide task list revealed the lack of a regular timed turning and repositioning task for R533. The Resident Care section of the Kardex documented for the aide to encourage to turn and reposition often. Additionally, the kardex directed that R533's should roll left and right. R533 was dependent on staff to reposition him while he was in bed. R533 was not repositioned for six out of forty-two opportunities from 9/17/24-9/25/24. Additionally, the times that R533 was repositioned in bed from 9/17/24-9/25/24 was not consistent, and the times were documented anywhere between two hours apart to fourteen plus hours apart, meaning R533 was left in one position for ten to fourteen hours on several occasions. 9/24/24 10:45 AM - During an interview E11 (LPN) confirmed that R533's Kardex documented to encourage to turn and reposition often, but that R533 could not turn himself in bed. 9/24/23 - A physician order was written to cleanse sacrum with wound cleanser, apply medical grade honey fiber and cover with bordered gauze, every day shift AND as needed for incontinence care. 9/25/23 - A review of a September Medication Administration report revealed that collagen particles/zinc oxide paste was applied once a day 9/19/24 thru 9/23/24, and not twice a day as ordered. 9/26/24 2:30 PM - During an interview, E9 (RN UM) confirmed that collagen particles/zinc oxide paste was applied once a day to R533 on 9/19/24 thru 9/23/24, and not twice a day as ordered. R533's stage II sacral wound was acquired after he was admitted to the facility. R533 entered the facility with a scar on his sacrum, but eight days later, that scar was a stage II 2.7 cm x 5 cm x 0.1 cm. pressure ulcer wound. The wound required changes to wound care management; the orders were not followed by nursing as written by the physician. R533 did not have bed turning and prepositioning as an aide task, which made it difficult to determine how often he was turned and repositioned in bed. 50650 3. Review of R105's clinical record revealed: 4/30/24 - R105 was admitted to the facility with a diagnosis of a stroke and had two existing pressure ulcers to her buttock area. 7/23/24- A review of the care plan revealed that R105 had a chronic wound or pressure ulcer: stage 4 on the right buttock and stage 4 on the left buttock. 8/21/24 - A physician's order was written by E4 (MD) to cleanse the left buttock wound with wound cleanser, apply collagen/ hydrogel, and to cover the wound with bordered gauze, every day shift. The same treatment order was written for the right buttock wound. 9/25/24 - A review of the treatment administration record (TAR) revealed the lack of dressing changes to both the left and the right buttock on 9/17/24 and 9/23/24. 9/25/24 - During an interview with E8 (LPN), she verbally confirmed the dressing changes were not documented on 9/17/24 and 9/23/24. 48409 4. Review of R228's clinical records included: 10/24/22 - R228 was admitted to the facility with diagnoses including muscle weakness and stroke affecting the left side. 4/8/24 - 4/12/24 - R228 was hospitalized . 4/13/24 - R228 was readmitted to the facility. The admission skin assessment documented open areas on her groin and sacrum. R228's physician's orders included, Weekly skin audits. An undated Kardex entry included, Daily skin audits. 6/5/24 - R228's clinical records documented, Clean sacral MASD . and cover with hydrocolloid dressing . 10/1/24 - A review of R228's clinical records lacked evidence that the daily or weekly skin audits were completed for 4/17/24, 4/24/24, 5/8/24, 5/15/24, 5/22/24 and 6/12/24. R228's clinical records lacked evidence of treatment for the groin and sacral area from 4/13/24 through 6/4/24. 10/2/24 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E46 (VPO) and a representative from the Ombudsman's Office.

Post IDR [DATE] revision Based on observation, interview and review of clinical records and other documentation as indicated, it was determined that for two (R1 and R2) out of four residents reviewed for follow-up appointments, the facility failed to ensure that the correct resident (R1) was sent to a cardiology appointment on [DATE]. R2, a newly admitted cognitively impaired resident, was sent with R1's medical paperwork and accompanied by a facility aide, who did not know the resident. At the appointment, R2 was slumped in a wheelchair with altered mental status and the facility aide did not know the resident's baseline. 911 was called and R2 was emergently sent to the emergency room (ER) with R1's medical paperwork. In the ER, R2 was initially registered under R1's name until it was brought to the ER's attention. The facility's failure placed R2 at risk for a serious adverse outcome or death as R2 had the potential to receive treatment based on R1's medical paperwork provided to the Cardiologist's office, to the EMTs for transfer to the ER and to the ER staff with respect to the different code status, medications, allergies and treatments. Due to this failure, an Immediate Jeopardy (IJ) was called at 2:31 PM on [DATE]. The IJ was abated on [DATE] at 4:30 PM. Also, for one (R3) out of one resident reviewed for injuries of unknown origin, the facility failed to ensure that nursing staff immediately reported an observed facial injury and implement interventions; failed to ensure that an RN documented her assessment after the resident's fall with a visible head injury; and failed to safely transfer the resident off the floor to protect the resident from further injury. Findings include: 1a. Review of R1 and R2's clinical records revealed: For R1: - admitted to the facility on [DATE] with diagnoses including, but not limited to, recent fall, supraventricular tachycardia, atrial fibrillation, acute kidney injury, hyperkalemia, cardiomyopathy, diabetes mellitus type 2; - full code status (requiring CPR); - no known allergies; - assigned room was XXX; and - the hospital Interagency Discharge Orders, dated [DATE] at 1:10 PM, documented that R1 had a follow-up cardiology appointment on [DATE] at 10:00 AM. - admission MDS assessment, dated [DATE], documented the BIMS (Brief Interview of Mental Status) of 14, revealing that R1 was cognitively intact. For R2: - admitted to the facility on [DATE] with diagnoses including, but not limited to, recent fall, several facial fractures, dementia, carotid artery stenosis, diabetes mellitis type 2, morbid obesity, obstructive sleep apnea, dysphagia, hypernatremia and atrial fibrillation; - DNR (Do Not Resuscitate) code status; - allergy to Sulfa antibiotics; - assigned room was YYY; and - admission MDS assessment, dated [DATE], documented the BIMS of 3, revealing that R2 was cognitively impaired. [DATE] at 7:25 AM - An appointment form was completed and faxed to the transport company for R1's 10:00 AM appointment with a pick-up time of 9:00 AM. The patient information section documented R1's name, facility name, address, phone number and a room number. The room number documented was incorrect as it was R2's room number (YYY). [DATE] at 12:00 Noon - The facility's incident report documented the following: - . [R2] was transported to a cardiologist appointment with [E6 TNA] as his escort. The appointment time and location was for a scheduled follow up but was intended for a different resident [R1] During the exam, the resident had a change in condition and was transferred via EMS/911 to the (hospital) ED (emergency department) . [DATE] - The hospital record documented: - at 12:29 PM, the patient (R2) arrived at the ER; - upon arrival at the ER, R2 was registered under R1's name; - at 12:41 PM under R1's name, C4 (ED Physician) documented, . [AGE] year-old gentleman history of ischemic cardiomyopathy with ejection fraction of 20 to 25%, atrial fibrillation/flutter on Eliquis, type 2 diabetes mellitus, chronic kidney disease stage III . reviewed discharge summary from [DATE] when he was admitted to the hospital after a fall Coming into the emergency department from cardiology outpatient follow-up visit noted to be altered and hypotensive, reviewed the note from cardiology from today, apparently he had been altered for about 3 hours prior to presenting to the cardiology office but the nursing facility staff who was with him was unfamiliar with his baseline . - at 2:06 PM, C3 (ED Physician) documented, . [AGE] year-old male with past medical history of cognitive decline, HTN, HLD (hyperlipidemia), obesity, OSA (obstructive sleep apnea) on BiPAP, diabetes, A-fib previously on Eliquis who was discharged on ,d+[DATE] after admission for a fall. Patient is actually benign and presents from a cardiology office for altered mental status. Unfortunately patient was taken to the cardiology appointment that was for a different resident of his skilled nursing facility. That patient is reportedly alert and oriented x4 at baseline however (R2) has cognitive decline and is alert to only self at baseline. Patient was brought with documentation of the other patients (sic) that was unfortunately registered under that patient's name. Patient's (R2) wife did arrive with patient's actual chart from the skilled nursing facility. She was able to clear out his medical history for me. Patient is at his mental baseline currently. She states he has had no recent complaints and has heard nothing from the facility about changes in mental status, vitals, any new symptoms. She states that if he had not been sent out for the cardiology appointment today, he likely would not have ever ended up in the emergency department. Of note however patient was noted to be hypotensive on arrival into the 80s. He is a poor historian and is unable to answer any questions. Was noted to be into the upper 80s while lying flat . (at) 12:37 (blood pressure) ,d+[DATE] . (at) 2:56 PM (blood pressure) ,d+[DATE] . Pulse Ox:98% . Nasal Cannula 4 L/min (placed on oxygen) . was also noted to be hypoxic . Disposition: pending labs, CT (diagnostic test), anticipate admission . [DATE] at 3:56 PM - C1 (PA) with the Cardiologist Office documented in a note, I was scheduled for a hospital follow-up today with (R1's name and date of birth). Patient was brought in by aide from [NAME] rehab with the paperwork for (R1's name). Due to altered mental status patient was unable to provide his own name or date of birth. Patient was unable to respond to questions or follow commands. Aide stated she was not familiar with the patient but this had been his current mental status for the past 3 hours. I called (Cardiologist Physician name) to discuss clinical findings and new altered mental status compared to baseline. 911 was notified and on EMS arrival discussed patient's condition. After patient left via EMS patient's aide returned and stated they had brought the wrong patient to the office. Discussed over phone with (facility staff person) that the patient brought in was actually (R2's name and date of birth). At the [NAME] ER patient had been identified as (R1's name) and had no previous identification bracelet from rehab. Discussed with clerk who changed encounter to appropriate patient. Patient's wife arrived and identified that he was in fact (R2's name) and mental status was at baseline given history of dementia and fall last month. Case was discussed with ED resident who resumed care at that time . The facility's investigative documentation provided to the Surveyor captured their immediate response: ([DATE] at 12:20 PM) Immediately upon notification of situation . - (at 12:14 PM) Facility was made aware that it was the wrong resident at the doctor's (sic) office and he was sent to the hospital. - (at 12:30 PM) Nurse called the wife to advise of his location and that he was being sent to the hospital . - (at 12:40 PM) Facility called the hospital to educate the hospital that the wrong resident was there and that his wife was there and could ID him and obtained information to fax correct residents paperwork to ER . On [DATE], the facility's investigation included the following typed and untimed statements: - E6 (TNA): Around 8:30 AM I was asked to go on an escort with a resident named (R1's first name) and I was directed to his room on the Arcadia unit with the transport team. He was dressed and, in his wheelchair, ready to go. Shortly after getting him off the unit, I was approached by his wife, and she was asking where he was going because she wasn't informed of any appointments. She stated she was informed of an appointment for [DATE]th but not for today. I asked [E5, Unit Clerk] where the resident was going, and she said the cardiologist. I directed his wife to [E5] because I wasn't aware of any other information from the resident and knew [E5] could better answer her questions. After we left the facility, the transport company stopped and picked up another person from a different facility. This person was dropped off before (R1's first name) and we didn't arrive at the appointment until 11 AM. He was checked in with his name and birthday based on the paperwork I was giving them. The resident was brought to the exam room and seen by [NAME] (Medical Office Assistant) and a PA (Physician Assistant). During this time, he put his hand on his chest and stated, 'help me'. The PA nor the [NAME] could get a BP (blood pressure) on (R1's first name). In the exam room, he would be alert then in a state of disorientation like he was sleeping. The PA notified the cardiologist who usually sees the resident (R1's first name) and based on this information, the PA informed me they were calling 911 and sending him to the ED. This was around 12 PM. About 12:20 PM, [E5] called my cell phone to let me know the wrong resident was at the appointment. The resident I have is [R2]. She asked to speak to the nurse, so I took the phone to the PA. - E5 (Unit Clerk): (R2's name) had left to go to the doctor's appointment when I realized it was the wrong resident. I checked the calendar and immediately called the Drs (Doctors) office. I let the staff know it was not (R1's name) but they had seen (R2's name). I let them know [R2] would be transported back to the facility. The nurse said he was a patient of theirs (sic) and they would see him. A few minutes later the TNA [E6] who escorted him called to let me know they were sending him to the ED. The nurse told me to send [R2's] info (information) to [NAME] Care ED in [NAME]. I sent everything the nurse told me to send. I gave the cardiology number to his direct nurse then sent his entire chart. The nurse notified his wife. - E7 (R2's Nurse): The TNA [E6] was with the resident and the transport company was here to pick up resident. His name was not on the schedule, so I asked the TNA to check with [E5, Unit Clerk]. E5 said he had an appointment. [E6], the TNA left with [R2] was working the morning (R2's name) was picked up for his appointment. The TNA [E6] reported to [E7] that the resident's wife was asking what the appointment was for as she had no knowledge of an appointment this week. [E7] directed the TNA [E6] to seek out clarification from [E5 Unit Clerk] who schedules the appointments . - E8 (Nurse): [E5, Unit Clerk] was upset and reached out to me for help. She explained to me what had happened with the resident mix up. [E5] asked me to call the wife and let her know about the appointment, his change of condition, and he was being transported to . ED. At this time, [E5] was on the phone with the cardiology office. The wife called me [E8] back when she arrived at the ED. She was asking for [R2], and being told he was not a patient. I spoke with the ED nurse and explained what had occurred, verified the resident in their care is [R2] and his wife was there. - E2 (DON): Soon after I gathered information leading up to the event, I spoke with [E5, Unit Clerk] in the presence of [E1 NHA]. She [E5] recalled giving the TNA [E6] . the room number of [YYY], not the room number of the scheduled resident. She agrees the scheduled appointment was for [R1] . with his cardiologist. We discussed the chain of events that led up to her giving the incorrect room number. She had printed the correct resident information, and this envelope was passed to the TNA [E6] . On [DATE], the facility documented the following actions taken: - (at 7:30 PM) NHA went into calendar on EHR (electronic health record) program and pulled up all upcoming appointments for the next 48 hours. She printed the appointments and the corresponding face sheets. These packets were put on each nursing station for staff who care for them . - (untimed) E2 (DON) documented an Employee Corrective Action for E5 (Unit Clerk) for Resident placed in unfamiliar environment. Became anxious and agitated. Spouse was given incorrect information. Was put in an eventful situation causing emotional & (and) physical stress. In addition, E2 documented .Soon after I gathered information leading up to the event, I spoke with [name of E5] in the presence of the Administrator . We discussed the chain of events that led up to her giving the incorrect room number . Following our conversation, we implemented a plan of correction immediately and started educating all staff. This education was given to [name of E5], and she verbalized understanding and signed the documentation. On [DATE], the facility documented the following actions taken: - (at 5:30 AM) Staff present were educated on below process change with staff education continuing on the following process. System changes to prevent reoccurrence: * All residents are to have a current photo uploaded into PCC within 72 hours from admission. At times a resident will refuse, however a second attempt to obtain a picture is to be made. * All scheduled appointments must be entered into the calendar. This calendar will be printed out daily and given to the front desk. Along with this, there will be a printout of the individual's face sheet. The night supervisor and or designee will be responsible to print these out. * Transportation companies are to be stopped at the receptionist desk and asked the name of patient/resident. Then they will be directed to the proper room. At which time a copy of the face sheet will be given to transport who will have a staffing member to verify identification. Validation made from photo, right name, and right appointment. Nursing staff will then sign the face sheet and direct transport back to the receptionist desk. * The reception desk will collect the signed face sheet and document the time they left the building. * If the appointment doesn't appear on the calendar, then a face sheet will not be printed. Facility will not release patient/resident until proper verification is made. DON and/or Administrator will also be notified. Education will be completed with nursing staff on the above process by [DATE]. - (at 8:00 AM) Receptionist was trained to stop everyone at the front door to verify the correct resident is leaving for the appointment and verify resident with signed face sheet. - (at 9:24 AM) The facility reported the following to the State Agency: Incorrect resident was transported out of the facility to a follow up appointment scheduled for another resident. It should be noted that despite the incident occurring on [DATE], the facility failed to report this incident within the required 8 hours per State Regulation and failed to disclose to the State Agency that the incorrect resident was emergently sent to the hospital from the appointment. - (at 9:45 AM) Administration team was notified of incident to be on alert and informed of the new system change. An Ad Hoc QAPI sign-in sheet was dated [DATE]. - (untimed) E2 (DON) documented an Employee Corrective Action for E7 (LPN) for Resident placed in unfamiliar environment. Became anxious and agitated. Spouse was given incorrect information. In addition, E2 documented . In my conversation with [name of E7], I pointed out she, as the nurse, should seek clarification herself, so as not to have it go through multiple staff. She also was given the place of correction steps and education . [DATE] at 1:24 PM - During an interview with the Surveyor, C2 (Nurse Manager) with the cardiology office confirmed that R2 was not a patient of this cardiology practice. C2 stated that she observed the resident (R2) sitting in a wheelchair in an evaluation room slumped over to the right and was somnolent with the aide present. Surveyor observed that R1's paperwork printed for the office appointment did not have a identification picture of the resident (R1). [DATE] by 5:00 PM - The facility documented that each resident's picture was uploaded into PCC except the two that were out at an appointment. [DATE] at 8:30 AM - The facility documented that (second) receptionist was trained regarding the new process. [DATE] at 9:15 AM - The facility documented that a written notification was sent to all employees through Hosted Time with the above education outlined on [DATE] at 5:30 AM. Those educated via Hosted Time will receive education again in person prior to starting their next shift. [DATE] at 10:00 AM - The facility documented that the remaining two residents (pictures) and the two admissions were uploaded in PCC. [DATE] at 10:29 AM - During an interview with the Surveyor, F2 (R2's wife) stated the following: - On [DATE], F2 arrived at the facility for a visit at approximately 9 AM. - Transport personnel and E6 (TNA) were taking R2 out of the Arcadia unit. F2 asked Where are you going? F2 was told that R2 was going to a follow-up with the cardiologist. F2 said that she did not know about the appointment. F2 followed them up in the elevator. F2 stated that E5 wrote the address down. F2 asked if the appointment was at (name of building) and was told it was in [NAME]. (It should be noted that the building F2 named was also located in [NAME].) F2 stated that she got into her car to follow the transport van. F2 stated that the transport van made a left hand turn onto to [NAME] Road and both back doors of the van opened. The van stopped on [NAME] Road and the back doors were closed from the inside. F2 stated that she could not follow the transport van and lost site of it. At 9:55 AM, F2 arrived at the cardiologist at the (name of building) and was told that R2 was not here. F2 stated that she went back to the car and looked at the paperwork with the cardiologist office address she was provided and went there. At approximately 10:15 AM, F2 arrived at the address she was provided and was told there was no one here by that name (R2) nor scheduled. F2 stated that R2's vascular surgeon was located in the same building, so she went to that office and no one knew anything there. F2 stated that she even went to the 3rd floor cardiologist office, which is affiliated with the 2nd floor, and no one knew anything. At approximately 11:30 AM, F2 stated she called the facility to find out the location of my husband, R2. F2 stated that she believed she spoke with E14 (PTA) and was told that she would find out. At 11:50 AM, F2 stated that she went home to get changed because she was soaked from getting in and out of her car as it rained all morning and called her son. At approximately 12:30 PM, F2 stated that she received a call from a facility nurse (E8) that said her husband, R2, was taken to the ER for a heart attack. F2 stated that she called both kids about this. At approximately 1:20 to 1:30 PM, F2 arrived at the ER receptionist desk and explained that she was told her husband (R2) was brought here with a heart attack. F2 said that she was told by the ER receptionist desk that they do not have him (R2's name) in the system. F2 stated that she called the facility back to find out what was going on and was asked if she was at the (name of) ER. A facility staff person asked to speak to the ER receptionist. At approximately 2:10 PM, F2 said she was taken back by an ER nurse, where R2 said What's up? to F2 when she entered his ER room. F2 stated that R2 did not have a heart attack, but was later admitted and treated for a urinary tract infection. [DATE] at 11:30 AM - During an interview with the Surveyor, E14 (PTA) stated that she believed she received two calls from F2 (R2's wife) but could not recall the exact times. E14 stated that F2 called and said she could not find R2. E14 stated that she would check with E5 (Unit Clerk) and would get back to her. E14 then said that F2 called from the hospital and told her that no one was here by R2's name. E14 said she handed the phone over to E8 (Nurse). [DATE] at 11:45 AM - During an interview with the Surveyor, E5 (Unit Clerk) stated that there were two unit clerks about six months ago who were scheduling appointments for residents. Currently, E5 schedules appointments and arranges transportation, coordinates with the Scheduler for those residents who need an escort, and E14 had recently been assisting E5 with the scheduling appointments. E5 stated that she was not in the facility on [DATE], the day that R1 was admitted . E14 entered his appointment on the calendar (but did not arrange transportation). E5 stated that she did not completely open the facility's electronic appointment calendar to review all the details regarding the [DATE] appointment. E5 stated that she made a mistake thinking it was R2's name, but the calendar actually had R1's name on it. E5 went to the scheduler to ask for someone to go to the appointment with R2. It should be noted that all appointments scheduled for the day are listed on the (name of electronic health record) electronic dashboard, which was accessible to all nursing staff. [DATE] at approximately 12:20 PM - During an interview with the Surveyor, E6 (TNA) stated she mainly does 1:1 observation, will help out in the kitchen and escorts residents to outside appointments (approximately 3 times since she started with the facility). E6 stated she was assigned a 1:1 with another resident on [DATE] when she reported to work at 7 AM. E6 stated that E5 (Unit Clerk) came a little after 9 AM to get me and take me to R2's room (YYY) and transport staff were already there in his room. E7 (Assigned Nurse) gave me the packet (medical records) for the appointment at the nurse's station. E6 stated that she asked where was R2 going and E7 checked the computer and could not find anything and told her to check with E5 (Unit Clerk). At approximately 9:20 AM, transport staff was taking R2 off the unit and we ran into R2's wife, who asked where was he going? E6 told F2 to the cardiologist and F2 asked where. E6 stated F2 then went to go talk to E5. E6 stated they left the facility at approximately 9:30 AM and confirmed that the two back doors of the transport van opened while turning left onto [NAME] Road. E6 stated that the transport van stopped at another facility to pickup a second patient in a stretcher and dropped that patient off at the (name of location) at 10:30 AM. E6 stated that the transport driver called the cardiologist office because the 10:00 AM appointment was missed and cardiologist office stated they had another opening at 11:30 AM. E6 stated that they arrived at the cardiologist office and to check in she entered the resident's name and date of birth (R1) based on the paperwork she had with her. E6 stated that the cardiologist office medical assistant was trying to get a blood pressure reading and could not. The PA consulted with R1's cardiologist by phone and decided to send patient to the ER to be evaluated. E6 stated that she called the facility at approximately 11:45 AM and spoke to E5 (Unit Clerk) and was put on hold, then the phone hung up and she kept calling. E6 stated that the EMTs (emergency medical technicians) stated the patient was in 'aFib' and had low blood pressure. E6 stated that she handed the EMTs R1's paperwork, which included the medication list. At approximately 12:20 PM, E5 told me that it was the wrong resident and transport would be returning to pick her up and the resident's wheelchair. E6 stated that she gave the phone to the cardiology PA and then waited for transport to pick her up. E6 stated that some appointment packets have photos, but there was no photo on R1's packet. [DATE] at 12:56 PM - During an interview with the Surveyor, C1 (Cardiology PA) stated that the resident who was at the appointment was minimally responsive. C1 called R1's Cardiologist and the resident's presentation was not typical as R1 was fully alert. After consulting and based on the altered mental status, the office called 911. Resident was transferred to the ER. The facility escort came back into the office and C1 learned that the wrong resident was sent to the appointment. C1 stated that she went over to the hospitalER on [DATE] at approximately 1 PM and spoke with the ER Triage and bedside nurses and the Resident Physician to make sure the ER was aware that they had the correct patient information. C1 stated that she was present when R2's wife arrived. [DATE] at 2:31 PM - An Immediate Jeopardy was called with E1 (NHA), E2 (DON) and E3 (RN RDCS). [DATE] at 4:30 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated and timed by E1 (NHA), as outlined below: System changes to prevent reoccurrence: * All residents are to have a current photo uploaded into PCC at time of admission by the activities department and/or nursing supervisor. Nursing supervisor educated on uploading pictures into [name of EHR] at [DATE] at 1602 (4:02 PM). At times a resident will refuse, a second attempt to obtain a picture is to be made by management staff/designee immediately upon notification and if they still refuse the facility will place an ID bracelet. If they refuse the ID bracelet, staff will . verbalize identification to verify residents identify (sic) (i.e. name and date of birth). If resident is confused or non-verbal identification of resident will be made with 2 staff members who are familiar with the resident. * All scheduled appointments must be entered into the calendar. This calendar will be printed out daily and given to the front desk. Along with this, there will be a printout of the individual's face sheet. The night supervisor and or designee will be responsible to print these out. * Transportation companies are to be stopped at the receptionist desk and asked the name of patient/resident. Then they will be directed to the proper room. At which time a copy of the face sheet will be given to transport who will have a staffing member to verify identification. Validation made from photo, right name, and right appointment. Nursing staff will then sign the face sheet and direct transport back to the receptionist desk. * The reception desk will collect the signed face sheet and document the time they left the building. * If the appointment doesn't appear on the calendar, then a face sheet will not be printed. Facility will not release patient/resident until proper verification is made. DON and/or Administrator will also be notified. Education will be completed with nursing staff in person on the above process by [DATE] . Based on the facility's response to the [DATE] incident involving R2, interviews with staff and no further incidents observed where the incorrect resident was sent to the wrong appointment, the facility's IJ was abated on [DATE] at 4:30 PM. 1b. Observation of the facility's new process for resident's leaving the facility for appointments revealed: [DATE] at 9:30 AM - Surveyor's observation of the facility's abatement plan in action revealed that the Transport staff were in the lobby waiting to transport R6 to an appointment. However, R6's name was not on the Receptionist list of residents that had an appointment that day and was confirmed with E11 (Receptionist). [DATE] at 9:45 AM - Surveyor observed R6 being brought in a wheelchair to the reception desk along with E10 (LPN). [DATE] at 9:50 AM - During an interview, E10 stated she was aware that R6 had an appointment and had the paperwork. E10 verified that she confirmed the correct resident (R6) was sent out to the appointment using the resident identification process. [DATE] at 10:00 AM - During an interview, E1 (NHA) stated that she prints out the resident appointment list each day and provided it to the receptionist. E1 stated that R6 must have dropped off the list for an unknown reason. E1 stated that she had not verified that the names on the list matched up with the individual resident face sheets that were printed for each resident that had an outside appointment that day. Going forward, E1 stated that she will have another person compare the resident's list with appointments each day with the face sheets of residents with appointments that are used for identification purposes. 2a. Review of R3's clinical record revealed: [DATE] - R3 was care planned for aspirin therapy and at risk for adverse effects with intervention that included: report bruising. In addition, R3 was care planned for at risk for alteration in skin integrity with an intervention that included: observe skin condition with ADL (activities of daily living) care daily; report abnormalities. [DATE] - An active physician's order documented to administer R3 Aspirin 81 MG every day for a diagnosis of coronary artery disease (CAD). [DATE] - The annual MDS assessment documented that R3 was rarely understood or understands; had short-term and long-term memory problems; was severely impaired for daily decision making; dependent for toileting, personal hygiene, showers and lower body dressing; and weighed 99 lbs. [DATE] at 11:21 AM - The Skin Observation Tool form by E18 (RN) documented that R3 had no skin alterations. [DATE] at 8:17 AM - E16 (CNA) documented in R3's clinical record that R3 was provided a shower. [DATE] at 1:35 PM - The facility's incident report by E18 (RN) documented, . At (1:35 PM) after nurse (sic) was assisted back to bed, resident was noted with purple bruise on right side of chin and philtrum (upper lip). [R3] could not explained (sic) what happened . Assessment done body audit done no other abnormal bruise or cut noted. Resident denied any s/s (signs or symptoms) of pain. No swollen noted . Oriented to person . Family Member (notified) at (2:49 PM) and NP notified at (2 PM) . The facility's investigation included, but was not limited to, the following documented staff written statements: - E15's (LPN) untimed/undated statement: . What did you observe? . A bruise on resident chin . At 8:30 AM when I went to resident room to give morning medicine, I noted a small redness on her right chin. I did not tell my preceptor about it because I did not know the resident well . - E16's (CNA) untimed/undated statement: . What did you observe? . Started my care with the resident. Overlook the bruise. I don't normally have (R3's name) as my resident, didn't notice it was abnormal . - E17's (CNA) 3:58 PM on [DATE] phone statement: . What did you observe? . Cared for resident ,d+[DATE] & ,d+[DATE] (prior evening and night shifts on [DATE] through [DATE]). Constantly check on her re (regarding) adjusting her in bed. Last provided care at 6:15 AM. No skin issues . Review of R3's clinical record lacked evidence that neurochecks were initiated and completed after injuries of unknown origin (right chin and upper lip bruises) were identified and monitoring for bleeding as R3 was administered aspirin daily. The facility failed to ensure that nursing staff immediately reported R3's injury of unknown origin (redness on the right chin) when identified at 8:30 AM and failed to initiate monitoring for bleeding and completing neurochecks. [DATE] at 9:52 AM - During an interview, E16 (CNA) stated that she came in on an off day on [DATE] and was pulled to the first floor on a different assignment as she usually works on the second floor. E16 stated that she provided care for R3 before, but not recently. E16 confirmed that she gave R3 a shower that morning, and the resident did not bump into anything. [TRUNCATED]

Based on observations, interviews, and reviews of clinical records and other documentation as indicated, it was determined that for four (R22, R51, R630 and R631) out of seven residents reviewed in three hallways, the facility failed to ensure these residents received timely administration of insulin due to no staff being available to provide the medication. The facility's failure placed the residents at risk for a serious adverse outcome, hypoglycemia and hyperglycemia. Due to this failure, an Immediate Jeopardy (IJ) was called at 3:40 PM on 7/21/23. The IJ was abated on 7/24/23 at 9:00 AM. Additionally, R80 was not administered physician ordered insulin on 7/16/23 at 6:00 AM due to no staff being available on the night shift. Findings include: The manufacturer's instructions documented, .Humalog is a .fast-acting insulin used to control high blood sugar . for Use of Humalog insulin for subcutaneous use, last revised on 7/2023, documented, . Humalog starts acting fast, so give . injection within 15 minutes before or right after you eat a meal. According to the facility's Food Cart Delivery Schedule, dated 3/8/22, estimated breakfast delivery times for the following units were: Heritage Unit - 7:20 AM; and Dover Unit - 7:35 AM. 1. Cross refer to F725, example 1 7/21/23 at 9:12 AM - Review of the daily Staff Posting posted at the second floor nurse's station lacked evidence of a second nurse assigned to the Dover Unit and a second nurse assigned to the Heritage Unit. 7/21/23 at 9:15 AM - An observation on the Dover Unit noted only one nurse, E36 (Agency LPN) present with two med carts. During an interview, E36 stated that she was still waiting for her PointClickCare (PCC) login to start the morning medication pass as she had asked multiple times since her arrival this morning. There was no nurse present on the other med cart. Review of E36's timecard for 7/21/23 revealed that E36 clocked in at 6:57 AM and had been waiting for approximately 2.25 hours with no PCC login access to start the medication pass. 7/21/23 at 9:20 AM - An observation on the Heritage Unit revealed that E37 (LPN/Wound Care) was reassigned to a med cart on this unit as the daily Staff Posting lacked evidence of a second nurse assigned to the Heritage Unit. 7/21/23 at 10:00 AM - The facility provided a list of all residents in the facility that receive diabetic medications, including insulin, per the Surveyor's request. Review of four residents' clinical records that had current insulin physician orders revealed: Dover Unit: - R22 had a physician order for Humalog insulin 9 units scheduled at 7:30 AM and at 11:30 AM to be given at breakfast and lunch. On 7/21/23, R22's eMAR lacked evidence of a blood glucose check at 7:30 AM and administration of Humalog insulin 9 units for 7:30 AM. The eMAR had an X marked in the spot where R22's blood glucose level (number) should have been documented. R22's blood glucose check was 113 and administration of the 11:30 AM Humalog insulin was signed off as administered at 12:57 PM by the E40 (RN/Staff Development). - R51 had physician orders for Humalog insulin 7 units scheduled at 7:30 AM and Humalog insulin per the sliding scale at 7:30 AM to be given before meals. On 7/21/23, R51's scheduled 7:30 AM blood glucose check was recorded in the clinical record under blood sugars as 253 at the same times of the administrations of Humalog insulin 7 units plus 4 units (sliding scale). E40 (RN/Staff Development) signed off both at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 had physician orders for Humalog insulin 6 units scheduled at 7:30 AM and Humalog insulin per the sliding scale at 7:30 AM to be given before meals. On 7/21/23, R630's scheduled 7:30 AM blood glucose check was recorded in the clinical record under blood sugars as 106 at the same times of the administrations of Humalog 6 units plus 2 units (sliding scale). E36 (Agency LPN) signed off both at 9:56 AM and 9:57 AM, approximately 2.5 hours later Heritage Unit - R631 had a physician order for Humalog insulin 6 units scheduled at 7:30 AM for DM breakfast. On 7/21/23, R631's eMAR lacked evidence of a blood glucose check and administration of Humalog insulin 6 units for 7:30 AM. The eMAR had an X marked in the spot where R631's blood glucose level (number) should have been documented. 7/21/23 at 3:29 PM - Based on observations and review of facility documentation, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON) and E4 (RCD). 7/21/23 at 10:30 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated, and timed. 7/24/23 at 9:00 AM - The facility's Immediate Jeopardy was abated at this time. Further observations of facility staffing, timely insulin administration and reviews of the residents' clinical records revealed that the IJ was abated on 7/24/23 at 9:00 AM based on the verification of the facility's following immediate corrective actions: - staffing was reviewed for 7/21/23, 7/22/23, 7/23/23, 7/24/23; - staffing agencies added for additional support; - implementation of a staffing agency orientation package and location in the nurse's stations; - process in place to address call outs and no call no shows to ensure sufficient staffing; - completed education with NHA, DON and Staffing Coordinator; - observations of blood glucose checks and timely insulin administration; - review of the residents' clinical records; and - observations of facility staffing over the weekend and 7/24/23 by two Surveyors. 2. Cross refer to F725, example 3 Review of R80's clinical record revealed: 7/20/22 - R80 had a physician's order for NPH Insulin inject 4 units subcutaneously in the morning for diabetes diagnosis. 7/16/23 at 6:00 AM - Review of the July 2023 eMAR revealed that R80 was not administered NPH Insulin because there was no assigned nurse on night-shift (11:00 PM to 7:00 AM) in the New Castle Unit. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO)

Based on observations, interviews and reviews of clinical records and other facility documentation, it was determined that the facility failed to ensure there were sufficient nursing staff to administer critical medications to meet the needs of the residents during the 7:00 AM to 3:00 PM shift on Friday, 7/21/23. For three residents (R22, R51 and R630) on the Dover Unit that were ordered Humalog insulin to be administered with breakfast (scheduled at 7:35 AM), revealed the following: - R22 was never administered insulin with breakfast. - R51 was administered insulin at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 was administered insulin at 9:56 AM and 9:57 AM, approximately 2.5 hours later. For one resident (R631) on the Heritage Unit that was ordered Humalog insulin with breakfast revealed that R631 never received the ordered insulin. The lack of available nurses to administer medications timely had the potential to cause a serious adverse outcome or death. An Immediate Jeopardy (IJ) was called at 2:50 PM on 7/21/23. The IJ was abated at 9:00 AM on 7/24/23. Additionally, two previous night shifts (11:00 PM to 7:00 AM), specifically 7/1/23 to 7/2/23 and 7/15/23 to 7/16/23, failed to have sufficient nursing staff where the residents in the two units were not administered medications, provided treatments and lacked monitoring/supervision by a nurse. Findings include: 1. Cross refer to F760, example 1 7/21/23 at 9:12 AM - Review of the daily Staff Posting posted at the second floor nurse's station revealed two blank spots for a second nurse's name assigned to the Dover Unit and a second nurse's name assigned to the Heritage Unit. 7/21/23 at 9:15 AM - An observation on the Dover Unit (rooms 226-244) noted two medication (med) carts: the first med cart with no nurse present and the second med cart with E36 (Agency LPN) waiting next to it. During an interview, E36 stated that she was still waiting for her PointClickCare (PCC) login to start the morning medication pass for 22 residents in her assigned area (rooms 234 to 244). E36 stated that this was her first day on the floor and she asked for her PCC login multiple times this morning. When asked who was working the other med cart in the unit, E36 stated that she did not know and she did not see anyone passing medications from that med cart. Review of the Dover Unit revealed three residents (R22, R51 and R630) with physician orders for Humalog insulin to be administered with breakfast. 7/21/23 at 9:20 AM - An observation on the Heritage Unit (rooms 200-225) revealed two nurses passing medications. It was noted and confirmed that E37 (LPN/Wound Care) was reassigned to a med cart on this unit as the daily Staff Posting lacked evidence of a second nurse assigned to the Heritage Unit. Review of the Heritage Unit revealed one resident (R631) with a physician order for Humalog insulin to be administered with breakfast. 7/21/23 at 9:25 AM - An observation of the two units on the first floor revealed only one nurse on each unit, New Castle and Arcadia (locked dementia unit). At 9:35 AM, E22 (LPN/UM) arrived on the New Castle Unit and start the morning medication pass. During an interview, E22 stated that she did not know her assignment and confirmed that she did not pass any medications on the assigned split med cart for the New Castle unit (rooms 126-130) and Arcadia unit (rooms 100-106) this morning. Review of the New Castle Unit revealed one resident (R1) with a physician order for Humulin N insulin scheduled for 8:00 AM, but was administered at 11:52 AM, approximately 4 hours later. Humulin N insulin was an intermediate-acting insulin that starts to work within 2 to 4 hours after injection, peaks in 4 to 12 hours, and does not require administration with meals. 7/21/23 at 10:31 AM - E2 (DON) informed the Surveyor that the facility had a census of 132 residents. Review of nursing staff timecards for the 7:00 AM to 3:00 PM shift on 7/21/23 revealed: On the Dover Unit: -E36 (Agency LPN) clocked in at 6:52 AM, assigned to a med cart on the Dover Unit. -E40 (RN/Staff Development) clocked in at 7:00 AM. She was reassigned to the second med cart on the Dover Unit. On the split med cart covering New Castle Unit and Arcadia Unit: - E22 (LPN/UM) - clocked in at 7:54 AM, and clocked out at 2:49 PM. Despite the day shift hours for facility nursing staff were 7:00 AM to 3:00 PM, E22 arrived almost one hour after the day shift started and left 10 minutes before the end of the shift. 7/21/23 at 11:31 AM - During an interview, E41 (LPN) stated that she just finished med pass in the New Castle Unit and will continue to pass meds to the following five residents in rooms 100-103 (R19, R44, R55, R70 and R92) in the Arcadia Unit. 7/21/23 at 12:31 PM - During a follow-up interview, E41 (LPN) stated that she was working a double (shift) as she had the New Castle Unit on night shift and this morning she was assigned the second med cart in the New Castle Unit. E41 stated that she performed the narcotic count with E22 (LPN/UM). 7/21/23 at 12:57 PM - During an interview, E30 (Agency LPN) stated that she received shift report and performed the narcotic count for her assigned residents in the Arcadia Unit. E30 also stated that she administered meds to some of the Arcadia residents who were assigned to the split med cart. 7/21/23 at 1:03 PM - During an interview, E22 (LPN/UM) stated that she checks the schedule at the nurse's station. E22 also stated that she already performed a narcotic count, but she doesn't believe that she signed the narcotic count book for today (7/21/23). 7/21/23 at 1:50 PM - During a follow-up interview, E22 (LPN/UM) stated that she received shift report from E41 (LPN). E22 stated that two other nurses (E41 and E30) assisted in administering meds in the Arcadia Unit today as she was administering meds in the New Castle Unit. 7/21/23 at 2:00 PM - During an interview, E40 (RN/Staff Development) stated that she was working with orientees this morning when E2 (DON) alerted her that she would need to work on the floor. E40 was assigned a med cart in the Dover Unit. E40 stated that she received shift report from E2 (DON) and performed a narcotic count with a nurse from the Heritage Unit. 7/21/23 at 2:15 PM - During an interview, E36 (Agency LPN) stated that she arrived at 7:00 AM and received shift report and performed a narcotic count with the offgoing nurse in the Dover Unit. 7/21/23 at 2:18 PM - During a follow-up interview, E22 (LPN/UM) was asked if she received shift report this morning. E22 stated that sometimes not much report is given because oncoming staff arrives late and the departing staff gets tired of waiting. 7/21/23 at 2:45 PM - During an interview, E37 (LPN/Wound Care) stated that she was reassigned to a med cart on the Heritage Unit. E37 stated that did not receive shift report nor did she perform a narcotic count at the start of her shift. 7/21/23 at 2:50 PM - Based on observations, interviews and review of facility documentation, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), and E4 (RCD). 7/21/23 at 9:50 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated, and timed. 7/24/23 at 9:00 AM - The facility's Immediate Jeopardy was abated at this time. Further observations of facility staffing and timely insulin administration revealed that the IJ was abated on 7/24/23 at 9:00 AM based on the verification of the facility's immediate corrective actions: - staffing was reviewed for 7/21/23, 7/22/23, 7/23/23, 7/24/23; - staffing agencies added for additional support; - implementation of a staffing agency orientation package and location in the nurse's stations; - process in place to address call outs and no call no shows to ensure sufficient staffing; - completed education with NHA, DON and Staffing Coordinator; - observations of blood glucose checks and timely insulin administrations; - review of the residents' clinical records; and - observations of facility staffing over the weekend and 7/24/23 by two Surveyors. 2. Cross refer to F684, example 1a Review of the facility's Staff Posting for the 11:00 PM to 7:00 AM shift on Saturday, 7/1/23, to Sunday, 7/2/23, revealed that there was no nursing supervisor listed, no nurse assigned to the Arcadia Unit (locked dementia unit) with 34 residents, and no CNA assigned to 1:1 supervision for R26, a resident with known aggressive behaviors. The Staff Posting listed two CNAs in the Arcadia Unit for this shift: E5 and E6. The facility's timecards for nurses on the 11:00 PM to 7:00 AM shift on Saturday, 7/1/23, into Sunday, 7/2/23, revealed: - E43 (RN) clocked in at 3:57 PM and clocked out at 9:02 AM, assigned to the Dover Unit. - E44 (LPN) clocked in at 10:48 PM and clocked out at 7:30 AM, assigned to the Heritage Unit. - E41 (LPN) clocked in at 11:01 PM and clocked out at 9:29 AM, assigned to the New Castle Unit. Review of the July 2023 eMARs and eTARs for 34 residents in the Arcadia Unit (first floor) revealed that E43 (RN), assigned to the Dover Unit on the second floor, administered and signed off medications, treatments and monitoring at the beginning of the night shift. Further review revealed that 15 residents were not administered medications or provided treatments at the end of the shift. 7/28/23 at 5:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (RCD). 3. Cross refer to F684, example 1b, and F760, example 2 Review of the facility's Staff Posting for 11:00 PM to 7:00 AM shift on Saturday, 7/15/23, into Sunday, 7/16/23, revealed that there was no nurse assigned to the New Castle Unit with 37 residents and E43 (RN) was listed as the night shift Supervisor and also assigned to a med cart on the Dover Unit. The Staff Posting listed two CNAs in the New Castle Unit for this shift: E46 and E47. The facility's timecards for nurses on the 11:00 PM to 7:00 AM shift on Saturday, 7/15/23, into Sunday, 7/16/23, revealed: - E48 (LPN) clocked in at 3:19 PM and clocked out at 7:30 AM, assigned to the Arcadia Unit. - E44 (LPN) clocked in at 10:43 PM and clocked out at 7:47 AM, assigned to the Heritage Unit. - E43 (RN) clocked in at 3:47 PM and clocked out at 7:47 AM, assigned to the Dover Unit. Review of the July 2023 eMARs and eTARs for 37 residents in the New Castle Unit revealed that 36 residents did not receive medications, treatments and monitoring during the night shift due to no assigned New Castle unit nurse on the night shift. 7/28/23 at 5:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (RCD). 46134 4. The following was reviewed in R284's clinical record: 9/3/21 11:10 PM - R284 was admitted to the facility with diagnoses including a stroke with right sided weakness. 9/4/21 - R284's admission baseline care plan documented that R284 had urinary incontinence related to R284's limited ability to move. A care plan intervention included to provide incontinence care as needed to R284. 9/14/21 - A progress note documented that R284 left the facility AMA (Against Medical Advice) with the assistance of R284's wife (FM3) because FM3 was not happy with the care that the facility provided to her husband. 7/19/23 12:20 PM - During a telephone interview, FM3 stated that she had not been happy with the care that her husband received while he was a resident at the facility. FM3 stated that her husband was not kept clean while he was a resident at the facility, and that he was often left for lengthy periods of time in wet briefs. 7/20/23 - A review of the 9/3/21 CNA Documentation Survey Report for R284 documented that toileting care was not provided to R284 on the 11-7 shift. 7/20/23 - During an interview, E60 (CNA) stated that a blank section for documentation on a documentation survey report means that the task was not done. 7/27/23 - A review of employee timecards for 9/3/21 revealed that six CNAs called out for 9/3/21. Based on an analysis of the CNA timecards and the locations of work for CNAs on 9/3/21, the unit that R284's room was located had one CNA for the 11-7 shift, and the other unit on the same floor had no CNA timecard entries for the 11-7 shift. 7/27/23 - During an interview, E16 (HR) stated that the 9/3/21 timecard documentation does not reflect that Agency CNAs that may have worked, but E16 said that there was no way to produce a staffing sheet for 9/3/21. 7/31/23 -- During an interview, E61 (CNA) stated that a blank section for documentation on a documentation survey report means that the task was not done. 40264 Cross refer to F689, example 1 5. Review of R26's clinical record revealed the following: 12/13/21 - R26 was readmitted to the facility with diagnoses including but not limited to repeated falls. A care plan was developed for R26's (created on 6/28/21 and revised 3/31/23) disruptive/compulsive behaviors including, roaming into other residents' rooms. R26's interventions included but not limited to 1:1 supervision (one staff person assigned direct supervision of a resident) for safety (created 6/15/22 revised 2/16/23). 4/9/23 - A facility investigation report documented that R26 had an unwitnessed fall. R26 was noted in the hallway with blood on the face and scalp. The report further documented that R26 had been wandering in the unit during the shift and was also noted with laceration on top of scalp, left eye and bridge of nose. 7/28/23 - Review of the facility Weekend Staffing sheet dated 4/9/23 on the 11:00 AM - 7:00 AM shift lacked evidence that a staff person was assigned to R26 for the 1:1 supervision for safety as the care plan indicated. The facility failed to ensure there were sufficient nursing staff to meet the needs of R26 during the 11::00 PM to 7:00 AM shift on Sunday, 4/9/23 that resulted to R26's fall with injuries and transfer to the hospital. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO). 8/14/23 11:13 AM - Findings were communicated in an email correspondence with E1 (NHA), E2 (DON) and E3 (RDC).

Based on interviews, record review and review of other documentation as indicated, it was determined that for one (R23) out of three residents sampled for falls, the facility failed to ensure that readmission physician orders for two anti-seizure medications were accurately transcribed into the electronic health record for R23's immediate care of her seizure disorder. From 9/8/23 through 9/20/23, R23 did not receive 24 doses of Vimpat and was administered five (5) incorrect doses of Keppra. On 9/29/23, R23 had a seizure and fell during a therapy ambulation session and was transferred to the hospital, evaluated and treated with anti-seizure medication. Due to the facility's failure, an Immediate Jeopardy (IJ) was called at 3:20 PM on 10/26/23. The IJ was abated on 10/27/23 at 5:00 PM. Findings include: R23's clinical record revealed: 8/28/23 - R23 was admitted to the facility with diagnoses that included, but was not limited to, seizure disorder (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). 9/8/23 at approximately 7:00 PM - On Friday evening, R23 was readmitted to the facility from the hospital. The hospital discharge orders documented the following anti-seizure medications: - Vimpat 50 mg (milligrams) oral tablet - give one (1) tablet two times a day with the next dose due on 9/8/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg, two times a day with the next dose due on 9/8/23 at 8:00 PM. 9/8/23 at 7:28 PM - E8 (RN) entered the following readmission physician orders into R23's electronic health record: - Vimpat 50 mg oral tablet - give one (1) tablet two times a day with a start date of 9/20/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give one (1) tablet = 500 mg, two times a day. From 9/8/23 at 8:00 PM through 9/20/23 at 8:00 AM, R23 did not receive the physician ordered Vimpat medication, a total of 24 doses. From 9/8/23 at 8:00 PM until 9/11/23 at 8:44 AM, R23 was administered only one 500 mg tablet of Keppra twice a day for a total of five doses instead of 1,500 mg twice a day. 9/11/23 at 8:44 AM - R23's 9/8/23 Keppra physician's order was discontinued. A new physician's order was entered for Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg two times a day. R23 received the correct dosage of Keppra from 9/11/23 through 9/29/23. 9/29/23 at 10:30 AM - A nursing note documented, Therapist called a 'falling leaf' (fall prevention program identifying residents that are at highest risk of falls). Per therapist, pt (patient) seized up during ambulation and started to fall, did not hit her head, landed on therapist . Seizure suspected . Pt reports to therapist that she is unable to see . 9/29/23 at 4:06 PM - The hospital record documented that . at baseline she has seizures at least once a year, her last seizure was a month ago, about a month ago her Vimpat dosing was increased from once a day to twice a day, and the semiology (signs/symptoms) of her seizures is typically unilateral bilateral hand shaking or blank staring rather than full tonic-clonic presentation (type of seizure that affects both sides of the brain and causes a loss of consciousness and violent muscle contractions) . at 5:01 PM discussed case with . neurology (study of the nervous system, which controls our thoughts, sensations, movements and emotions) . amenable (agree) to increasing her Vimpat to 100 mg twice daily . at 6:04 PM about 30 minutes ago was in the room updating her (family member) when (R23) began speaking, then began having relatively rapid stuttering repeating a single syllable, tremors noted in the bilateral hands, her arms then raised up to a flexed (bent) position at the elbow, and her gaze was to the right. (R23) did not lose consciousness. (R23) then lowered her arms but continued to have tremors in the right hand and stuttering when she spoke. Given concern for an ongoing focal seizure (begin in one area of the brain, but can become generalized and spread to other areas) we did administer 0.5 mg of Ativan (used to treat active seizures) twice, about 2 minutes apart, with resolution of this activity. 10/12/23 at 10:51 AM - The hospital discharge summary documented that R23 presented to the hospital . with seizure-like activity, through her hospitalization underwent continuous EEG (electroencephalogram - diagnostic test that records brain waves) with titration (increase/decrease) of her anti-seizure medications with assistance of neurology. On discharge, R23's anti-seizure medications were changed to: - Vimpat 50 mg oral tablet - give three (3) tablets = 150 mg twice a day; and - Keppra 1,000 mg oral tablet - give one (1) tablet twice a day. 10/26/23 at 1:07 PM - During a combined interview, E2 (DON) and E3 (RCD) confirmed that the facility failed to identify that R23's Vimpat medication admission order had the incorrect start date and R23 did not receive the medication until 9/20/23; confirmed that the facility did not identify that R23's Keppra medication admission order had the incorrect dosage until three days after readmission during a Monday morning (9/11/23) review and was corrected, but no investigation was conducted. E2 and E3 confirmed that the facility completed Medication Error Reports for both medications today, 10/26/23. E2 and E3 stated that the facility's licensed nursing staff conduct 24 hour chart checks of physician orders, however the nursing staff do not document that this second check was performed in the resident's clinical record. R23's clinical record lacked evidence that a 24 hour chart check was completed. Despite identifying the Keppra incorrect dosage on 9/11/23 during a Monday morning review, the facility failed to complete an incident report and conduct an investigation as to why this medication error occurred. 10/26/23 - The facility provided copies of each Medication Error Report for Vimpat and Keppra. Each report documented .What was the effect of the error on the resident? Increased potential for seizure activity . 10/26/23 at 3:20 PM - An Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), E3 (RCD) and E5 (VPO). The facility failed to ensure that R23's readmission physician orders for both Vimpat and Keppra were accurately entered into the electronic health record (EHR) to meet her immediate need and care of her seizure disorder. 10/27/23 at 12:00 Noon - An amended IJ template was provided to the facility. 10/27/23 at 2:17 PM - E1 (NHA) submitted an acceptable amended Abatement Plan signed, dated, and timed. 10/27/23 at 5:00 PM - The facility's Immediate Jeopardy was abated at this time. 11/7/23 - Based on verification of the facility's following immediate corrective actions listed below through interviews and review of residents' clinical records and facility documentation revealed that the IJ was abated on 10/27/23 at 5:00 PM: - R23's active physician orders were reconciled (reviewed) by the medical provider; - Facility's audit/reconciliation of all new admissions/readmissions physician orders in the last 30 days and any discrepancies identified to be communicated with the provider for further recommendations; - Education provided to NHA/DON on reviewing all new admissions/readmissions physician orders and reconciling those orders entered into the EHR; - New facility admission/readmission process: Admitting nurse will call and reconcile the resident's orders with the provider and will include start dates. The admitting nurse will document on the discharge summary/medication list the provider name, date and time. The admitting nurse will then enter the orders into the resident's EHR (electronic health record). A second nurse will validate those orders entered for accuracy within 24 hours. The second nurse will sign and date the discharge summary/medication list. The signed discharge summary/medication list will be placed in a file at the nurses' station. The medical records clerk will then remove the document and upload it into the resident's EHR within 5 business days; and - Education provided to all licensed nurses and the records clerk on the new facility process.

Based on interviews, record review and review of other documentation as indicated, it was determined that for one (R23) out of three residents sampled for falls, the facility failed to ensure that readmission physician orders for two anti-seizure medications were accurately transcribed into the electronic health record for R23's immediate care of her seizure disorder. From 9/8/23 through 9/20/23, R23 did not receive 24 doses of Vimpat and was administered five (5) incorrect doses of Keppra. On 9/29/23, R23 had a seizure and fell during a therapy ambulation session and was transferred to the hospital, evaluated and treated with anti-seizure medication. Due to the facility's failure, an Immediate Jeopardy (IJ) was called at 3:20 PM on 10/26/23. The IJ was abated on 10/27/23 at 5:00 PM. Findings include: R23's clinical record revealed: 8/28/23 - R23 was admitted to the facility with diagnoses that included, but was not limited to, seizure disorder (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). 9/8/23 at approximately 7:00 PM - On Friday evening, R23 was readmitted to the facility from the hospital. The hospital discharge orders documented the following anti-seizure medications: - Vimpat 50 mg (milligrams) oral tablet - give one (1) tablet two times a day with the next dose due on 9/8/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg, two times a day with the next dose due on 9/8/23 at 8:00 PM. 9/8/23 at 7:28 PM - E8 (RN) entered the following readmission physician orders into R23's electronic health record: - Vimpat 50 mg oral tablet - give one (1) tablet two times a day with a start date of 9/20/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give one (1) tablet = 500 mg, two times a day. From 9/8/23 at 8:00 PM through 9/20/23 at 8:00 AM, R23 did not receive the physician ordered Vimpat medication, a total of 24 doses. From 9/8/23 at 8:00 PM until 9/11/23 at 8:44 AM, R23 was administered only one 500 mg tablet of Keppra twice a day for a total of five doses instead of 1,500 mg twice a day. 9/11/23 at 8:44 AM - R23's 9/8/23 Keppra physician's order was discontinued. A new physician's order was entered for Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg two times a day. R23 received the correct dosage of Keppra from 9/11/23 through 9/29/23. 9/29/23 at 10:30 AM - A nursing note documented, Therapist called a 'falling leaf' (fall prevention program identifying residents that are at highest risk of falls). Per therapist, pt (patient) seized up during ambulation and started to fall, did not hit her head, landed on therapist . Seizure suspected . Pt reports to therapist that she is unable to see . 9/29/23 at 4:06 PM - The hospital record documented that . at baseline she has seizures at least once a year, her last seizure was a month ago, about a month ago her Vimpat dosing was increased from once a day to twice a day, and the semiology (signs/symptoms) of her seizures is typically unilateral bilateral hand shaking or blank staring rather than full tonic-clonic presentation (type of seizure that affects both sides of the brain and causes a loss of consciousness and violent muscle contractions) . at 5:01 PM discussed case with . neurology (study of the nervous system, which controls our thoughts, sensations, movements and emotions) . amenable (agree) to increasing her Vimpat to 100 mg twice daily . at 6:04 PM about 30 minutes ago was in the room updating her (family member) when (R23) began speaking, then began having relatively rapid stuttering repeating a single syllable, tremors noted in the bilateral hands, her arms then raised up to a flexed (bent) position at the elbow, and her gaze was to the right. (R23) did not lose consciousness. (R23) then lowered her arms but continued to have tremors in the right hand and stuttering when she spoke. Given concern for an ongoing focal seizure (begin in one area of the brain, but can become generalized and spread to other areas) we did administer 0.5 mg of Ativan (used to treat active seizures) twice, about 2 minutes apart, with resolution of this activity. 10/12/23 at 10:51 AM - The hospital discharge summary documented that R23 presented to the hospital . with seizure-like activity, through her hospitalization underwent continuous EEG (electroencephalogram - diagnostic test that records brain waves) with titration (increase/decrease) of her anti-seizure medications with assistance of neurology. On discharge, R23's anti-seizure medications were changed to: - Vimpat 50 mg oral tablet - give three (3) tablets = 150 mg twice a day; and - Keppra 1,000 mg oral tablet - give one (1) tablet twice a day. 10/26/23 at 1:07 PM - During a combined interview, E2 (DON) and E3 (RCD) confirmed that the facility failed to identify that R23's Vimpat medication admission order had the incorrect start date and R23 did not receive the medication until 9/20/23; confirmed that the facility did not identify that R23's Keppra medication admission order had the incorrect dosage until three days after readmission during a Monday morning (9/11/23) review and was corrected, but no investigation was conducted. E2 and E3 confirmed that the facility completed Medication Error Reports for both medications today, 10/26/23. E2 and E3 stated that the facility's licensed nursing staff conduct 24 hour chart checks of physician orders, however the nursing staff do not document that this second check was performed in the resident's clinical record. R23's clinical record lacked evidence that a 24 hour chart check was completed. Despite identifying the Keppra incorrect dosage on 9/11/23 during a Monday morning review, the facility failed to complete an incident report and conduct an investigation as to why this medication error occurred. 10/26/23 - The facility provided copies of each Medication Error Report for Vimpat and Keppra. Each report documented .What was the effect of the error on the resident? Increased potential for seizure activity . 10/26/23 at 3:20 PM - An Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), E3 (RCD) and E5 (VPO). The facility failed to ensure that R23's readmission physician orders for both Vimpat and Keppra were accurately entered into the electronic health record (EHR) to meet her immediate need and care of her seizure disorder. 10/27/23 at 12:00 Noon - An amended IJ template was provided to the facility. 10/27/23 at 2:17 PM - E1 (NHA) submitted an acceptable amended Abatement Plan signed, dated, and timed. 10/27/23 at 5:00 PM - The facility's Immediate Jeopardy was abated at this time. 11/7/23 - Based on verification of the facility's following immediate corrective actions listed below through interviews and review of residents' clinical records and facility documentation revealed that the IJ was abated on 10/27/23 at 5:00 PM: - R23's active physician orders were reconciled (reviewed) by the medical provider; - Facility's audit/reconciliation of all new admissions/readmissions physician orders in the last 30 days and any discrepancies identified to be communicated with the provider for further recommendations; - Education provided to NHA/DON on reviewing all new admissions/readmissions physician orders and reconciling those orders entered into the EHR; - New facility admission/readmission process: Admitting nurse will call and reconcile the resident's orders with the provider and will include start dates. The admitting nurse will document on the discharge summary/medication list the provider name, date and time. The admitting nurse will then enter the orders into the resident's EHR (electronic health record). A second nurse will validate those orders entered for accuracy within 24 hours. The second nurse will sign and date the discharge summary/medication list. The signed discharge summary/medication list will be placed in a file at the nurses' station. The medical records clerk will then remove the document and upload it into the resident's EHR within 5 business days; and - Education provided to all licensed nurses and the records clerk on the new facility process.

Based on observation, interview and record review, it was determined that for one out of one resident (R49) reviewed for respiratory/tracheostomy care, the facility failed to provide tracheal suctioning consistent with professional standards of practice. Findings included: The following was reviewed in R49's clinical record: 9/18/22 - R49 was admitted to the facility from an acute hospital with a diagnosis of respiratory failure. 10/29/20 - Per physician's order, trach care daily and as needed: for disposable: remove and dispose inner cannula. Replace with new inner cannula as needed for reduce risk of infection. 2/21/22 - Per physician's order, suction every shift and as needed for maintain patent airway. 10/3/22 - Per physician's order, cool air mist via trach collar at 70% humidification with O2 (oxygen) titrated in at 3 liters to maintain a pulse ox greater than 92%. Notify MD if pulse ox is equal to or less than 92%. Every shift. 7/19/23 at 10:40 AM - During observation of preparation to perform tracheal suctioning for R49, E66 (LPN) did not perform hand hygiene. After donning sterile gloves, E66 touched unclean surfaces (the suction canister tubing, outside of the bottle of sterile water, and the inside of the solution receptacle prior to pouring sterile water in it) using both gloved hands interchangeably. E66 was noted to switch between both hands when holding and/or grabbing items used for suctioning, including the suction catheter. During suctioning of R49, part of the suction catheter touched the clean, but unsterile trach dressing before being inserted in the inner cannula. The O2 (oxygen) level was set at 2 liters. The O2 tubing was not dated and labeled. The suction canister had not been emptied after prior use. Hand hygiene not observed being performed by E66 after removing gloves. 7/19/23 at 10:45 AM -During an interview and observation with E66, R49's oxygen was noted to be at 2 liters/minute. E66 stated that the order was for 3 liters/minute and adjusted the setting. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO)

Based on observations, interviews and reviews of clinical records, facility and other documentation as indicated, it was determined that for three (R86, R135 and R137) out of three residents sampled for hydration, the facility failed to ensure the residents were offered, assisted and monitored for sufficient fluid intake to maintain proper hydration and health, which resulted in harm for all three residents where they required emergent treatment. For R86, the facility's failure to encourage and monitor the resident's fluid intake to ensure adequate hydration resulted in an emergent transfer and hospitalization requiring administration of four liters of intravenous (IV) fluids and treatment for a UTI (urinary tract infection). For R135, the facility failed to ensure that she was offered and assisted with sufficient fluid intake in the setting of daily loose stools as evidenced by her abnormal lab result and a change in condition. For R137, the facility failed to ensure that the resident was monitored for sufficient fluid intake as evidenced by two hospitalization s where her Sodium level was elevated (normal ,d+[DATE]) at 153 on [DATE] and 160 on [DATE]. Findings include: [DATE] - The facility's Hydration Policy and Procedures documented, Patients will be appropriately hydrated by offering a variety of fluids and encouraging ongoing fluid intake throughout the day. Each patient (except those who are allowed nothing by mouth on fluid restrictions or are on thickened liquids) will have fresh ice and water at least once each shift. The staff will encourage patients to consume all fluids on meal trays and in-between meals supplements/snacks. A licensed nurse will offer patients fluid with each medication pass, CNAs (Certified Nursing Assistants) will be expected to offer fluids periodically each shift .Patients will be monitored for signs and symptoms of dehydration as a part of general provision of care and routinely as part to the . MDS (Minimum Data Set) process. 1. Review of R86's clinical record revealed: [DATE] - R86's hydration care plan, last revised on [DATE], documented, Risk for alteration in hydration related to constipation and recent hospitalization for sepsis/urinary tract infection .Maintain adequate hydration. Obtain Lab results as ordered and notify physician of results. Report changes related to signs of fluid deficit (tongue furrows, dry mouth etc). [DATE] 9:30 PM - A nursing progress note documented, .Change of condition, patient noted with decreased appetite and confusion. Upon assessment patient noted with slurred speech and slow to respond. Patient was awake and conversant, no respiratory distress or SOB (shortness of breath) noted. Patient has left sided paralysis from previous stroke. Patient hypotensive (low blood pressure) ,d+[DATE]. On call NP (Nurse Practitioner) notified and new order given to send patient to [NAME] ER (emergency room ). Patient was sent to the hospital via 911 ambulance at 9:07 PM. [DATE] - Review of the hospital records revealed that R86 was administered four (4) Liters of crystalloid fluids (used to treat low fluid volume, sepsis and dehydration) in the ER. In addition, R86 was diagnosed with a UTI and treated. [DATE] - The MDS revealed R86 was readmitted to the facility with a BIMS (brief interview for mental status) score of 15 (cognitively intact). R86 did not require assistance with eating or drinking. [DATE] 12:33 PM - R86's readmission hydration assessment, completed by E56 (Dietician), documented her fluid requirements to be 1,936 mls per day. Observations during the survey revealed: [DATE] 8:30 AM - During an interview, R86 stated, I was in the hospital for almost two weeks. I had a very bad bladder infection because I was not drinking enough. An observation of R86's breakfast tray revealed one 120 ml container of juice and one 120 ml container of milk, totaling 240 mls. No other fluids were observed on R86's meal tray or on the bedside table. [DATE] 11:15 AM - An observation revealed that R86 did not have any fluids on the bedside table. R86 rang the call bell and requested water from E62 (CNA). E62 returned with a Styrofoam cup of water and gave it to R86. [DATE] 8:30 AM - An observation revealed that R86 had one 120 ml container of juice and one 120 ml container of milk on the breakfast tray. No other fluids were observed on the tray or on the bedside table. [DATE] 2:00 PM - An observation revealed that R86 did not have a fresh water cup or any other fluids on the bedside table. [DATE] 2:30 PM - Two large containers of water were observed on the Dover Unit nursing station. [DATE] 2:45 PM - Observation of the water containers were still on the Dover Unit nursing station with the same amount of fluids in them. [DATE] 8:30 AM - Observation revealed that R86 had one 120 ml container of juice and one 120 ml container of milk on the breakfast tray. A warm undated empty Styrofoam cup was on the bedside table. [DATE] 11:05 AM - During an interview about how residents receive fluids, E62 (CNA) stated, I give them water or other fluids when they ask for it. [DATE] 2:20 PM - E56 (Dietitian) was interviewed about how the residents are monitored to ensure that they receive adequate hydration. E56 stated, The residents get water with med pass, and fluids on their meal trays. The aides ask them if they want coffee or tea, and if they want water during the day. The ADL sheets record their fluid intake. Fluids are brought up to the units to give to the residents. [DATE] 2:00 PM - E56 (Dietician) was interviewed on whether R86's fluid intake prior to, post hospitalization , and current intake were reviewed to determine if R86 was meeting the estimated fluid goal. E56 stated, The intakes were not reviewed. [DATE] 2:15 PM - R86's fluid intakes from [DATE] through [DATE] and [DATE] through [DATE] were reviewed. Despite having a recommended fluid intake goal of 1,936 mls per day, R86's daily fluid intakes did not meet this goal for 23 out of 23 days reviewed (listed below). Daily Fluid Intakes: [DATE] - 240 ml [DATE] - 480 ml [DATE] - 980 ml [DATE] - 1,040 ml [DATE] - 740 ml [DATE] - 520 ml [DATE] - 280 ml [DATE] - 580 ml [DATE] - 720 ml [DATE] - 560 ml [DATE] - 1,240 ml [DATE] - 960 ml [DATE] - 480 ml [DATE] - 600 ml [DATE] - 480 ml [DATE] - 820 ml [DATE] - 940 ml [DATE] - 1,260 ml [DATE] - 410 ml [DATE] - 1,122 ml [DATE] - 720 ml [DATE] - 302 ml [DATE] - 500 ml Due to the facility's failure to monitor and encourage R86's fluid intake to ensure adequate hydration, R86 was emergently transferred and hospitalized for low fluid volume, acute kidney injury and UTI. [DATE] at 2:00 PM - Findings reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO). 32545 2. Review of R135's clinical record revealed: [DATE] at 11:10 AM - R135's lab results revealed her BUN as 21 (normal range ,d+[DATE]). According to Mosby's Diagnostic and Laboratory Test Reference, Eighth Edition 2007, the BUN measures the amount of urea nitrogen in the blood. It is directly related to the function of the liver and the removal function of the kidneys. Overhydration and underhydration affects its levels. [DATE] - An admission MDS (Minimum Data Set) assessment documented R135's BIMS (Brief Interview for Mental Status) score as 9, which reflected moderate cognitive impairment. [DATE] at 12:50 PM - R135's BUN lab result was 18. From [DATE] through [DATE], R135 was having daily loose stools per the CNA Documentation Survey Report. In addition, R135's clinical record lacked evidence that her hydration was being monitored in the setting of daily loose stools. [DATE] - An Occupation Therapy (OT) note documented that . Pt (Patient) drank juice from a small plastic cup . She drank very slowly, taking very small sips with long pauses between sips . [DATE] - An OT note documented, Pt seen for self-feeding during lunch today due to visitor concern about pt needing assistance. Pt required therapist assistance to fully bring spoon of food to mouth often placing spoon below chin. Pt acknowledges decreased depth perception. Therapist assisted patient in properly repositioning for optimal function during self-feeding reclined in bed. [DATE] - A Speech Therapy note documented, . Pt was in bed asleep. She was noted with pronounced R (right) facial droop and mild dysarthria (slurred speech) . [DATE] at 12:00 Noon - R135's BUN lab result was 60 (abnormal high level). [DATE] - A Speech Therapy note documented, .Pt was asleep upon entry to her room. Her mouth and lips were very dry. She was repositioned for liquid intake. She drank oj (orange juice) and grimaced stating her mouth hurt. Her upper dentures were removed and soaked. Oral care was provided. She was fed ice cream and oj. She demonstrated prompt swallow. She required verbal cues to keep eyes open. She was noted with R (right) facial droop and lean. [DATE] at 2:21 PM - A progress note by E68 (NP) documented, . Therapy requested (R135) to be evaluated for (slurred speech) and R side facial droop . (R135) is very frail and is a limited historian. Per therapy she has been having overall decline for past couple of days . Acute Kidney Injury . BUN 60 . Start Hypodermoclysis (method of administering fluids under the skin) . Discussed with patient she does not want to go to ER (emergency room ). Monitor clinically . patient drank with no issues with swallowing . Monitor closely. Nursing to notify (Physician) with any acute changes . Despite the physician order, R135 never received the Hypodermoclysis on this date per review of the [DATE] eMAR. [DATE] at 6:25 PM - R135 was emergently transferred to the hospital for altered mental status and shortness of breath at the request of a family member present at R135's bedside. [DATE] at 6:42 PM - The hospital record documented, . (R135) extremely dry oropharynx (part of the throat behind the mouth and nasal cavity) and lips . Additional documentation at 9:55 PM revealed . patient looks very dehydrated and volume depleted . is tachypneic (rapid and shallow breathing) and lethargic (sleepy) . Patient continues to have persistent hypotension (low blood pressure) . despite 4 L (Liters) normal saline bolus (intravenous fluids) . patient is critically ill . [DATE] at 5:00 PM - During a combined interview with E1 (NHA), E2 (DON) and E4 (RCD), the facility's lack of monitoring R135's hydration while having daily loose stools was reviewed. [DATE] at 8:35 AM - Finding was reviewed with E56 (Dietician) regarding how was the facility monitoring of R135's hydration. No further documentation was provided to the Surveyor. [DATE] at 2:00 PM - Finding was reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO). The facility failed to ensure that R135 was offered and assisted with sufficient fluid intake to maintain proper hydration in the setting of daily loose stools as evidenced by her abnormal BUN lab result of 60 and her change in condition. 3. Review of R137's clinical record revealed: [DATE] - R137 was admitted to the facility with diagnoses including, but was not limited to, Multiple Sclerosis (nervous system disease that affects the brain and spinal cord), left hand contracture (joint limitations with fixed high resistance to passive stretch of a muscle), paraplegia (impairment in motor or sensory function of the lower extremities), urinary ileal conduit (small pouch that holds urine) and recurrent urinary tract infections. [DATE] - R137's ADL self care deficit related to physical limitations care plan documented an intervention to assist with eating as needed. [DATE] - R137's nutrition care plan documented an intervention to encourage and assist as needed to consume foods and/or supplements and fluids offered. [DATE] - The quarterly MDS assessment documented that an interview to assess R137's BIMS was attempted, but revealed that R137 had a change in mentation; and she required supervision with setup help only for eating/drinking. [DATE] - A physician note documented that R137 . was evaluated this AM as follow-up to altered mental status and patient with apparent poor oral intake and labs completed and found to have an elevated sodium of 150 (normal ,d+[DATE]). I will initiate hypodermoclysis (method of administering fluids under the skin) . for 3 L (liters) and asked staff to encourage PO (oral) intake as well .I have asked nursing to notify clinician of any changes . [DATE] - A physician note documented that R137 was seen for . elevated sodium, altered mental status . found to have an elevated sodium of 150 and initiated with hypodermoclysis and sodium now stable at 139 patient actually appears at her baseline . PO (oral) intake has improved as well . Acute hypernatremia: Sodium now stable . encourage PO intake and maintain hydration . [DATE] through [DATE] - Review of the CNA Documentation Survey Report revealed that fluids were offered and R137 consumed 81 out of 90 meals and accepted all houseshakes (nutritional supplement). However, the documentation does not capture the amount of fluids R137 consumed for each shift to determine if she was maintaining proper hydration and meeting her fluids needs. The Report documented that R137 received setup help only by staff when the meal tray was delivered 79 out of 90 meals served; and for 72 out of 90 meals served, R137 was independent, where there was no help or staff oversight at any time during her meals. [DATE] at 10:42 AM - A nutrition note by E65 (Dietician) documented that R137's intake more variable than usual, consuming ,d+[DATE]%. Supplemented with houseshakes TID (three times a day) . which are accepted per documentation . Juven (supplement) currently unavailable due to supply issues . [DATE] to [DATE] - Review of the CNA Documentation Survey Report revealed that fluids were offered and R137 refused one out of 12 meals offered and accepted all houseshakes. Again, the documentation lacked evidence of the amount of fluids R137 actually consumed for each shift. The Report documented that R137 received setup help only by staff 11 out of 12 times; and for seven out of 12 meals, R137 was independent, where there was no help or staff oversight at any time during her meals. [DATE] at 9:07 AM - R137 was sent to the hospital due to a change of condition related to a fall. [DATE] at 11:52 AM - The hospital record documented a consultation for management of R137's Hypernatremia (high sodium level). The Consultation stated, . on presentation, patient was found to have sodium level of 153 . Patient tells me that she has not been drinking fluids recently . Assessment/Plan: Hypernatremia . This is likely due to poor oral intake and free water deficit . [DATE] - R137 was readmitted to the facility. A physician's order was received for labs, including a BMP (measures sodium level), scheduled for [DATE]. [DATE] at 1:39 PM - A nutrition note by E56 (Dietician) documented that R137 was readmitted to the facility . following hospitalization for a fall and a urinary tract infection (UTI) . Feeds self post setup . Noted decrease in po (oral) intake ,d+[DATE]-,d+[DATE] prior to hospitalization . IVF (intervenous fluids) administration in hospital for hypernatremia. Good fluid acceptance today . Recommend new BMP to monitor hydration status . Will monitor and f/u (follow-up) prn (as needed). Please refer to the completed assessment for further information. [DATE] at 1:39 PM - R137's nutrition assessment by E56 (Dietician) documented, thin fluids, n/a (not applicable) supplement . Functional Problems Affecting Ability to Eat: contractures, hemiplegia, recent decline in ADLs . recent mental status changes . recent lab Na (sodium) 149 . most recent labs obtained from hospital records. Hypernatremia (high sodium level) treated with IVF in hospital . fluid needs in mls 2018 . Recommend new BMP to monitor hydration . [DATE] - R137's BMP lab results were received and showed Na was 144. Despite obtaining a BMP lab result, the facility failed to implement additional interventions to monitor R137's fluid intake and to ensure her fluid needs were being met after being hospitalized . Review of the CNA Documentation Survey Report from [DATE] through [DATE] revealed that fluids were offered and R137 refused nine out of 40 meals and 6 out of 39 houseshakes. Again, the documentation lacked evidence of the amount of fluids R137 consumed for each shift. The Report documented that she received setup help only by staff 26 out of 41 times; and for 27 out of 41 meals, R137 was independent, where there was no help or staff oversight at any time during her meals. It should be noted that R137 refused: - lunch and dinner meals on Friday, [DATE]; - breakfast and lunch meals on Saturday, [DATE]; - breakfast and lunch meals on Sunday, [DATE]; - breakfast and lunch on Tuesday, [DATE]; and - breakfast on Wednesday, [DATE]. There was no evidence in the clinical record that R137's repeated refusals of meals above were acted upon by nursing staff and the Physician/Dietician were notified. [DATE] - An acute Progress Note by E3 (Physician) documented that an . initial call came over of a CODE BLUE (for R137). However when I entered the room the patient had spontaneous respirations and had a pulse .therefore no need for CPR .found to be tachycardic with a heart rate in the 130s and . tachypneic with a respiratory rate of 30. Based on clinical findings at this time patient most likely with sepsis and does have a history of UTIs and decision made to send to the hospital for further evaluation and treatment . [DATE] at 9:15 AM - The Hospital Record documented R137's Sodium as 160 and Suspect that the pt (patient) has not had adequate oral intake in the setting of acute illness. She received 2 liters of IVF (intravenous fluids) in the ED (emergency department) . [DATE] at 5:00 PM - During an interview, R137's hydration and two hospitalization s were discussed briefly with E1 (NHA), E2 (DON) and E4 (RCD). [DATE] at 8:35 AM - Finding was reviewed with E56 (Dietician) regarding how was the facility monitoring R137's hydration. E56 provided copies of her notes and nutritional assessment to the Surveyor as captured above. The facility failed to ensure that R137 was monitored for sufficient fluid intake to maintain proper hydration as evidenced by two hospitalization s where her Sodium level was 153 on [DATE] and 160 on [DATE]. [DATE] at 2:00 PM - Finding was reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO).

Based on observation, interview, record review and review of other documentation, it was determined that for three (R140, R38 and R36) out of four residents reviewed for pressure ulcers, the facility failed to ensure that residents at risk for pressure ulcers, or those with pressure ulcers received the care and services to promote healing and to prevent new pressure ulcers from occurring. For R140, the facility lacked evidence of a turning and repositioning intervention causing harm to the resident related to avoidable new unstageable and suspected deep tissue pressure ulcer development. In addition, for R140, the facility failed to identify and treat R140's pressure ulcers. For R38 the facility lacked evidence of physician ordered wound treatments and interventions being implemented causing harm to the resident related to new avoidable pressure ulcer development. This lack of treatment also failed to promote healing of an existing pressure ulcer.For R36, the facility failed to ensure that R36 received the necessary daily treatment frequency of pressure ulcer dressing changes to promote the healing. Findings include: A facility policy entitled Pressure Ulcer Monitoring & Documentation (initiated 11/1/2019) included: -A licensed nurse will assess patients for the presence of pressure ulcers/injuries. A facility policy entitled Skin Assessments (initiated 11/1/2019) included: -A licensed nurse will ensure that the skin risk assessment is done upon admission and quarterly thereafter. -The weekly skin assessment will be completed thereafter. 1. Review of R140's clinical record revealed: 12/9/22 - R140 was admitted to the facility following an abdominal surgery. 12/9/22 - R140's Braden Scale Assessment on admission revealed mild risk for pressure ulcer development. 12/9/22 5:30 PM - R140's nursing evaluation on admission documented no pressure ulcers at the time of entry to the facility. 12/9/22 - A physician's order included body audits on every evening shift every Tuesday and Friday for skin observation. 12/12/22 - A physician's order included that R140 was required to wear an abdominal binder when out of bed OOB week 2 until f/u (follow up) appointment with surgeon. May remove for care/hygiene. 12/12/22 - R140's care plan for being at risk for alteration in skin integrity had not intervention the resident required assistance for turning and repositioning in bed. The facility lacked evidence of turning and repositioning in the CNA tasks. 12/15/22 - R140's Admission MDS assessment documented that R140 required extensive assistance of two staff members to be repositioned in bed, was at risk for pressure ulcers and R140 did not have any pressure ulcers. There was no update to the care plan for the resident's repositioning needs. 12/23/22 - R140's discharge (to the hospital) MDS assessment documented that R140 did not have any pressure ulcers. 12/23/22 4:04 PM - A nursing progress note documented: Patient sent out to the ER at (name of) hospital due to abnormal lab (sic) and change of mental status. 12/23/22 11:24 PM - A nursing transport team picked up R140 to transfer her from one hospital to another for further care. The transport documentation included: - Abdominal Comments: distended and tender to touch. PT (patient) has 5 [NAME] (sic) drains with brownish drainage in drains. PT [NAME] drainage site with yellow foul odor drainage from all sites. PT had additional wounds around where abdominal binder was in place. - Back Findings: meplex (a type of wound dressing) in place in sacral area. PT has multiple pressure wounds to right and left buttocks with eschar noted. - Skin Findings: . multiple open wounds noted on PT skin. 12/23/22 - A physician hospital history and physical progress note documented that R140 had multiple ulcerations of patient's backside. 12/24/22 (untimed) - Hospital nursing admission assessment documented: - Abdomen noted with multiple suspected deep tissue injuries surrounding edges of binder. Previously noted suspected pressure injuries to left thigh and right thigh are the posterior aspect/ischial regions. - Suspected pressure injuries: Right buttock, left thigh and right thigh all present on admission to the hospital. 7/24/23 1:46 PM - E2 (DON) confirmed the physician ordered body audits were just initialed on the MAR and the facility lacked evidence of the skin assessments completed by facility staff. R140 sustained harm when she developed avoidable pressure ulcers due to the lack of assessment, binder use, and lack of turning and repositioning. 7/27/23 10:17 AM - During an interview, E1 (NHA) confirmed that the facility lacked evidence of a thorough skin assessment and turning and repositioning schedule for R140. The facility lacked evidence of a turning and repositioning intervention causing harm to the resident related to avoidable new unstageable and suspected deep tissue pressure ulcer development. In addition, the facility failed to identify and treat R140's pressure ulcers. The resulted in harm to the resident. 48409 2. Review of R38's clinical records revealed: 12/10/22 8:35 PM - R38 readmitted to the facility with a surgical incision on her right hip and orders to clean the incision with normal saline and cover with dry dressing daily. 12/22/22 - A significant change MDS (Minimum Data Set) documented that R38 required extensive assistance and one person for bed mobility, was at risk for pressure ulcers, had a pressure ulcer reducing device for the bed and chair and was not on a turning and repositioning program. The facility lacked evidence of a current care plan for the prevention of pressure ulcers including the failure to identify the need for a turning and repositioning program and the need to offload / remove pressure of the heels by floating off of the bed. 1/26/23 - A significant change MDS documented that R38 was at risk for pressure ulcers, utilized pressure ulcer reducing devices for the bed and chair and was not on a turning and repositioning program. 1/31/23 - The Wound Care Practitioner Evaluation documented, Sacral (area at the base of the spine) was wound (sic) identified with multiple open areas - combined measurement with epithelial (new skin cells that are a different color - usually white or pink from surrounding area) ridging measured 11.5 cm x 14.0 cm x unable to determine with 30% slough - yellow, tan, gray, green or brown dead tissue: 30% granulation- new tissue with blood vessels formed during wound healing; and 40% necrosis (dead tissue). Moderate serous (watery red) drainage. Treatment: Clean with normal saline, apply wet to dry dressing every day and evening shift. R38 developed an avoidable pressure ulcer. R38 lacked a care plan for pressure ulcer prevention and was not on a turning and repositioning program to reduce pressure. 1/31/23 - A new care plan was created - Unstageable ulcer to sacro-coccyx area (sacrum - large triangular bone at base of spine, coccyx - tailbone), with interventions to Elevate heels as able, Repositioning during ADLS (activities of daily living). Encourage to reposition as needed; use assistive devices as needed. 1/31/23 - A physicians order for daily skin checks was written. 2/1/23 - A Wound Care Practitioner Order stated, Clean sacro-coccyx ulcer with normal saline, apply Medi honey (gel treatment to remove dead tissue to area of slough and necrosis, cover site with dressing daily. February 2023 - The TAR lacked evidence that R38's daily skin checks were performed on 2/15, 2/16 and 2/17/23. February 2023 - March 2023: The TAR lacked evidence of treatment to R38's sacro-coccyx ulcer on 2/9, 2/15, 2/16, 2/17, 2/28, 3/8, 3/9, 3/24 and 3/28/23. Additionally, there was no evidence that R38 refused care. 4/14/23 - A physician order for Skin Prep (liquid dressing for intact skin to form protective film) to bilateral heels every shift. Review of the record lacked evidence of an approach to reduce pressure to heels by floating / offloading pressure when in bed. 4/23/23 - The TAR lacked evidence of skin prep treatment to R38's heels. April 2023 - The TAR lacked evidence that R38's sacro-coccyx ulcer treatment was completed on 4/14, 4/15, 4/21 and 4/24/23. 4/28/23 - A quarterly MDS documented that R38 had a pressure ulcer, was at risk for developing pressure ulcers and was not on a turning and repositioning program, 5/1/23 - The TAR lacked evidence of R38's sacro-coccyx treatment. May 2023 - The TAR lacked evidence of R38's skin prep treatment to bilateral heels on 5/6, 5/7, 5/14/23. 5/9/23 11:05 PM - Review of a progress note documented, During care, resident noted with unstageable pressure ulcer to right medial heel, measuring 3/(by)3 cm. Sight is warm, with dry scab, painful to touch, no drainage noticed. Skin prep applied as ordered, off-loading boots applied to B/L (bilateral) feet. R38 developed an avoidable pressure ulcer to the right heel. There was no evidence of heel off-loading prior to the identification of the unstageable pressure ulcer. 5/9/23 - A physicians order for Prevalon (Pressure Redistribution Device) boots to bilateral heels while in bed. 5/12/23 - A wound note documented, .right heel Measurements Length: 2.5 cm Width: 2 cm L x W: 5 cm Depth: 0.00 cm Observations Location: right heel Etiology: Pressure Stage/Severity: Unstageable, 100% eschar . 5/18/23 - A Wound Care Practitioner documented, New wound on right heel - 3 cm x 3 cm x unable to determine, clean area with normal saline, apply Medi-honey, calcium alginate foam dressing daily. June 2023 - July 2023 - The TAR lacked evidence of wound treatment to R38's right heel on 6/24, 6/25, 7/12, 7/20/23. The TAR lacked evidence of R38's sacro-coccyx treatment on 6/24 and 6/25/23. June 2023- July 2023 - R38's MAR (Medication Administration Record) and TAR were reviewed for orders for turning, repositioning and floating heels. There was no evidence of physician's orders or approaches for providing this care. June 2023 - July 2023 - R38's CNA's (Certified Nursing Assistant) records were reviewed for floating of heels. There was no evidence that this care was provided. 7/13/23 - A Wound Care Practitioner documented, Clean wound on sacro-coccyx area with wound cleanser, apply medi- honey cover with gauze daily and PRN (as needed). The TAR lacked evidence of R38's sacral wound care on 7/15/23 - 7/20/23. The following was observed: 7/17/23 8:00 AM - R38 was observed laying on her left side with her heels flat on the bed. No heel boots were on bilateral feet despite order for Prevalon boots bilaterally. R38 was care-planned for bilateral heel boots when in bed. 7/17/23 9:45 AM - R38 was observed laying on her left side with her heels flat on the bed. No heel boots were on bilateral feet. 7/17/23 10:05 AM through 10:30 AM - R38 was observed laying on her left side with her heels flat on the bed. No heel boots were on bilateral feet. Observations were confirmed with E31(LPN) who stated, I don't work often on this floor but R38 should have been wearing her heel boots. 7/21/23 8:30 AM, 9:30, 10:30 AM and 11:30 AM - R38 was observed laying on her left side with her heels flat on the bed. No heel boots were on bilateral feet. 7/21/23 11:30 AM - E60 (CNA in the resident care are) was asked if resident should be wearing the Prevalon boots. E60 stated, I don't have that resident. Observations confirmed with E31. 7/24/23 7:07 AM - The Electronic Health Record (EHR) noted, R38 was noted with a new open area of 1 x 1 cm on lower bottom towards the left side. 7/24/23 8:30 AM - R38 was observed laying on her left side on the bed with her heels flat on the bed. No heel boots were on bilateral feet. This observation was confirmed with E40 (RN). July 2023 - A review of CNA documentation revealed R38 was provided bed mobility / turning and repositioning 68 out of 144 opportunities. 7/14/23 - 5 times 7/15/23 - 5 times 7/16/23 - 7 times 7/17/23 - 7 times 7/18/23 - 6 times 7/19/23 - 7 times 7/20/23 - 5 times 7/20/23 - 5 times 7/21/23 - 4 times 7/22/23 - 7 times 7/23/23 - 7 times 7/24/23 - 4 times Residents at risk or that have pressure ulcers should be turned and repositioned at least every two hours and as needed (National Institute of Health 2/1/20). The facility failed to implement approaches including turning and repositioning and heel off-loading to prevent pressure ulcer development resulting in R38 developing avoidable pressure ulcers. Additionally, the facility failed to carry approaches and orders that were in place to treat existing pressure ulcers and prevent new pressure ulcers from developing. 7/31/23 at 2:00 PM - Findings reviewed during the Exit Conference with E1(NHA), E2( DON), E4 (RCD) and E18 (VPO). 40264 3. Review of R36's clinical records revealed: 12/27/22 - R36 was readmitted to the facility. 4/21/23 - R36's Significant Change MDS revealed that R36 had an unhealed Stage 4 pressure ulcer (ulcer has become so deep that there is damage to the muscle and bone and sometimes to tendons and joints) injury with treatment for pressure ulcer or injury care. 6/16/23 - originated 5/1/23 - A care plan was developed for R36's risk for pressure ulcers and an actual Stage 4 chronic pressure ulcer to the sacrum. R36's interventions included but not limited to referral to wound physician as indicated and treatment per TAR (Treatment Administration Record). 6/23/23 - R36 had an active physician's order to cleanse sacral wound with NSS (normal saline solution), pack with iodaform and to apply bordered foam dressing every day shift every other day. Review of the following skin and wound notes by E67 (NP Wound Care) revealed conflicting frequency of treatments for R36's Stage 4 sacral pressure ulcer dressing changes: 6/15/23 - change daily and PRN (when necessary) 6/23/23 - change daily and PRN, BID (two times a day) 6/29/23 - change daily and PRN, BID 7/6/23 - change daily and PRN 7/13/23 - change daily and PRN 7/20/23 - change daily and PRN 7/26/23 10:00 AM - Review of R36's June 2023 TAR revealed that the daily sacral treatment was discontinued on 6/23/23 with a new order to start R36's sacral wound dressing changes on dayshift every other day. The staff nurses were noted signing off for the every other day dressing changes on the TAR. Review of R36's July 2023 TAR revealed that staff nurses were noted signing off for the every other day dressing changes on the TAR. 7/26/23 11:15 AM - In an interview, E11 (LPN) confirmed that, . Resident (R36) has a Stage 4 sacral wound and the treatment is done every other day. 7/27/23 12:55 PM - In an interview, E2 (DON) confirmed that, .Resident's (R36) sacral wound frequency is daily and PRN and not every other day. A new doctor's order was obtained yesterday (7/26/23) with the correct order. E2 provided this surveyor a copy of the new treatment order. 7/31/23 8:30 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (RCD).

Based on record review, interview, review of facility documentation and hospital records, it was determined that the facility failed to ensure that treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan, for two (R1 and R2) out of eight sampled residents. For R1, the facility failed to assess R1's and his/her medication needs prior to admission and on admission to ensure that they could provide the care and services necessary to treat R1's [MEDICAL CONDITION] (low sodium). The facility was aware prior to admission that R1 required the medication Tolvaptan in order to keep his/her sodium levels within normal limits. On 5/31/19, R1 was admitted to the facility with a discharge summary from the hospital with instructions stating to pick up R1's Tolvaptan medication at the hospital pharmacy. The facility failed to obtain R1's Tolvaptan medication resulting in harm to R1 when his/her sodium levels dropped to a critical range, and R1 had to be readmitted back to the hospital on [DATE] for [MEDICAL CONDITION] after not receiving Tolvaptan for 5 days. For R2, the facility failed to implement his/her constipation care plan resulting in R2 going 14 shifts between bowel movements. Findings include: 1. Review of R1's clinical record revealed: 5/31/19- R1 was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. 5/31/19- Review of R1's hospital discharge paperwork, that was sent with the resident to the facility, revealed that R1 was to remain on daily medication ([MEDICATION NAME] = Tolvaptan) for the foreseeable future to control the sodium concentration in R1's blood stream. In the medication section it was documented that R1 was to receive one 15 mg Tolvaptan tablet orally every day, and had the last dose administered on 5/31/19 at 8:00 AM. Instructions included that there were three refills and to pick them up at the hospital pharmacy. It was documented that the hospital nurse also gave this information verbally in report to the facility. This document was received by the facility when the resident arrived and the surveyor found the original copy in the resident's facility chart. It was unclear if anyone from the facility was responsible for reviewing R1's hospital discharge summary/instructions. 5/31/19- A facility physician order [REDACTED]. 6/1/19- Review of R1's baseline care plan revealed that his/her care plan was created on this date, but did not include his/her risk for [MEDICAL CONDITION] and the interventions required to ensure that his/her sodium level did not decline. Consequently the facility failed to identify and plan for critical care and services needed for R1. 6/1/19 5:06 PM- A late entry progress note documented that the pharmacy stated that R1's Tolvaptan had to be ordered from a specialty pharmacy. It was noted that the pharmacy faxed paperwork to order the medication to the specialty pharmacy. The on call NP (nurse practitioner) was notified. There was no documentation of attempting to contact the hospital pharmacy per the hospital discharge summary instructions. 6/2/19 12:55 PM- A progress note documented that R1's Tolvaptan was not administered due to unavailability and it was noted that the medication was to be supplied by an outside pharmacy. 6/2/19 6:13 PM- A progress note documented that the on call NP was notified that R1's Tolvaptan medication was on order at the specialty pharmacy. 6/3/19 10:21 AM- A progress note documented that R1's Tolvaptan was enroute from the (specialty) pharmacy and that the facility physician was aware. 6/3/19 6:58 PM- A physician H&P (history and physical) documented that R1's most recent sodium level (in the hospital) was 143 (Normal: 136-146). 6/3/19 7:16 PM- A progress note documented that the specialty pharmacy stated they needed more information and paperwork to be faxed to them. The note documented that R1's medication list and the requested paperwork was faxed to the specialty pharmacy and that the facility physician was aware. Despite prior notification to the NP and the physician regarding the unavailable medication the facility did not have any prior interventions in place to monitor R1's [MEDICAL CONDITION]. A physician order [REDACTED]. 6/4/19 2:33 PM- A progress note documented that the specialty pharmacy stated they would fax a form regarding the written prescription for R1's Tolvaptan medication and the physician was made aware. 6/4/19 4:00 PM- A progress note documented that the specialty pharmacy stated they now had all the information needed and that R1's Tolvaptan medication would be sent. It was noted that the specialty pharmacy would not give a time frame for when the medication would arrive and that the facility physician was aware that the medication was unavailable at that time. 6/4/19 8:57 PM- A progress note documented that R1's lab results were received and his/her sodium level was 126 (Normal Range: 136-146). The NP was made aware and gave an order for [REDACTED]. 6/5/19 12:10 PM- A progress note documented that the specialty pharmacy was called to follow up on R1's Tolvaptan delivery time. The pharmacist reported that they had all the required documents and the order was in process. It was noted that the process might take up to 24 hours. The physician was made aware. 6/5/19 4:12 PM- A progress note documented that R1's sodium level was 119 and the physician was made aware. 6/5/19 7:36 PM- A progress note documented that due to R1's 119 sodium level the physician gave a new order to send R1 to the ER for evaluation and treatment. R1 was sent to the hospital via ambulance at 5:45 PM. 6/5/19 7:54 PM- Review of R1's hospital record ED physician note revealed that the long term care facility had been unable to give R1 the Tolvaptan that was prescribed on discharge. It was noted that R1 had not received his/her Tolvaptan as prescribed since discharge from the hospital 5 days ago. The physician wrote that it was anticipated that R1 would be readmitted in order to restart the Tolvaptan medication and for the hospital to ensure upon discharge that R1 would be able to have Tolvaptan available (for administration at the nursing home facility). 6/5/19 8:11 PM- Review of R1's hospital lab results revealed that his/her sodium level was critical at 116. 6/5/19 8:19 PM- Review of R1's hospital discharge planning notes revealed that R1 presented in the ED because the nursing home never got a specific medication ordered and administered resulting in the steady decline of R1's sodium level. 6/25/19 1:32 PM- During a telephone interview, H2 (Hospital Floor Nurse) stated that she called report to the facility prior to R1's discharge from the hospital on [DATE]. H2 stated that she informed the facility nurse of the importance of R1's daily Tolvaptan medication. H2 stated that she spoke with H1 (Hospital Case Manager), and was told that the facility stated not to send R1's Tolvaptan medication, that they would get it from their pharmacy. 7/1/19 4:43 PM- Review of an email from E6 (Facility Pharmacy Services) to E1 (NHA) revealed that in regard to R1's Tolvaptan the specialty pharmacy notified the facility via fax and a follow up phone call on 6/1/19 at 8:55 AM, that it may take as long as 96 hours for the facility to receive the medication. There was no mention of the facility attempting to contact the hospital pharmacy per the hospital discharge summary instructions after they became aware how long it could take to get R1's medically necessary medication. 7/1/19 12:43 PM- During a telephone interview, H1 (Hospital Case Manager) stated that prior to R1's discharge from the hospital on [DATE] she spoke with E5 (Facility Liason). H1 stated that E5 was informed that R1 needed her Tolvaptan medication daily and that E5 never commented to her that the medication may be difficult to get. H1 stated that after R1 was discharged to the facility on [DATE] and they began to have difficulty getting the medication, the facility never contacted the hospital to try to obtain the medication. 7/1/19 3:14 PM- During an interview, E2 (DON) stated that the facility relied on the paperwork with discharge instructions that came with the resident from the hospital. Once the resident arrived at the facility, it was reviewed and orders were placed. E2 stated that she was not aware of any specialty medication for R1 prior to him/her arriving at the facility. E2 stated that before a resident gets admitted , they look at the resident clinically to see if they can provide the care for residents. E2 stated that medications are not an area that the facility takes into consideration prior to a resident's admission, therefore, the facility did not check to see if they would be able to get R1's Tolvaptan from their pharmacy prior to R1's admission. 7/2/19 9:28 AM- During a telephone interview, E5 (Facility Liason) stated that prior to R1's admission to the facility on [DATE], she screened R1 to make sure he/she was appropriate for the facility. E5 stated that she reviewed R1's medication list and was unfamiliar with one of his/her medications, Tolvaptan. E5 stated that she spoke with a hospital case manager about R1's Tolvaptan and was told that R1 needed it for his/her sodium levels. E5 stated that the hospital case manager told her that the medication was costly, but that the hospital had gotten prior authorization for a 90 day supply. E5 stated that she told E1 (NHA) this information. E5 stated that she was not aware that the facility had not received R1's Tolvaptan until R1 was readmitted to the hospital on [DATE]. 7/2/19 11:40 AM- During an interview, E1 (NHA) stated that E5 told her that R1's Tolvaptan had a prior authorization and she did not think there would be an issue getting the medication. E1 stated that the facility just knew the medication was expensive, not that it would be difficult to obtain. E1 stated that once the resident came she gave the authorization number to the nursing supervisor and later they found out that the medication needed to come from a specialty pharmacy. E1 stated that she did not know they could get the medication from the hospital pharmacy, and was unaware that on the hospital discharge summary that it stated to pick up R1's Tolvaptan medication at the hospital pharmacy. 7/9/19 11:15 AM- During a telephone interview, H3 (Nephrologist) stated that when R1 was in the hospital she did the prior authorization for R1's Tolvaptan medication. H3 stated that she spoke with hospital case management about the need for R1's Tolvaptan to be sent with him/her upon discharge. H3 stated that she specifically wrote on the discharge summary paperwork next to R1's Tolvaptan that the medication was to be picked up at the hospital pharmacy. H3 stated that the discharge summary should have been reviewed by the facility on admission, so they should have been aware that R1's Tolvaptan was to come from the hospital pharmacy. 7/2/19 1:46 PM- During a telephone interview, E4 (Medical Director) stated that he first saw the resident, after he/she was admitted on [DATE], on 6/3/19. E4 stated that at that point he did not know the resident at all, and did not know the severity of his/her SIADH and the importance of him/her taking Tolvaptan daily. E4 stated that he did get immediate lab work on R1 and filled out the paperwork to get R1's Tolvaptan prescription from the speciality pharmacy, once it was known that the medication was unavailable at the facilities regular pharmacy. E4 stated that once R1's sodium dropped to 119 he sent him/her to the hospital because he/she needed to be monitored since R1 had the potential for adverse reactions. E4 stated that as a facility retrospectively they now know the importance of R1's Tolvaptan, and the hospital knowing this information should have made every effort to notify the facility of the importance. E4 stated the hospital should have stated it could be picked up at their pharmacy or sent R1 to the facility with the medication until the facility could sort it out. When asked by the surveyor if he reviewed R1's hospital discharge paperwork that stated that the Tolvaptan could be picked up at the hospital pharmacy, E4 stated that he did not remember seeing that information. 7/2/19 at 4:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference. The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan, as evidenced by the facility's failure to assess R1's medication needs prior to admission and on admission to ensure that they could provide the care and services necessary to treat R1's [MEDICAL CONDITION] (low sodium). The facility was aware prior to admission that R1 required the medication Tolvaptan in order to keep his/her sodium levels within normal limits. On 5/31/19, when R1 was admitted to the facility, they received a discharge summary from the hospital with instructions stating to pick up R1's Tolvaptan medication at the hospital pharmacy. The facility failed to review the discharge summary/instructions and failed to obtain R1's Tolvaptan medication which resulted in harm to R1 when his/her sodium levels dropped to a critical range, and R1 had to be readmitted back to the hospital on [DATE] for [MEDICAL CONDITION] after not receiving Tolvaptan for 5 days. 2. Review of R2's clinical record revealed: Physician orders [REDACTED]. 5/30/19 - [MEDICATION NAME] Suppository insert rectally every 24 hours as needed for constipation one time a day. 5/30/19 - [MEDICATION NAME] Sodium Liquid via PE[DEVICE] every 12 hours as needed for constipation. 5/30/19 - GaviLAX Powder (Polyethylene [MEDICATION NAME] 3350) give via PE[DEVICE] every 24 hours as needed for constipation. 6/13/19 - Milk of Magnesia Suspension give via PE[DEVICE] every 24 hours as needed for constipation daily if no BM (bowel movement) in 3 days. 6/13/19 - Senna Syrup give via PE[DEVICE] at bedtime for constipation. 5/31/19 - A care plan was developed for the problem of being at risk for constipation with a goal to have no complications related to constipation. Interventions included, report signs and symptoms of constipation, such as no bowel movement for three days, and treatment per physician's orders [REDACTED]. Review of R2's (MONTH) 2019 Documentation Survey Report revealed that he/she had a bowel movement on 6/4/19 at 1:03 AM, and then no other bowel movement until 6/10/19 at 1:14 PM, approximately 14 shifts later. Review of R2's (MONTH) 2019 MAR indicated [REDACTED]. On 7/2/19 at approximately 11:30 AM, during an interview, E2 (DON) confirmed that no interventions were implemented for R2 for constipation during the above dates. Findings were reviewed with E1 (NHA) and E2 (DON) on 7/2/19 at the exit conference.

Based on observation, clinical record review, interviews, review of the facility's policy and procedures, and review of other facility documentation as indicated, it was determined that the facility failed to ensure emergency equipment was available for accidental extubation for 2 (R1 and R2) out of 2 active residents in the sample with tracheotomies. The lack of available emergency equipment, in addition to the lack of competent trained staff in [MEDICAL CONDITION] care posed an immediate jeopardy (IJ) situation to residents with tracheostomies. The IJ was identified on [DATE] at 10:15 AM and abated on [DATE] at 10:30 AM. In addition, it was determined that the facility failed to ensure that 1 (R3) out of 3 (2 active and 1 closed record) residents in the sample received [MEDICAL CONDITION] care, consistent with professional standards of practice and comprehensive person-centered care plan. Despite the R3's history of [MEDICAL CONDITION] and a complaint of respiratory distress, the facility failed to complete an assessment of R3's respiratory distress, including evaluation of lung sounds and vital signs and failed to notify the R3's attending physician. This failure resulted in harm, in which R3 was found unresponsive with no pulse and no respiration. Findings include: 1a. EMERGENCY EQUIPMENT: The facility's policy and procedure, titled [MEDICAL CONDITION] Care, with the most recent revision date of ,[DATE] indicated a spare [MEDICAL CONDITION] (trach) tube of the same size and type and an Ambu bag should be kept at the bedside for each resident for emergency purposes. [DATE] at approximately 9:50 AM - During an interview with E2 (DON), confirmed for each resident with [MEDICAL CONDITION], a [MEDICAL CONDITION] and an Ambu-bag should be kept at the resident's bedside. [DATE] at approximately 10:15 AM - An observation of two current residents with tracheostomies, R1 and R2, was conducted with E2 (DON). E2 confirmed R1's room did not have a [MEDICAL CONDITION], however, an Ambu bag was at the bedside. Observation of and interview confirmed R2's room did not have a [MEDICAL CONDITION] or an Ambu bag. E2 reported the lack of emergency equipment to E4 (RN, UM) who proceeded to clarify the type of the tube needed. Subsequently, E2 proceeded to the central supply room, located in the lower floor of the building, where [MEDICAL CONDITION] were located. E2 brought [MEDICAL CONDITION] to E4, who was in the process of clarifying the specific size and type for each of the residents, through chart review. Subsequently, E4 obtained an order for [REDACTED]. 1b. COMPETENT TRAINED STAFF: The facility's policy and procedure, titled [MEDICAL CONDITION] Insertion/Reinsertion, with the most recent revision date of ,[DATE] indicated only licensed nurses or respiratory therapists may reinsert the tube to restore the airway. [DATE] at approximately 1:00 PM - During a subsequent interview with E2 (DON), the surveyor was informed, for accidental extubation, any licensed nursing staff, after competencies for inserting a [MEDICAL CONDITION] have been completed, may insert a [MEDICAL CONDITION]. E2 related the competencies are completed upon hire and on an annual basis. The surveyor requested evidence of the competencies for all licensed nursing staff. [DATE] from approximately 1:20 PM to 1:45 PM - Surveyor interviewed the following licensed nursing staff, E6 (RN, UM), E11(RN), E12 (RN), and E13 (LPN). Each of the staff reported that they have had education related to care of [MEDICAL CONDITION] including suctioning, however, all four staff verbalized that they have not had education related to insertion of [MEDICAL CONDITION] when accidental extubation occurs. [DATE] at 3:21 PM - Interview with E1 (NHA) was conducted. E1 was advised that the lack of emergency equipment and lack of competent trained staff for insertion of a [MEDICAL CONDITION] was an Immediate Jeopardy citation. Findings were confirmed with E1. [DATE] at 3:22 PM - The facility initiated one on one staff observation and monitoring of R1 and R2. [DATE] at approximately 3:22 PM - The facility initiated coordination of training to be provided by E9 (Registered Respiratory Therapist/RRT). [DATE] at approximately 5:00 PM - Training for the first group of licensed nursing staff, to include nursing leadership staff was initiated by E9 (RRT). [DATE] at approximately 8:30 PM - The facility had evidence of competent trained staff for the evening shift, 3:00 PM - 11:00 shift and the night shift, 11:00 PM - 7:00 AM. In addition, a written plan to train remaining licensed nursing staff was developed. [DATE] at 8:30 PM - The one on one observation and monitoring of R1 and R2 was terminated. [DATE] at approximately 10:30 AM - The facility had abated the IJ with 76% of the licensed nursing staff trained. [DATE] approximately 3:15 PM - Above findings were reviewed with E1(NHA), E3 (ADON), E4 (RDOO), and E5 (QAC). The facility failed to ensure that: -appropriate supplies were available at the bedside for these residents [MEDICAL CONDITION]; -staff were trained and competent in providing care [MEDICAL CONDITION] becomes dislodged. 2. [MEDICAL CONDITION] CARE. Review of facility's policy titled, Respiratory: Nebulizer Mist Therapy, dated ,[DATE], indicated, prior to and post administration of the nebulizer treatment, to assess lung fields and heart rate. Review of R3's clinical record revealed the following: [DATE] - R3 was readmitted to the facility, from the hospital following treatment for [REDACTED]. R3's additional [DIAGNOSES REDACTED]. [DATE] - A care plan for risk of respiratory impairment related to [MEDICAL CONDITION] had a goal that patency of R3's airway will be maintained for the next 90 days. This care plan included the most recent revision date of [DATE]. Interventions included: - Evaluate lung sounds and vital signs as needed. Report abnormalities to physician. - Position as upright as possible for meals and afterwards. - Obtain pulse oximetry and report abnormal findings. - Administer medications/treatments per physician orders. - Elevate head of bed. - Suction per physician order. -[MEDICAL CONDITION] per protocol. - Maintain [MEDICAL CONDITION] and Ambu bag at bedside. The above care plan did not include the type and size of the airway. In addition, the specific risks for complications including mucous plug, including signs of an obstructed airway or the need for suctioning were not addressed in the care plan. These signs may include secretions draining from mouth or trach., inability to cough to clear chest, audible crackles or wheezes, dyspnea, restlessness or agitation. [DATE] - Medication Review Report (A summary of current orders) included the following: - Clean [MEDICAL CONDITION] daily with water, apply [MEDICATION NAME] (medicated)ointment and [MEDICAL CONDITION] every day. - Cool air mist [MEDICAL CONDITION] with oxygen at 6 liters per minute and check pulse ox every shift. - [MEDICAL CONDITION] shift and as needed. -[MEDICAL CONDITION] daily and as needed, remove and dispose of inner cannula and replace with new inner cannula every shift. [DATE] - The ENT Specialist Consultation, by E19 (ENT MD) documented the reason for consultation as, working on decannulation. The documentation included the following recommendations: -Try plugging with red cap at half an hour intervals to exercise lungs and force air up and out through mouth. Try for longer capped intervals of up to ,[DATE] hours if possible. - Light sedation, [MEDICATION NAME] 0.25 mg., half an hour before 8:00 AM appointment on [DATE]. The documentation included the initial's of R3's attending physician (E20), indicating agreement with the recommendations. Record review indicated that the facility lacked a policy to ensure transcription and implementation of consultant physician order [REDACTED]. [DATE] through [DATE] - Review of Treatment Administration Record (TAR) lacked evidence of plugging schedule of the trach. tube with a red cap, as recommended by E19 (ENT MD). [DATE] - Medication Administration Record [REDACTED] - Suctioning: The MAR indicated [REDACTED]. -[MEDICAL CONDITION]: The MAR indicated [REDACTED]. [DATE] - The subsequent E19 (ENT MD) Consultation documentation, included the reason for consultation as, Planning decannulation. The documentation included the following recommendations: -[MEDICAL CONDITION] 8:30 AM on [DATE] - Try to maintain plug for at least 24 hours, check oxygen saturation every 8 hours during the day and every ,[DATE] hours at night. - When plugged, keep in room humidifier. When open with cannula [MEDICAL CONDITION] with oxygen 21% in room humidity. - Administer [MEDICATION NAME] 2.5 mg nebulizer every 8 hours. - If patient fails 24 [MEDICAL CONDITION] trial, unplug and try plugging at 08:00 tomorrow; call E19 for information. The above document included E20's (attending physician) initial, an indication that he was in agreement with the recommendation. In addition, this document contained a handwritten comment of DONE. Record review indicated that the facility lacked a policy to ensure transcription and implementation of consultant physician order [REDACTED]. Specifically, record review lacked evidence that the following orders were transcribed and implemented: - When plugged, keep in room humidifier. When open with cannula [MEDICAL CONDITION] with oxygen 21% hi humidity. - If patient fails 24 [MEDICAL CONDITION] trial, unplug and try plugging at 08:00 tomorrow; call me for information. [DATE] and timed 4:00 PM - MAR indicated [REDACTED]. [DATE] from 3:00 PM to 11:00 PM - Review of Progress Note revealed no documentation was completed for this period of time. [DATE] at 00:18 AM and 4:08 AM - Pulse ox reading of 97 % and 96% respectively [MEDICAL CONDITION]. [DATE] and timed Midnight - MAR indicated [REDACTED]. [DATE] from 11:00 PM to [DATE] at 7:00 AM - Review of Progress Note revealed no documentation was completed for this period of time. [DATE] from 7:00 AM through 2:15 PM - Review of Progress Note revealed no documentation was completed for this period of time. [DATE] and timed 8:00 AM - MAR indicated [REDACTED]. [DATE] and timed 2:16 PM - Progress Note by E21(LPN), documented resident expired. [DATE] and timed 2:49 PM - Progress Note by E17 (RN Supervisor) documented at 11:10 AM, E17 was called to R3's room by nurse who stated that R3 was unresponsive. Upon assessment, patient noted with no respirations, no pulse noted on auscultation and blood sugar of 358. CPR was initiated at 11:12 AM, AED applied and 911 called, no shock advised by AED and CPR continued until paramedics arrival at 11:22 AM. [DATE] at approximately 2:45 p.m. - An interview with E21 (LPN), who was assigned to R3 during the days shift on [DATE], revealed that she was told by another nurse that R3 was complaining of respiratory distress. E21 proceeded to administer the scheduled [MEDICATION NAME] treatment at approximately 7:30 a.m. The resident's pulse ox before and after the treatment was 96%. No additional assessments of the lung fields or heart rate were conducted before or after the treatment. E21 did not feel that any additional assessments were necessary since she did not hear wheezing or notice any visual signs of respiratory distress; in addition, E17 (RN Supervisor) had stated that R3 reported Feeling better. Despite the resident's history of [MEDICAL CONDITION] and a complaint of respiratory distress, E21 Failed to complete an assessment of R3's respiratory distress. In addition, the care plan for risk of respiratory impairment (last revised [DATE]) included an intervention to evaluate lung sounds and vital signs as needed. E21 Failed to assess lung sounds and vital signs. [DATE] at approximately 4:00 PM - A copy of the facility's written statement dated [DATE] was provided to the surveyor. This documentation indicated E21 (LPN) was interviewed by E3 (ADON). In summary, the statement documented that R3 was on the phone with her daughter and E21 proceeded to provide breathing treatment and R3's pulse ox was 96% and R3 was not exhibiting signs or symptoms of respiratory distress. At the conclusion of this statement, E21 asked E25 (CNA) about the last time E25 saw R3 and E25 reported she was not aware of the time but that R3 stated to E25 that she was hot so she turned the air on. [DATE] at 10:25 AM - Surveyor received a written communication from FM1 (Family Member 1), regarding the telephone contact made by another family member, FM2 on [DATE] as follows: - 9:15 AM: Telephone call to R3, which was FM2's daily routine. R3 stated she was having problems breathing. FM2 called the nurses station to inform them that room [ROOM NUMBER] was having problems breathing. Whoever answered, said they would give her (R3) a breathing treatment and FM2 said ok. - At approximately 10:00 AM: FM2 called R3 back, and R3 said she felt a little better. - At approximately 11:15 AM: FM2 called R3 and did not get an answer, so FM2 called the nurses station and spoke with (Name of E17 RN Supervisor) and FM2 asked him if R3 was walking the hall because she was not answering the phone. (Name of E17) stated your mother just left my station and she's going to lay down. FM2 told (Name of E17) something is wrong, because that is not her routine. FM2 told (Name of E17) you need to go check on her!! - Approximately 15 minutes later, 11:30 AM: FM2 received a call from (Name of the Facility) that they were doing CPR on R3. FM2 stayed on the phone and refused to hang-up until FM2's family (Name) arrived. [DATE] at approximately 12:40 PM - An interview with E17 (RN Supervisor) was conducted. E17 reported that [MEDICAL CONDITION] was plugged at approximately 10:00 PM on [DATE], after R3 returned to the facility from a family outing. E17 indicated that the resident was not experiencing respiratory distress but was tired, thus, the cap was removed. In addition, E17 was the RN supervisor during the day shift on [DATE]. E17 recalled during shift report from the night shift nurse, E22 (RN) that R3 had no respiratory distress and [MEDICAL CONDITION] remained unplugged the entire shift. E17 related he only had one telephone conversation with R3's family member, (FM2) in which FM2 asked whether E17 had seen R3 since R3 was not answering her telephone in her room. E17 reported to FM2 that the resident was recently at the Nursing Station, however, R3 has returned to her room. E17 reported that FM2 did not verbalize, during the telephone call to check on R3. Subsequent to this telephone conversation, E17 verbalized he was informed by E21 (LPN) that R3 was unresponsive, he had assessed the resident and the resident was without respiration or pulse. E17 reported that he visually checked for obstruction of [MEDICAL CONDITION] and there was no obstruction, however, E17 was uncertain if the inner cannula remained in [MEDICAL CONDITION]. E17 indicated that the CPR was being completed by E21 and E22 (LPN). [DATE] at approximately 10:00 AM - An interview with E25 (CNA) was conducted. E25 was assigned to R3 and verbalized that R3 was visibly upset towards beginning of the shift because R3 did not receive her breakfast and E25 proceeded to obtain and provide the breakfast to R3. Upon consuming her breakfast, R3 activated the call bell and E25 responded. R3 complained of being hot to E25 and was using her upper extremities to fan herself. E25 related that this was a change for R3 since R3 usually complains of being cold. E25 proceeded to turn the air conditioner on and set it to 65 degrees and reported R3's complaint to E21(LPN). Approximately 5 minutes afterwards, E25 checked R3 and R3 again complained of being hot and E25 further lowered the AC. The next time E25 observed R3 sitting up in bed with eyes open. Record review revealed no documentation of respiratory distress and no documentation that resident was so hot that she was using her upper extremities to fan herself. The Facility failed to identify these complaints as a significant change in condition and failed to notify R3's attending physician. [DATE] approximately 3:15 PM - Above findings were reviewed with E1(NHA), E3 (ADON), E4 (RDOO), and E5 (QAC). [DATE] at approximately 2:30 PM - A subsequent interview with E21 (LPN) revealed that E21 had initiated the compression portion of the CPR on [DATE] and related that E21 did not visually check for obstruction in the trach. tube. prior to initiating CPR. [DATE] at approximately 3:24 PM - An interview with E22 (LPN) revealed that E22 was the staff who provided oxygenation during the CPR on [DATE] and E22 verbalized she did not visually check for obstruction when R3 was found unresponsive. Surveyor inquired if any other licensed staff visually checked for obstruction in the trach. tube and E22 related that she was uncertain. [DATE] at approximately 2:30 PM - An interview with E3 (ADON), confirmed the facility failed to transcribe the recommendations from E19's Consultation dated [DATE] and [DATE], thus, these orders were not implemented. The Facility failed to: - Accurately and completely assess R3 after a compliant of respiratory distress. - Accurately and completely assess R3 after a complaint of feeling hot. - Report a change in condition (respiratory distress and feeling hot) to the physician. This failure resulted in harm - R3 was found unresponsive with no pulse or respirations.

Based on observation, record review, interview, and review of other documents as indicated, it was determined that for two (R217 and R274) out of 42 Stage 2 sampled residents, the facility failed to provide care and services to prevent PUs from developing and failed to thoroughly assess a PU. For R217, the facility failed to ensure the resident, who entered the facility without a PU, did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. The facility failed to: develop a specific turning and repositioning schedule for R217, who was identified at risk for developing PUs; failed to identify an area of pressure until it presented as suspected deep tissue injury (DTI); and failed to offload R217's heels in an attempt to prevent PUs from developing. For R274, the facility failed to identify her sacral PU on the 5/4/16 admission skin assessment and failed to stage her sacral PU identified on the 5/5/16 skin assessment until 5/11/16. Findings include: The facility's Skin Practice Guide, issue date 01/2013, states: .Prevention Interventions Reposition frequently in bed and chair Rehabilitation team consultations .Elevate heels Select appropriate support surfaces Complete thorough skin observations .Skin Observations Nursing assistants perform daily skin observations with routine care. The Skin Worksheet is completed by the nursing assistant at least two times per week with the patient's bath (shower, tub, bed). Results are submitted to the licensed nurse for review and follow-up as needed .Note: The Skin Worksheet is a communication tool and is not maintained as part of the clinical record .Positioning, Mobility, Restraints .elevate or float heels, even if patient is on specialty support surface . The International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel) Clinical Practice Guideline, second edition published 2014, Pressure Ulcer Classification System identifies six (6) categories/stages. Two (2) of those categories/stages are: - Unstageable: Depth Unknown - Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. - Suspected Deep Tissue Injury (sDTI): Depth Unknown - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue .Pressure Ulcer Assessment .3. Assess and document physical characteristics including: location, category/Stage, size, tissue type (s), color .exudate, and odor .General Repositioning for All Individuals 1. Reposition all individuals at risk of, or with existing pressure ulcers, unless contra-indicated .Repositioning Frequency 1. Consider the pressure redistribution support surface in use when determining the frequency of repositioning .2. Determine repositioning frequency with consideration to the individual's tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort .3. Establish pressure relief schedules that prescribe the frequency and duration of weight shifts .4. Regularly assess the individual's skin condition and general comfort .Frequent assessment of the individual's skin condition will help to identify the early signs of pressure damage and, as such, her/his tolerance of the planned repositioning schedule. If changes in skin condition should occur, the repositioning care plan needs to be re-evaluated .Repositioning To Prevent And Treat heel Pressure Ulcers .The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. General Recommendations 1. Inspect the skin of the heels regularly .Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed .Ideally, heels should be free of all pressure - a state sometimes called 'floating heels' .Continue to reposition individuals placed on a pressure redistribution support surface . 1. Review of R217's clinical record revealed the following: 12/8/15 - R217 was admitted to the facility following hospitalization for b/l thalamic infarcts. 12/9/15 3:52 AM - Braden Scale completed and identified R217 as being at moderate risk for skin breakdown. 12/9/15 4:12 AM - admission progress note states R217 is alert to self, non verbal but blinks eyes appropriately to simple questions, has a Peg tube for feeding and requires total assistance with ADLs. 12/9/15 3:47 PM - Skin progress note completed by WCN stated, Skin assessment completed .requires total assist of staff for ADLs .An area of pink closed scarred tissue without drainage is present to the right Achilles. Bony prominences and skin folds are free of abnormality . 12/9/15 - Care Plan developed for At risk for alteration in skin integrity related to: incontinence, impaired mobility, cognitive loss, DM, Braden score of 11. Interventions included: APM mattress to bed/cushion to w/c; Diet and supplements per physician order; Encourage to reposition as needed; Float heels as able; Observe skin condition with ADL care daily; report abnormalities; Prevalon boots while in bed; Use pillows/positioning devices as needed. Although an at risk for skin integrity impairment care plan was developed, the facility failed to specify the frequency of turning and repositioning. 12/15/15 - The admission MDS assessment stated that during the seven (7) day review period R217: - had unclear speech; - daily decision making skills were severely impaired; - required extensive assist from two (2) staff for bed mobility and toilet use; - did not ambulate in room or corridor; - had a feeding tube that provided 51% or more of total calories received; - was at risk of developing PU, but did not currently have any PU; - had a pressure reducing device for chair/bed. The CAA portion of the 12/15/15 admission MDS assessment triggered pressure ulcer as a potential problem area. 12/25/15 - Braden Scale was completed and now identified R217 as being at high risk for development of pressure ulcers. 1/8/16 - A Body audit was signed off as completed on the ETAR. There was no evidence of any skin issues noted in the clinical record. Review of the electronic Documentation Survey Report, completed by CNAs, for repositioning and/or toileting revealed that on the following dates and times R217's repositioning exceeded three (3) hours: 1/8/16 - repositioned and/or toileted at 6:00 AM and then not until 2:57 PM, approximately nine (9) hours; 1/9/16 - repositioned and/or toileted at 2:36 AM and then not until 6:14 AM, approximately four (4) hours; 1/9/16 - repositioned and/or toileted at 11:39 AM and then not until 3:45 PM, approximately four (4) hours; 1/9/16 - repositioned and/or toileted at 3:45 PM and then not until 7:39 PM, approximately four (4) hours; 1/9/16 - repositioned and/or toileted at 10:22 PM and then not until 1:15 AM on 1/10/16, approximately three (3) hours; 1/10/16 - repositioned and/or toileted at 3:55 PM and then not until 7:11 PM, approximately three (3) hours; 1/10/16 - repositioned and/or toileted at 7:11 PM and then not until 10:38 PM, approximately three (3) hours; 1/11/16 - repositioned and/or toileted at 3:10 AM and then not until 6:11 AM, approximately three (3) hours; 1/11/16 - repositioned and/or toileted at 6:11 AM and then not until 12:59 PM, approximately six and one half (6 and 1/2) hours; 1/11/16 - repositioned and/or toileted at 12:59 PM and then not until 4:25 PM, approximately three and one half (3 and 1/2) hours; 1/11/16 - repositioned and/or toileted at 4:25 PM and then not until 7:29 PM, approximately three (3) hours; 1/11/16 - repositioned and/or toileted at 7:29 PM and then not until 10:30 PM, approximately three (3) hours; 1/12/16 - repositioned and/or toileted at 12:59 AM and then not until 6:23 AM, approximately five and one half (5 and 1/2) hours; 1/12/16 - repositioned and/or toileted at 10:20 AM and then not until 1:35 PM, approximately three (3) hours; 1/12/16 - repositioned and/or toileted at 7:26 PM and then not until 12:15 AM on 1/13/16, approximately five (5) hours; 1/13/16 - repositioned and/or toileted at 12:15 AM and then not until 5:32 AM, approximately five (5) hours; 1/13/16 - repositioned and/or toileted at 5:31 AM and then not until 9:32 AM, approximately four (4) hours; 1/13/16 - repositioned and/or toileted at 9:32 AM and then not until 2:59 PM, approximately five and one half (5 and 1/2) hours; Review of the CNA's electronic Documentation Survey Report revealed R217 had bed baths on 1/8/16 at 2:57 PM and on 1/12/16 at 2:36 PM. There was no evidence in the clinical record that any skin issues had been identified. 1/13/16 at 4:44 PM - A progress note stated, Patient with suspected deep tissue injury to bilateral heels. Left medial heel area of (sic) dark purple tissue that is intact skin measuring 2.2 x 2.8 cm. Right heel medial dark purple area that is dry and callused area of intact skin. Patient with recent [MEDICAL CONDITION]. decreased mobility .Prevalon boots in place on feet, APM in place on bed, therapy eval to improve mobility. Nutrition is managed with tube feeding. Review of progress notes, EMARs, ETARs, and CNA Documentation Survey Reports from 12/8/15 through 1/13/16 lacked evidence of the use of Prevalon boots and/or offloading of the heels. According to the 12/9/15 at risk for skin impairment care plan, staff were to monitor and report any skin abnormalities. Despite this intervention, the b/l heel wounds were not identified until they were sDTI. 1/14/16 - blood test for [MEDICATION NAME] level was completed and results were within normal range. 1/15/16 - The Kardex Task History has entry Prevalon boots, remove only for hygiene. 1/15/16 - Ultrasound report stated The ankle brachial indices (ABI) are normal bilaterally. 1/24/16 - PT Discharge Summary stated D/C Reason: Achieved Highest Practicable Level and that upon discharge R217 was totally dependent without any attempts to initiate bed mobility. 6/6/16 at 2:55 PM - Observation with E13 (RN) noted R217 to be in bed, lying on her back, asleep. R217 did have b/l Prevalon boots on, however, it was noted that the left boot was not applied properly. The resident's foot was turned inward inside the boot causing the left lateral heel to be in direct contact with the inner boot. The boot was to be positioned so that R217's heel was in the open area of the boot, thus providing a floating heel. E13 proceeded to correct the positioning of R217's left Prevalon boot. 6/7/16 at approximately 3:30 PM - During an interview E2 (DON) stated that when Body audits are completed the nurse initials the ETAR signifying it was completed. If there are no new findings then that is all they document, but if there are new findings then they must complete either a pressure ulcer document in PCC or the paper copy for non pressure ulcer skin issues. E2 also stated that if there is a skin issue identified then a progress note should be written in PCC. 6/9/16 at approximately 1:10 PM - findings were reviewed with E2 and E15 (Corporate RN/NHA). The facility failed to provide evidence of use of the Prevalon boots despite a care plan intervention for same, and they failed to implement an individualized turning and repositioning schedule for R217, who was identified a high risk for the development of pressure ulcers. 2. Review of R274's medical record revealed: R274 was admitted to the facility on [DATE] at 3:30 PM. The admission nurse's note, dated 5/4/16 and timed 6:58 PM, stated that R274 was alert and oriented and a body audit was completed with no open skin areas noted. The admission skin assessment, dated 5/4/16 and timed 7:23 PM, stated that R274 did not have an existing pressure ulcer (PU). The facility's Pressure Ulcer form, dated 5/5/16 and timed 1:10 PM, identified that R274 had an existing PU on her sacrum. A nurse's note, dated 5/5/16 and timed 1:12 PM, stated that R274 was alert and oriented and could make her needs known to staff. A second skin assessment was completed on 5/5/16, which revealed that R274 had an open area on her sacrum measuring 0.8 x 0.6 x 0.2 cm in size with 50% slough in the wound bed. R274 stated to E3 (Wound Care RN) that the open area on her sacrum had been there for a couple of days. It was unclear how the facility failed to identify the PU on R274's sacrum during the 5/4/16 admission skin assessment. A nurse's note, dated 5/11/16 and timed 3:03 PM, stated that R274's sacral PU was unstageable and measured 0.6 x 0.6 cm in size with 100% slough in the wound bed. It was unclear why it took the facility seven (7) days since admission to stage R274's sacral PU. In an interview on 6/9/16 at 9:09 AM, E4 (RN, UM) confirmed that R274's sacral PU was not identified during the 5/4/16 admission skin assessment. In an interview on 6/9/16 at 9:40 AM, E3 (Wound Care RN) confirmed that she did not stage R274's sacral PU when it was identified on the 5/5/16 skin assessment. The sacral PU was staged on 5/11/16. Findings were reviewed with E2 (DON) on 6/9/16 at 1:40 PM. The facility failed to identify R274's sacral PU on the 5/4/16 admission skin assessment. In addition, the facility failed to stage the sacral PU identified on the 5/5/16 skin assessment until 5/11/16.

Based on record review, observation, interview and review of other documentation as indicated, it was determined that the facility failed to ensure that one (R18) resident out of 30 Stage 2 sampled, who entered the facility without a pressure sore did not develop an avoidable pressure sore. Additionally, the facility failed to ensure that a resident having pressure sores receives the necessary care and services to promote healing, prevent infection and prevent new sores from developing. Findings include: The facility's Skin Practice Guide, issue date 01/2013, stated risk factors for the development of pressure ulcers included immobility, friction and shear forces and excessive moisture conditions. Prevention Interventions included Reposition frequently in bed and chair, use barrier cream products, manage continence with toileting programs, use patient positioning device to reduce friction and shear, select appropriate support surfaces, and complete thorough skin observations. Initial evaluation included, review the hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development.The Braden Scale.used to identify potential levels of risk for pressure ulcer development.The Braden Scale is completed for four (4) weeks total (at the time of admission and then weekly for the next three (3) weeks), quarterly, with a significant change and as clinically indicated.even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially if their condition changes.A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown that do not have a pressure ulcer. Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the Treatment Administration Record . According to the NPUAP prevention interventions included: Reposition frequently in bed and chair; manage incontinence with toileting programs; use patient positioning devices to reduce friction and shear; and complete thorough skin observations. R18 was admitted to the facility on [DATE], from an out of state facility, with [DIAGNOSES REDACTED]. Review of R18's discharge instructions from the out of state facility included a physician's orders [REDACTED]. This area was healed at the time of R18's transfer. The facility Patient Admission screen, dated 1/29/15 and timed 7:14 PM, stated in the area of skin assessment, coccyx slight red area.right buttock redness of 7 cm x 0.2, left buttock red area 3cm x 3 cm, left buttock redness 6cm x 1 cm and right thigh (rear) red area measuring 2.8cm x 0.2. This skin assessment failed to note the measurement of the red area on the coccyx, and failed to identify whether all the reddened areas were blanchable or non-blanchable. The Braden Scale, dated 1/29/15, indicated R18's score was 16, or low risk (score of 15 to 18) for skin breakdown. A physician's orders [REDACTED]. The facility initiated care plan #1, dated 1/30/15, for At risk for alteration in skin integrity related to: incontinence, impaired mobility, recent surgery. The care plan goals were Skin will remain intact, free from [DIAGNOSES REDACTED], breakdown, excoriation or bruising. Interventions included: barrier cream to peri-area/buttocks as needed; Encourage to reposition as needed; use assistive devices as needed; float heels as able; Observe skin condition with ADL care daily, report abnormalities; provide preventative skin care routinely and prn; Use pillow/positioning devices as needed. This care plan did not address R18's history of a healed Stage 2 pressure sore on the sacrum and the potential problem for friction and shear to include individualized interventions such as Reposition frequently in bed and chair, Manage incontinence with toileting programs, Use patient positioning device to reduce friction and shear and complete thorough skin observations. A progress note, completed by E3 (WCN) on 1/30/15 and timed 2:49 PM stated, Skin assessment completed.bilateral buttocks are red and blanchable.The right heel is noted with a non-blanchable reddened area medially measuring 3x3cm in size. The left posterior lateral heel is also noted with a non-blanchable reddened area measuring 5x6cm in size.remaining bony prominences free of abnormality.requires assist of one to turn side to side in bed. A progress note completed by E3, dated 2/4/15 and timed 2:28 PM, stated Stage 1 pressure ulcers to bilateral heels noted resolved. According to R18's admission MDS assessment, dated 2/5/15, this resident's skills for daily decision-making were severely impaired and she was always incontinent of bowel and bladder. This same MDS stated R18 required extensive assist of two (2) staff for bed mobility and transfer, and extensive assist of one(1) staff for eating, toilet use and hygiene. R18 did not walk in the room or corridor and was noted to have a functional limitation in range of motion of both upper and lower extremities on both sides of the body. The 2/5/15 MDS assessment also stated R18 was at risk for developing a pressure ulcer and had two (2) Stage 1 pressure ulcers (right and left heels according to the 1/30/15 skin assessment note). 2/5/15 - Review of the February TAR revealed that the body audit was signed off as completed. A progress note, dated 2/9/15 and timed 11:24 AM, stated .assisted with shower skin intact No open areas. A progress note, dated 2/11/15 (Wednesday) and timed 3:18 PM, stated .0.3cm (length) x 0.3cm (width) excoriation observed on right lateral buttock, new order received.to apply Z-guard. A Skin Alteration Record (not used for assessment of pressure ulcers) was initiated on 2/11/15 for Excoriation Right Lateral buttock and was to be completed weekly according to directions on the record and the facility Skin Practice Guide. Review of the EMR for CNA documentation revealed that although Z-Guard was listed on 2/11/15 as part of the tasks they were to complete, it was not designated as a task that required a signature when completed. 2/12/15 and 2/19/15- Review of the February TAR revealed that the body audits were signed off as completed. Review of the Skin Alteration Record for the right lateral buttock excoriation revealed that the next assessment was not completed until 2/25/15, two (2) weeks later. Review revealed that the size had increased to 0.5cm x 0.5cm. 2/26/15 - Review of the February TAR revealed that the body audit was signed off as completed. The Skin Alteration Record for the right buttock excoriation was next completed on 3/2/15, five (5) days later and the documented size was 0.6cm x 0.8 cm, again increasing in size. A progress note, dated 3/2/15 and timed 2:22 PM, stated Excoriated area on right buttock no (sic) resolving and increase in size (0.6x0.8cm), new order received from MD to apply [MEDICATION NAME] every three (3) days.treatment administered as ordered. A physician's orders [REDACTED]. This order was transcribed onto R18's TAR. Review of the TAR revealed the right buttock treatment was signed off as completed on 3/6/15, four (4) days after the initial treatment on 3/2/15, instead of three (3) days as ordered. The treatment failed to be signed off for 3/9/15 and was not signed off until 3/12/15, resulting in a total of five (5) days between treatments. Review of progress notes revealed no mention of the right buttock area during this time frame. The EMR lacked evidence that treatments were completed as ordered. The next Skin Alteration Record was dated 3/18/15 and noted a size of 0.5 cm x 0.5 cm with a scant amount of clear serous drainage and the skin surrounding the alteration was firm/hard. However, this document failed to identify what area was being assessed. Additionally, there was no evidence that the physician and/or WCN were notified regarding the changes of the area. There was no evidence that a Skin Alteration Record was completed between 3/2/15 and 3/18/15 a 16 day time frame. Review of the TAR revealed the right buttock treatment was signed off completed as ordered from 3/12/15 through 3/21/15. On 3/24/15 the treatment was not signed off as completed. The next treatment signed off as completed was on 3/27/15, resulting in a total of five (5) days between treatments. The facility failed to consistently complete wound treatments as ordered. The next Skin Alteration Record (same document used for the 3/18/15 weekly assessment that failed to identify the area being assessed), dated 4/8/15, noted a size of 2 cm x 2 cm with reddened skin surrounding the alteration. There was no evidence that the skin alteration on the right buttock had been assessed for three (3) weeks from 3/18/15 through 4/8/15. Review of progress notes from 3/18/15 through 4/7/15 lacked any mention of the right buttock skin alteration. A Skin progress note (Late Entry), dated 4/8/15 and timed 5:00 PM, stated Open area on right buttock measures 4.6 x 2.8 cm. Tissue type is 40% granulation, 50% dark yellow slough, 10% necrotic. Wound is moist with drainage that is light blue green. Discussed with (name of physician) new treatment order given. Although a Skin Alteration Record was completed on 4/8/15 (did not identify area being assessed), it did not match the findings listed in the 4/8/15 progress note regarding the right buttock area. This record stated the size was 2cm x 2 cm, pale pink tissue, no drainage, and surrounding skin reddened. Additionally, on 4/8/15 the facility began to utilize the PUSH Tool, signifying that the right buttock wound was now being classified as a pressure ulcer. The PUSH Tool score on 4/8/15 was equal to 15. The discrepancy between the two (2) assessment tools completed on 4/8/15 by different staff leads to concerns regarding accuracy and validity of the assessments prior to 4/8/15. The new treatment order, dated 4/10/15, stated Cleanse open area right buttock with NSS apply Meglisorb AG cover with foam and [MEDICATION NAME] roll, Change QOD one time a day every other day for wound. Review of the electronic TAR revealed treatments were signed off as completed on 4/10/15, 4/12/15 and 4/13/15. Review of care plan #1, initiated 1/30/15, revealed that on 4/14/15, the facility included the intervention pressure redistributing device on bed/chair. The facility failed to include this intervention initially on the 1/30/15 plan of care. On 4/14/15, care plan #2 was initiated for open wound at right posterior hip related to: impaired mobility with new interventions added such as Special mattress/cushion on bed/wheelchair (specify location); Report evidence of infections such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn. This care plan failed to identify the type of wound the open area was, such as pressure ulcer, nor did it identify the stage of the wound. According to the facility Skin Practice Guide, the presence of a pressure ulcer required daily body audits by a licensed nurse. Review of the electronic TAR revealed that the weekly body audit was completed on 4/9/15, however there were no daily body audits completed from 4/10/15 through 4/13/15. Review of the EMR revealed the following sequence of events: 4/15/15 3:58 PM - Skin note stated, Wound rounds completed.open area to right posterior hip measuring 4.4 x 2.0 cm in size.wound bed is 90% slough and 10% red and granular.scant amount of serous drainage is noted. MD notified and treatment changed.PUSH has decreased to 13. 4/17/15 11:47 AM - physician's orders [REDACTED]. 4/22/15 8:02 PM - Skin note stated, Wound rounds completed.ulcer to right posterior hip.measures 3.5 x 2 cm in size.wound bed is 100% slough.area is unstageable. Reviewed with physician during rounds. The PUSH score was 11 on 4/22/15. During an interview with E3 (WCN) on 4/24/15 at approximately 11:00 AM, she stated that she was not aware of R18's wound since she was not informed about it. Her role as WCN was to treat open wounds/Pressure Ulcers and the staff treats all other skin alterations. E3 stated It was 4/13/15 when she was asked to assess R18's wound. She stated, that staff were doing the treatment previously, treating it as an excoriation. Review of the facility's Skin Practice Guide under Medical Care Initiative it stated Patients admitted with skin alterations are ideally evaluated by a qualified health profession (physician.or a certified wound specialist) within 24 hours or as soon as practicable, after admission or new skin alteration identification. It is unclear why the facility failed to refer R18 to the WCN when the areas of excoriation continued to increase in size. The following observations were made of R18's turning and positioning: 4/27/15 R18 was observed in bed and was laying on her right side from 10:30 AM until 12:00 PM. At 1:00 PM, R18 was seated in a wheelchair in the lounge area with a family member. R18 was observed to be leaning more on the right side of the hip. Her left outer knee was pressed against the right inner knee, causing her weight to be shifted onto the right hip (close to the site of the wound) while sitting in the chair. 4/28/15 was seated in a wheelchair at around 12:00 PM to 2:00 PM, R18 remained in the same position with her weight shifted onto her right side. Position was not observed to be changed. 4/29/15 remained seated in wheelchair from approximately 11:30 AM to 2:00 PM. Position was not observed to be changed. In an interview with E9 (CNA) on 4/29/15 at approximately 2:00 PM, she stated that she was not aware that R18's position needed to be shifted when she was seated in a wheelchair. E9 stated that she did not shift R18's position when she was seated in the wheelchair. On 4/29/15 at 9:00 AM, observation of R18's wound treatment by E3 was completed. The pressure ulcer was located on the upper right buttock (on bony prominence). The wound bed was observed with slough and a necrotic area. On 5/6/15, E3 completed her wound rounds and at around 11:00 AM handed this surveyor a note with current measurements and description of R18's right buttock pressure ulcer. The note stated the wound measured 3.4 cm x 1.8 cm with 100% slough, with granulation at periulcer (around), and scant serous drainage. The facility failed to ensure that R18, who developed a pressure ulcer, received the necessary treatment and services in accordance with the plan of care including treatments that were provided at the ordered frequency. This finding was discussed with E2 (DON) and E7 (Corporate Nurse) on 4/30/15 at 9:10 AM.

Based on record review and interview, it was determined that for one resident (R10), who had a pressure sore (ulcer), out of ten (10) residents sampled, the facility failed to provide the necessary treatment and services to promote healing. The facility failed to monitor and assess R10's pressure ulcer when treatments were provided in order to identify worsening of the ulcer and failed to evaluate the treatments' effectiveness. Record review lacked evidence that weekly wound assessments were completed from 1/2/13 through 3/5/13. While facility staff provided the wound treatments there was no evidence in the clinical record that staff assessed the wound. Findings include: The facility's protocol entitled "Ongoing Management Strategies" for wound management stated, "...The goal of the wound management team is to assist with ongoing wound management and monitoring. The members of the wound team collaborate with the patient's attending physician to assist in determining wound etiology (cause or origin), individualized treatment strategies and evaluating the effectiveness of the current plan of care. The wound management team re-evaluates pressure ulcers and complex wounds weekly...Documentation of findings is completed on the PUSH Tool (Pressure Ulcer Healing Chart - monitors on a graph the progression or healing of a pressure ulcer) or Skin Alteration Record, whichever is appropriate for the type of wound and a progress note. Documentation may include, but not be limited to: wound location; description of wound edges and surrounding tissue; depth, presence of, location and extent of any undermining, tunneling or sinus tract formation; presence of possible complications, such as signs of increasing area of ulcer or evidence of soft tissue infection; presence of and changes in pain management. If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the patient's overall clinical condition needs to be re-evaluated. Re-evaluation of the treatment plan, including determining whether to continue or modify the current interventions may be indicated...The complexity of the patient's condition may limit responsiveness to treatment or tolerance for certain treatment modalities..." R10 was readmitted post hospitalization on [DATE]. R10's [DIAGNOSES REDACTED]. R10's clinical record revealed a history of a resolved pressure ulcer on the coccyx (tailbone at the base of the spine) area. An annual Minimum Data Set (MDS) assessment, dated 2/19/13, stated R10 was independent for daily decision making and required extensive assist of two staff for bed mobility. This MDS stated that R10 was at risk for developing pressure ulcers and had one (1) unstageable (unable to describe the severity of the wound) pressure ulcer. A care plan for risk for alteration in skin integrity, last revised on 10/16/12, included the interventions air mattress to bed, encourage and assist to reposition as needed based upon patient's needs, monitor skin condition with care daily and report abnormalities, notify physician, pressure redistribution device (cushion) on wheelchair and pillows/positioning devices as needed. On 10/16/12 a care plan for "readmitted with sacral (sacrum - area directly above the coccyx/tailbone) slit wound" was developed and included the interventions to monitor for infection, report to the physician and provide treatment as ordered. A skin progress note completed by E20 (former wound care nurse), dated 10/16/12 and timed 10:24 AM, stated that a readmission assessment was completed by the wound team. The note stated R10's sacrum had scar tissue and a dry red wound measuring 1.0 cm (centimeters) with the appearance of having been a slit or scratch. The surrounding skin also had partial scarring, there was no drainage and R10 denied having any pain. On 10/16/12 a physician's orders [REDACTED]. The treatment administration record (TAR) documented that the Z Guard was applied as ordered through 12/6/12. A care plan, initiated on 12/7/12 for "reopened sacral wound secondary to friction over fragile scar tissue" was developed. Interventions included: treatment per physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The treatment administration record (TAR) documented that weekly skin checks were completed by nursing staff from 10/16/12 through 2/22/13. On 2/22/13 the TAR documented that daily skin checks were completed. On 12/7/12 a skin progress note completed by E20, stated that a sacral open area was assessed by the wound team. "Area measured 0.8 (by) 0.5cm of dry red tissue. Border in vague 'w' shape. No drainage. Peri wound (area surrounding wound) skin scarred with pale pink discoloration. Wound appears to be secondary to friction over fragile scar tissue." E20 began documenting on a "Skin Alteration Record" (not used for pressure ulcers) and noted that the type of alteration was "re open sacral friction wound." A physician's orders [REDACTED]. Apply scant amount [MEDICATION NAME] (antibiotic ointment) cover (with) gauze and foam (every day). This treatment was documented as having been completed through 12/11/12. On 12/11/12 a new order was transcribed onto the TAR which stated, "Reopen sacrum: cleanse (with) NSS. Cut purachol (sic) (Puracol - wound dressing) dressing to fit inside wound. Place in wound. Moisten (with) few drops NSS. Cover (with) DCD (dry, clean dressing) q3d (every third day) and prn (as needed)." Although this order appeared on the TAR written in by E20, the original handwritten order was never found in the physician's orders [REDACTED]. E20's last skin progress note was dated 12/26/12 and stated that the wound to the sacral area measured 1.0 x 1.0 x 0.2 cm, had moist red tissue, the border slightly macerated (skin softening related to fluid), peri wound skin normal, no drainage, no complaint of pain with treatment. The Skin Alteration record was completed weekly by E20 through 1/2/13. On 1/2/13 it stated that the wound measured 1.0 x 1.0 x 0.0 cm, had pale, pink tissue, no drainage and the surrounding skin had some maceration. There was no corresponding skin progress note for 1/2/13. The TAR from 1/3/13 through 2/6/13 documented that the Puracol treatment was completed as written on the TAR. During this time frame nursing staff were completing the treatments, as the facility's wound care nurse left employment at the beginning of January, 2013. The clinical record revealed that there were no skin progress notes and no weekly wound assessments completed between 1/3/13 through 2/6/13. The clinical record lacked evidence that facility staff were monitoring and assessing R10's sacral wound during this time. There was no evidence that the physician was notified of any deterioration of the pressure ulcer during this time. On 2/7/13, E21 (newly hired wound care nurse/WCN) began completing treatments to R10's sacrum. E21 began to utilize the PUSH Tool. On 2/7/13, E21 documented that the wound had light drainage and slough. Additionally, the wound had increased in size based on the PUSH Tool score, although no actual measurements were found in the clinical record. This indicated that the sacral ulcer had deteriorated at some time between 1/2/13 (when it had been documented as having pale,pink tissue with no drainage measuring 1.0 x 1.0 cm with no depth) and 2/7/13 when it had increased in size and was covered with slough. The clinical record lacked a corresponding skin progress note and lacked evidence that the physician had been notified regarding deterioration of the pressure ulcer. There was no evidence that R10's care plan was reviewed to evaluate the effectiveness of the current interventions when the wound worsened. Although the PUSH Tool was completed weekly by E21 through 3/4/13, there were no corresponding skin progress notes and no other assessments/evaluations of the pressure ulcer in the clinical record. Review of the TAR revealed that R10 continued to receive the Puracol treatment to the pressure ulcer through 3/4/13 (written on 12/11/12 - approximately 12 weeks) despite evidence that the pressure ulcer was not responding to this treatment and had in fact deteriorated. Review of the PUSH Tool revealed that on 2/7/13 the total score was 11, on 2/14/13 the score was 10, on 2/21/13 the score was 7 and on 3/4/13 the score was 12. A healed wound would be scored as "0." On all these dates the tissue type was documented as having slough. Drainage amounts were noted as "light" until 3/4/13 when it was noted to be "moderate." The only measurements found were for 2/14/13. Based on review of these scores, the wound appeared to be healing between 2/7/13 and 2/21/13. However on 3/4/13, the amount of drainage increased and the wound score increased from "7" to "12." While the facility began to use the PUSH Tool, it is unclear why the facility failed to document and comment on the development of the slough, which was a new development in the wound. Additionally, actual measurements were difficult to locate in the clinical record and were only present for 2/14/13. On 3/5/13 at 11:45 AM, E6 (nurse/DCD-Director of Care Delivery) was interviewed. E6 stated that the wound care team consists of E21 (WCN - heads team), E2 (Director of Nursing - DON), the unit DCD and at times E3 (Assistant Director of Nursing - ADON). E6 stated the team rounds weekly on Wednesday mornings. E6 confirmed that the facility did not have a WCN from the beginning of January 2013 through the beginning of February 2013. When asked who headed the team at that time, she stated the DON had. E6 stated that the participants on last weeks' rounds (2/27/13) were herself, E21 (WCN), E3 (ADON), E7 (staff education nurse) and E12 (Nurse Practitioner). She stated that E12 was aware of the wound, but confirmed that there was no mention of it in the physician progress notes [REDACTED]. E6 stated that the previous wound care nurse (E20) was tracking the wound as a non-pressure friction wound. When the new wound care nurse (E21) started, she assessed it as being a pressure ulcer and began using the PUSH Tool and that is why there is no PUSH Tool until 2/7/13. E6 acknowledged that the clinical record lacked evidence that other than the PUSH Tool (being completed starting 2/7/13) there was no evidence of assessment of R10's wound. Review of the clinical record revealed that on 3/5/13 at 1:00 PM (after the surveyor had spoken with E6), a "Change in Status" form was completed which stated "worsening of lower sacral chronic wound, larger and deeper." A skin progress note was also completed on 3/5/13 at 4:01 PM. It stated "Chronic sacral pressure ulcer has become bigger: on 2/14/13 it measured 2.6 cm x 2.5 cm x 0.3 cm, with red, nongranulating wound base (the 2/14/13 PUSH Tool documented the wound had slough). Presently measures 2.8 cm x 2.7 cm x 0.4 cm: pale wound base; raised edges. MD notified..." On 3/6/13 a physician's orders [REDACTED]. During an interview with E2, she stated that R10 had a history of [REDACTED]. She stated that historically it takes R10 longer to heal due to her comorbidities and history of steroid use and that they would usually wait longer to change treatments on her to give it the opportunity to heal. Findings were reviewed with E2, including the lack of assessment and monitoring of pressure ulcer from 1/2/13 when the wound was "pale, pink tissue" with no drainage and measured at 1.0 x 1.0 cm and then on 2/7/13 was described with slough and increased size on 2/14/13. Additionally these findings were reviewed including the Puracol treatment which had been in use since 12/11/12 with no evidence of healing and that there was no evidence in physician progress notes [REDACTED]. On 3/8/13, E2 submitted a corrected PUSH Tool document. She stated that when reviewed, it was found that E21 had incorrectly calculated the total scores. Also, E2 provided a document which stated that E21 had been in serviced on the correct completion of the PUSH Tool and weekly documentation of wound notes. A handwritten note, dated 3/7/13 and completed by E21 stated that she had "miscalculated the dimensions" of R10's wound and "at no time did (resident's name) wound decrease in size and then precipitously worsen from one week to the next; it remains consistent." There were no additional documents provided. Review of physician's progress notes, dated 12/12/12 through 2/27/13 (a total of 9 notes), lacked any mention of R10's sacral pressure ulcer. On 3/7/13, a physician's progress note stated "Sacral pressure ulcer. Asked to review (patients) chart (secondary to) skin alteration...sacral breakdown - unavoidable despite all current interventions due to multiple comorbidities such as (intravenous) steroid use, which causes delayed healing. Goal is to keep wound free from infection." R10 was observed on 3/4/13 at 11:15 AM seated in her wheelchair (w/c) on a cushion next to her bed, which had an air mattress. On 3/4/13 at 2:45 PM, she remained seated in her w/c and when asked if she is turned and repositioned every two (2) hours, she stated that she was and that if they are late she rings her call light. On 3/7/13 at 11:45 AM, R10 was again observed seated on a cushion in her w/c. She stated that she spends most of the day seated in her w/c and that she does not want to be put back to bed in between. The facility failed to monitor and accurately assess R10's pressure ulcer from 1/3/13 through 2/7/13 and failed to identify that the wound was deteriorating. From 2/7/13 through 3/5/13 the facility failed to thoroughly assess this wound and failed to consider that the wound was not healing. The treatment plan was not re-evaluated, the physician was not notified and the pressure ulcer continued to deteriorate. The facility failed to provide care and services for R10, who had a pressure ulcer, to promote healing.

Based on observation, record review, review of hospital records and interview it was determined that the facility failed to ensure that 1 (R3) out of 10 sampled residents remained as free from accident hazards as possible and received adequate supervision to prevent accidents. On 2/5/13 R3, a resident with advanced dementia and agitation sustained harm when she fell out of her gerichair (a wheelchair that reclines) in the hall when left unsupervised and out of staff view. R3 sustained scattered areas of SAH (subarachnoid hemorrhage- bleeding between brain and the thin tissue that covers the brain) and lacerations (cuts) above her right (R) eye and behind her R ear. R3 was subsequently hospitalized from 2/5 to 2/8/13. Findings include: R3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A significant change MDS (minimum data set) assessment, dated 12/28/12, listed R3 with severe cognitive impairment (unable to make own decisions), unclear speech, dependent on 1-2+ persons for activities of daily living (bathing, transfers, etc.), non-ambulatory (unable to walk) and she had 3 falls since the prior assessment of 11/6/12 (one without injury and two with non-major injuries). Review of R3's care plan revealed: 10/8/12- at risk for adverse effects related to use of antidepression medication trazadone. Goal- show improvement in mood/behavior. 9/6/12- at risk for self-inflicted skin alterations due to increased agitation, refusal to let staff trim nails. 8/23/12- verbal/physical agitation/aggression related to unfamiliar environment, cognitive impairment. Interventions included: "... If strategies are not working, leave (if safe to do so) and reapproach later. 8/20/12- resistive/noncompliant with treatment/care. 8/18/12- at risk for falls due to impaired balance/poor coordination, unsteady gait, history of falls. Interventions include: "... Geriatric chair when OOB (out of bed)...". R3 was observed from 2/19/13 to 2/21/13 lying in a low bed with fall mats on both sides of the bed. R3 was noted to be very thin with her eyes closed. R3 was rubbing her face and was somewhat restless on 2/19 and she appeared to be asleep on 2/20 and 2/21. The R side of R3's face was bruised- purple/greenish-yellow. The bruising extended into the R side of R3's scalp and from the forehead to the cheek. There was a swollen area on the R forehead to the R side of the eye with 2 small scabbed areas. A soft cervical (neck) collar was in place, the left (L) arm had bruises and healing open areas- one above and two below the elbow. There was a dressing on the L elbow and the backs of both hands were dark and appeared bruised. Review of nurses notes revealed that R3 had falls with resultant skin tears on 12/15/12, 12/23/12, 12/28/12 and 1/27/13. R3 was found on the fall mat each time. In response to R3's falls the facility reviewed R3's medications on 12/18/12 (evaluation for chronic pain), 1/3/13 (pharmacy consultation) and 1/29/13. Rehabilitation Screenings were completed on 12/17/12 and 1/2/13. R3 was placed on hospice on 12/19/12. Nurse's notes revealed that R3 was monitored post fall from 1/27 through 1/30/13. On 2/4/13 R3 was restless and uncooperative- she refused treatment to her L arm and spit out her medications twice. A change in status note, dated 2/5/13 and timed 9:25 PM, stated that R3 fell out of her gerichair to the floor and sustained a laceration above her R eye. A physician was notified at 9:40 PM and ordered R3 to be sent to the emergency room (ER). The facility incident report, dated 2/5/13 and timed 9:35 PM, stated R3 had an unwitnessed fall out of her gerichair onto the floor in the hallway on her R side. The investigation report, dated 2/6/13, listed a timeline of events (with approximate times) for the fall on 2/5/13 as follows: 6:30- 7:30 PM- R3 was with licensed nurses in the gerichair at the nurse's station. 8:00 PM- Nurses began medication passes and brought R3 to hallway for increased observation. 8:30 PM- accepted trazadone (antidepressant). 8:45 PM- accepted snack. 9:15 PM- R3 was noted with decreased agitation. Nurse (E13- assigned to R3) went to room to administer medications. (untimed)- certified nurse's aide (CNA) (E14) looked out of another resident's room to see if another CNA was coming to assist her. She saw R3 on floor in hallway next to her gerichair and called for nurse. Another CNA (E10- assigned to R3) came from shower room and went to assist. First aid applied to laceration. R3 sent to ER. The summary of critical information obtained during the investigation stated, "... confused... currently on hospice for debility (weak; feeble) secondary to end stage cardiac disease... history of dementia with agitation and was last seen by psych on 1/22/13.... receives trazadone 25 mg (milligrams) HS (at bedtime) which has been effective with improving her sleep... history of impulsive behavior during periods of agitation." The conclusion of the investigative report stated, "... noted with agitation, refusing medications. Staff increased sight and supervision and patient eventually accepted ordered medication... appeared to calm down with intervention and was last seen relaxing in her geri chair in the hallway...". All staff statements/interviews were reviewed (included in the facility investigation). E10 (CNA assigned to R3) stated on 2/6/13 that she took R3 to the nurse's station after removing her from the dining room after dinner on 2/5/13. When asked how R3 got into the hallway, E10 stated, " About 7:45 (PM) (E13- nurse assigned to R3) was going to start her med pass and asked what do you do with her when she is like this?" When asked what she meant by "like this" E10 stated, "Because she was screaming and yelling and trying to get out of her chair... I told her (E13) what they usually do is bring her down to the med cart so that everyone can keep an eye on her... pushed (R3) down to the cart...". E10 stated about 8:45 PM, not quite 9 PM " I told (E13) can you keep an eye on (R3) while I take the other resident off of the toilet, even though she is sleeping now her mood can change in an instant." When asked "Did (E13) hear you?, E10 stated, "Yes, I was standing not even 5 feet from her." When asked if E13 acknowledged her, E10 stated, "Yes, she shook her head and said ok." E14 (CNA) stated on 2/6/13 that she poked her head out of a resident's room on 2/5/13 to see if another CNA she was waiting for was coming. At this time, she observed R3 lying on the floor. E14 stated, " I screamed for a nurse and no when (sic) came... I still could not find a nurse so I started going down the hallway towards the nursing station when I saw (E10) come out of the shower room...". When asked when was the last time she saw either nurse, E14 stated it was before she went into a resident's room. E14 stated she was in the resident's room for 5-10 minutes; she changed his brief and sheets. In response to being asked "Before you went into (resident) room and you saw (E13) and (R3) what were they doing?" E14 stated, "(R3) was trying to get up, saying her normal things, trying to get out of the chair." E16 (nurse) was the other medication nurse working on the unit when R3 fell on [DATE]. On 2/6/13 E16 stated that E10 (CNA assigned to R3) mentioned to me after that all (sic) (E13- nurse assigned to R3) had to do was wait a couple of minutes and I was getting ready to put her to bed." E13 (nurse assigned to R3) on 2/5/13 stated on 2/6/13 that R3 would not take her medications, but she finally took her Trazadone (antidepressant- causes drowsiness) around 8:30 PM. E13 stated, "after she had her trazadone, she calmed down. I even said to (E10- CNA assigned to R3), 'look, she's not trying to get out of her chair.' She wasn't yelling...". When asked if she left R3 unattended E13 confirmed that she did- she went into a resident room to administer medication and the resident told her she liked her medicine in chocolate pudding, so E13 went to get pudding from the other medication cart and planned to go to the dementia unit for another medication she needed as well. E13 stated that as soon as she got the pudding and before she had a chance to go to the dementia unit, she heard the aide (CNA) screaming. The EMS (Emergency Medical Services-ambulance), ER and hospital records from 2/5 to 2/8/13 were reviewed. Upon arrival of EMS on 2/5/13 at 9:21 PM (approximately 50 minutes after Trazadone administered), R3 had a "... dressing wrapped around the head with blood soaking through... bruising around the right eye socket as well... yelling throughout the assessment and transport... extremely agitated...". R3 received multiple doses of medications to help calm her down in the ER and she was closely monitored with a 1:1 sitter (a staff member was specifically assigned to be with her continuously) in the ER and on the floor after she was admitted to the hospital. Trauma Service/Critical Care Progress notes (was followed by trauma in ER throughout hospital admission), dated 2/8/13, listed [DIAGNOSES REDACTED]. The CT (computed tomography- imaging) scan of the head dated 2/5/13 stated, "Impression: Multiple foci (points of convergence) of subarachnoid hemorrhage... right frontal subcutaneous (fatty layer of tissue under skin) soft tissue hematoma (localized collection of clotted blood)...". A follow-up CT scan of the head on 2/6/13 stated, "Impression: ... Scattered areas of subarachnoid hemorrhage in the right frontal (forwardmost portion of brain), temporal (lower, back part of brain), and occipital (back of brain) areas are again seen...". E10 (CNA assigned to R3) was interviewed on 2/21/13. E10 stated that she worked in the facility for [AGE] years and was very familiar with R3. E10 confirmed that she was assigned to R3 on 2/5/13 and she stated that R3 was "out of control"- yelling, screaming and putting her feet over the sides of her gerichair trying to get up on 2/5/13. E10 relayed events and stated that she asked E13 (nurse assigned to R3) to watch R3 while she toileted R3's room mate. E10 stated that E13 verbalized agreement. E10 stated that E13 worked in the facility occasionally and was unsure if E13 was still employed in the facility. E10 stated that E13 was not very familiar with R3 and if she had watched her for a few minutes as asked "this didn't have to happen." Findings were reviewed with E1 (Nursing Home Administrator), E2 (Administrative Director of Nursing Services- ADNS) and E4 (Medical Director) on 3/6/13. E2 stated that R3 took her Trazadone at 8:30 PM and ate a snack. E2 stated that E13 (nurse assigned to R3) had a higher skill level than a CNA so she was capable of determining that R3 no longer required observation since she was assessed by E13 as being calm, safe and asleep. E4 (Medical Director) stated that R3's Trazadone would have had some effect within 45 minutes as the geriatric population is sensitive and it affects them sooner. E4 stated that Trazadone would reach its peak effect in 3 hours (11:30 PM) in a "normal" person. E4 also stated that R3's falls were a "reflection of her illness" which he described as "unpredictable", a part of her disease process and there was no way to prevent this. EMS was contacted post survey on 3/13/13 and it was learned that the facility called 911 for R3 at 9:10 PM on 2/5/13. The facility probably called 911 5-10 minutes post fall, therefore R3 received her Trazadone about 30 minutes prior to falling. On 2/5/13, R3 who was at very high risk for falls and had a fall history was left in a geri chair in the hallway without adequate supervision/out of staff view. She was agitated and trying to climb out of her gerichair. R3 was known to have impulsive behavior when agitated and mood/behavior issues. The facility failed to ensure that R3 received adequate supervision and consequently fell out of her gerichair and sustained harm as evidenced by head and facial trauma. R3 was hospitalized from 2/5 to 2/8/13.

Based on record review, interview, and review of other documents as indicated, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with physician's orders [REDACTED]. The facility failed to follow the plan of care when R1 experienced decreased responsiveness and respiratory distress with low blood oxygen levels. The clinical record lacked evidence that monitoring was completed for one hour and ten minutes, after R1 was found with decreased responsiveness and a low blood oxygen level at 5:00 AM on 7/12/12. R1's blood oxygen levels decreased further and the resident became totally unresponsive requiring 911 transport to the emergency room (ER). R1 was subsequently intubated (placement of a flexible plastic tube into the windpipe to maintain an open airway) while in the ER and placed on mechanical ventilation (method to mechanically assist or replace spontaneous breathing). The facility failed to follow the plan of care for a two (2) person assist on 12/6/12 for R4. One staff was providing care when R4 fell out of bed and sustained injuries. The facility failed to provide timely care and services when R8 fell and sustained an injury which showed as abnormal findings on x ray results of 2/27/12. The facility failed to follow the plan of care for two (2) staff to be present during care for R7 due to a history of false allegations against staff. Findings include: 1. R1 had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The facility initially developed a care plan on 7/29/09 for the need for monitoring related to [MEDICAL CONDITION] activity. The goal of this care plan was to detect and intervene with early or worsening neuro (neurological) problems. Interventions for this care plan included: monitor for and report any decline in physical or mental abilities; monitor vital signs (heart beat, breathing rate, temperature, and blood pressure) as needed and report significant changes to physician as needed; neurological system evaluation as needed report changes to physician as needed; and report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech. A care plan for the risk of respiratory impairment related to obstructive sleep apnea and asthma, developed on 7/29/09, revised 10/27/12 , included interventions: notify physician and family/responsible party of changes in respiratory condition; obtain pulse oximetry (pulse ox - device that measures blood oxygen levels - 92 to 100% desirable range) and report abnormal findings; monitor for and report adverse changes in respiratory rate, cough, and respiratory effort. Although this care plan stated to obtain pulse oximetry, it failed to state the desired goal of the pulse oximetry level for staff reference. A nurse's note, dated 7/12/12, timed 7:28 AM and completed by E27 (nurse) stated that R1 received [MEDICATION NAME] 50 mg (non-narcotic pain medication) at 12:00 AM, at which time the resident was easily aroused and took the medication without difficulty. This nurse's note also stated, "...At 0500 (5:00 AM) nurse called to residents room by CNA (certified nurse aide). Resident not responding to voice. Resident did respond to touch by opening eyes and then immediately closing them again. Vitals at that time 98.3 (temperature) - 98 (heart rate) - 14 (respirations per minute), 99/51 (blood pressure) FS (fingerstick-measures blood sugar level) 310, breathing labored. Pulse (oximetry) 76% on 2 L/min (liters/minute) via N/C (nasal cannula). Oxygen mask applied and oxygen titrated to 4 L/min. Pulse ox increased to 86%. Resident assessed every 5 minutes. At 0610 (6:10 AM) (one hour and ten minutes later) resident no longer responsive to voice or touch pulse ox 78% via mask at 4 Liters. Md (sic) (medical doctor) notified ordered nonrebreather (mask utilized when high-flow oxygen is required) to be applied and to send to ER. Nonrebreather applied and pulse ox increased to 86%. 911 called at 0615 (6:15 AM) and family made aware. Emergency personnel arrived approximately 0625 (6:25 AM). Paramedics took over care of resident at that time. Resident transferred to (name of) hospital via ambulance at 0645 (6:45 AM) with nonrebreather in place." The New Castle County EMS (Emergency Medical Services) patient care report, dated 7/12/12, stated they arrived at the patient at 6:25 AM and "...Staff reports finding pt. (patient) with inadequate respirations and not responding appropriately at 05:00 (5:00 AM) hours. They relay that she continued to get worse and 911 was called at approximately 06:15 (6:15 AM). Upon our arrival, pt. was not responding with inadequate respirations...Arrived to find female pt. supine (lying down with the face up) on bed on a non-rebreather at 15 lpm. Pt. was not responding to any stimuli with labored, snoring respirations, appearing in significant distress..." The report goes on to state that R1's pupils were sluggish (in response to light) and she had a pulse oximetry reading of 89%. EMS inserted a nasal airway (tube inserted into nasal passage to secure an open airway) and administered oxygen at 15 lpm via a Bag valve mask (Ambu bag - used for patients who are not breathing or breathing inadequately). EMS administered 2 mg of [MEDICATION NAME] (counteracts effects of narcotics) via inhalation. R1's pulse oxygen level improved slowly to 96% and the resident began opening her eyes but was not answering questions. Upon arrival at the hospital ER, R1's pulse ox was at 98%. A second dose of 2 mg of [MEDICATION NAME] via inhalation was administered and R1 became more alert to pain. R1 was placed on [MEDICAL CONDITION] (machine that helps the patient breathe) and at approximately 11:00 AM was intubated (tube placed into the windpipe through the mouth or the nose) and placed on mechanical ventilation. On 7/14/12, R1's breathing tube was removed and she returned to the long term care facility that day at her insistence. The hospital's interagency discharge orders, dated 7/14/12, stated discharge [DIAGNOSES REDACTED]. The hospital orders also included a notation to avoid use of long acting narcotics. Although the facility initially identified that R1 had decreased responsiveness and decreased blood oxygenation levels on 7/12/12 at 5:00 AM, the facility failed to immediately notify the physician as per the plan of care. The facility alleges the resident was "monitored" for one hour and ten minutes before calling the physician. It is unclear in the medical record the type and extent of the monitoring that did occur. There was no evidence that R1's blood oxygenation level ever rose to an acceptable level even after oxygen administration was increased to 4 lpm via mask. The pulse ox only increased to 86% (desired range 92-100%), there was no evidence that R1 became more responsive, and there was no evidence of any further assessments being completed until 6:10 AM when R1 became totally unresponsive with a pulse ox of 78%. The physician was called at 6:10 AM, one hour and ten minutes after R1 was found with decreased responsiveness, labored breathing and an inadequate blood oxygen level. The facility failed to provide the necessary care and services to attain or maintain R1's highest practicable physical well-being as per the plan of care. On 3/1/13 at 10:15 AM, E5 (R1's physician) was interviewed and the 7/12/12 nurse's note was reviewed. After review of the nurse's note E5 stated, "Yes, it would have been nice to be called sooner." During an interview with E2 (Administrative Director of Nursing Services/ADNS) on 3/8/13 at 10:10 AM, E2 stated that E28 (house nursing supervisor) was aware of R1's condition on the morning of 7/12/12 and that the nurse was monitoring the resident. E2 stated that it was thought that R1 may have had a [MEDICAL CONDITION] and that when there was an increase in the unresponsiveness and a decrease in the pulse ox then the physician was called. E2 stated that she feels the facility did not cause harm to the resident as R1 was not intubated immediately upon arrival to the hospital ER. On 3/8/13 at approximately 3:00 PM during the exit conference, E4 (Medical Director) stated that it could not be proved that an earlier call to the physician could have changed R1's having to be sent to the ER and/or being intubated. 2. R4 was admitted to the facility in 2007. [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment, dated 11/1/12, listed R4 with severe cognitive impairment, she was totally dependent on staff for activities of daily living (bathing, toileting, etc.), she required 2+ person extensive assistance with bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed) and 2+ persons total dependence for transfers using a hoyer lift (sling-type hydraulic lift). R4 was non-verbal and unable to walk. Review of R4's fall care plan dated 1/29/08 and revised on 11/23/11, stated, "At risk for falls as she seems to have a fear of falling and will stiffen up when turned or moved... dx (diagnosis) of dementia, [DIAGNOSES REDACTED] and has a hx (history) of falls... has hx to hang her legs over the side of the bed, with her head on the other side of the bed. She will cross her legs and this at times causes her to slide down in her chair/bed. Interventions included "... 2 person for care as indicated." R4 also had a care plan, dated 1/29/08, for "Repetitive physical movements aeb (as evidenced by) jerking of whole body related to dx of [DIAGNOSES REDACTED]. She also crosses her arms and holds her elbows and will lean to side in chair. Puts hands on wheels and flails arms when transferred in hoyer (lift)." Review of R4's (undated) PIW (Patient Information Worksheet), used by CNA's (certified nurses aides) to guide the specific care needs for resident, stated, "... * FALL RISK * Resident is to be a 2 person for care as indicated... SPECIAL NEED... Jerking movements- 1 person on each side of bed during care (FYI)." On 2/19/13 at 10:40 AM R4 was observed seated in a broda chair (type of wheelchair that tilts and reclines) during an activity. R4 had frequent jerky movements of her arms and legs (like when someone is startled), her arms were crossed over each other and she leaned to the left for the most part. On 2/19/13 at 2:35 PM R4 was lying in bed turned towards the window and she had frequent, small jerky movements. R4 was centered in the bed and the bed was in a low position. A change in status progress note/assessment (completed by nurse), dated 12/7/12 for an incident that occurred on 12/6/12 at 10:30 PM, stated, "... fell off a low bed after pm care (getting ready for bed). Nurse aide (E22) said she had some jerking motions and ladded (sic) on the floor... hit the bedside table sustaining bruise on left cheek and lacerations (cuts) on the lips." A nurse's note, dated 12/7/12 and timed 4:26 AM, stated, "... s/s (signs and symptoms) fall with minor injuries, some scant bleeding noted still from her mouth. Ice pack applied and resolved. Continues on neuro- checks (to assess neurologic function). WNL (within normal limits), no change noted... continue to monitor." R4's neuro-checks remained at her baseline and on 12/13/12 a physician order [REDACTED]. A written statement by E22 (CNA assigned to R4) on 12/6/12 stated, "after giving... pm care, I put the bed down and resident was more on the left side when she jerked/twisted, I tried to hold her but was not successful and she ended up falling hitting her face on the bedside table." During an interview with E6 (nurse-unit manager) on 2/19/13 at 2:12 PM she stated that R4 was not sent to the hospital post fall. E6 stated that CNA (E22) was new and did not know how to access the PIW (Patient Information Worksheet) which showed that R4 required 2 person assisted transfers. E6 confirmed that E22 provided pm care and repositioning by herself on 12/6/12 at 10:30 PM instead of with 2 persons as she required. E22 was provided 1:1 inservice/education post fall. 3. R8 was admitted to the facility on [DATE] from the hospital for short-term rehabilitation after a right total hip replacement. During the evening shift on 2/27/12, R8 slid off of the shower chair in the shower room and sustained an avulsion fracture (torn bone fragment) of the right femur (thigh) bone. R8 was seated forward in the front of the shower chair while E24 (CNA- certified nurses aide) pulled the chair towards himself. Per the facility's incident report dated 2/27/12, E23 (nurse) "was called to shower room by CNA (E24), resident was in a sitting position with buttock on foot rest of shower chair and thighs on floor. No injuries noted. Denies pain, mild discomfrot (sic)." Review of nursing notes from 2/27/12 to 2/28/12 revealed: 2/27/12 at 1:30 PM, R8 was alert and oriented and required one staff member's assistance with activities of daily living (i.e. bathing, toileting, dressing). 2/27/12 at 11:00 PM, E23 (nurse) was called to shower room and no injuries noted. E23 (nurse) medicated R8 with [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety) at 9:50 PM which were effective. STAT (immediate) x-ray of right hip completed per E12's (nurse practitioner) orders and results pending. 2/28/12 at 3:05 AM, E15 (nurse) indicated no injuries noted, x-ray completed, and "results pending...". E15 medicated R8 with [MEDICATION NAME] (for severe pain) and applied ice with positive results. 2/28/12 at 10:45 AM, At the request of E5 (physician), E25 (nurse) faxed R8's x-ray results to the orthopedic surgeon's office. 2/28/12 at 11:00 PM, E26 (nurse) received a verbal order to send R8 to the hospital under the care of the orthopedic surgeon. R8 left the facility at 7:00 PM. A STAT (immediate) radiology report of the right hip was faxed and called to the facility on [DATE] at 1:37 AM. The diagnostic company confirmed on 2/25/13 at 10:15 AM that the STAT x-ray results were sent to the facility and called to E9 (supervisor) on 2/28/12 at 1:37 AM. During an interview on 2/26/13 at 7:45 AM, E9 (supervisor) confirmed the diagnostic company practice is to fax and call STAT and routine test results to the facility. E9 stated she had no recollection of receiving the phone call from the diagnostic company and confirmed that she was the only employee with that name at the facility at the time. During an interview on 2/26/13 at 7:34 AM, E15 (nurse) stated she did not receive the STAT x-ray results during the midnight shift on 2/28/12. E15 also stated she did not call the diagnostic company to follow-up on pending STAT x-ray results for R8. According to the Division of Long Term Care Residents Protection's investigation report, R8 stated that E5 (physician) "came to her room on another matter (morning of 2/28/12). Stated that she asked about the xray & (E5) thought she was talking about another incident (the previous week)...Stated that (E5) went to look into (it) and that's when she found out she had a fracture...." Per the facility's investigation dated 2/27/12, E5 (physician) noted R8's x-ray results at 10:40 AM on 2/28/12 (after resident asked about her x-ray results E5 became aware of fall and fracture). A physician's progress note dated 2/28/12 (untimed) revealed "R8 seen today...fall last night...STAT x-ray done of R (right) hip...I reviewed himself. Pain managed currently. Discussed case c (with) nurse & faxed copy of report to (orthopedic surgeon) & will have (diagnostic company) e-mail (electronic mail) actual film. R8 stable currently...call out to (orthopedic surgeon) for further instructions. NWB (non-weight bearing) currently. Pain managed." A physician order [REDACTED]." R8 was admitted to the hospital on [DATE] at 9:00 PM with an admitting [DIAGNOSES REDACTED]. According to the orthopedic surgeon's note dated 3/22/12, R8 "developed wound drainage from her right hip. In view of the wound drainage, it was not recommended to perform surgical stabilization as the concern would be to convert a subcutaneous draining wound into an infection of the hip prosthesis. Therefore, she was treated with local wound care and conservative treatment...Prognosis is guarded in view of the drainage in her right hip wound her right proximal femur fracture and hip replacement secondary to her fall postoperatively" (after surgery). The facility failed to provide timely care and services upon receipt of R8's abnormal STAT x-ray results transmitted by both fax and phone call on 2/28/12 at 1:37 AM. Approximately nine hours later on 2/28/12, E5 (physician) learned of R8's fall after the resident inquired about her x-ray results. R8 was subsequently admitted to the hospital on [DATE]. 4. R7 had [DIAGNOSES REDACTED]. During morning care on 8/11/12 in the shower room, R7 alleged that E8 (certified nurses aide-CNA) hit him with a deodorant can. On 5/22/08 and last revised on 11/14/10, R7 was care planned for "Paranoid/suspiciousness behavior AEB (as evidenced by): false accusations toward staff & others...staff is 'out to get' him...related to: cognitive impairment, psychiatric illness." On 3/28/12, an intervention was initiated to "Use 2 caregivers when providing ADLs (activities of daily living, i.e. bathing, toileting, dressing) and/or assisting resident." R7's medications included: [MEDICATION NAME] 100mg (milligrams) every 12 hours for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION], [MEDICATION NAME] 500mg every morning and 750mg every night for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION], and [MEDICATION NAME] 20mg every day for depression. According to a psychiatry progress note dated 7/27/12, [MEDICATION NAME] was increased from 10mg to 20mg every day per R7's complaint of increased depression. On 7/23/12, a [MEDICATION NAME] acid level (blood test to measure if [MEDICATION NAME] medication was within the therapeutic range) was normal. Nurses notes from 8/8/12 to 8/10/12 revealed numerous behavioral episodes with evidence of paranoia, anger, agitation, verbal aggression/threatening towards self (broke compact disc on 8/10/12 and threatened to cut his wrist) and staff (threatened to kill CNA on 8/10/12), difficult to redirect, yelling and screaming. R7 was sent to an acute care hospital for an evaluation on 8/10/12 and they did not keep him. R7 returned to the facility on [DATE] and remained agitated. On 8/11/12 E8 (CNA) "...reported that while giving R7 shower he was attempting in many ways to harm self, he used the cover of his deodorant to hit himself on the head...got the nurse. After the nurse left the room, R7 then started again to hit himself on the thigh telling E8 he will tell the cops you did this to me." On 8/11/12 E19 (nurse) stated, "...was called into shower room by assigned E8 (CNA) because R7 was trying to hurt himself by hitting his head and R (right) leg c (with) deodorant can. When E19 asked R7 what was going on, he said E8 hit him. E8 denied and can was sitting at his foot on the floor." During an interview with E8 (CNA) on 3/4/13 at 12:15 PM, E8 stated R7 was making inappropriate sexual comments to her in the shower room. E8 told him to stop. R7 became upset, started to hit himself with the deodorant can and stated he would say that E8 hit him. E8 stated she put the call light on and yelled for the nurse. E8 stated that E19 (nurse) came and E8 asked E19 to stay in the shower room with her until she finished care. E8 stated that E19 stayed in bathroom. E8 stated she told E18 (supervisor) what happened. Upon further questioning, E8 stated that R7 was a 1-person assist during bathing at the time of the incident and became a 2-person assist "later" (time unknown) due to his behavior. In contrast to statements made by E8 during her interview, R7 was care planned for "2 caregivers when providing ADL's (activities of daily living, i.e. bathing, dressing, toileting) and/or assisting resident" secondary to "paranoid/suspiciousness behavior as evidenced by false accusations toward staff and others...staff is out to get him" starting on 3/28/12. On 8/11/12, one CNA (E8) was with R7 during his shower and R7 alleged that E8 "hit him". The facility failed to follow R7's care plan for 2 caregivers.

Based on interview, record review and other facility documentation as indicated, it was determined that the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 (R10) out of 10 sampled residents. The facility failed to have an adequate system to communicate R10's transfer needs as assessed by the rehabilitation and nursing departments. The result was that facility also failed to implement R10's transfer status of extensive assistance with 2 or more persons and the use of a hoyer lift for transfer. On 7/20/11, R10's left hip was fractured during a transfer with assistance of 1 without the use of a hoyer lift. Findings include: Cross Refer F279 R10 was admitted to the facility on [DATE] for short term rehabilitation and was discharged to home on 8/13/11. Upon admission, R10 had [DIAGNOSES REDACTED]. On 7/20/11, R10 sustained a left intertrochanter (hip) fracture during transfer of 1 by E18 (CNA) from shower chair to bed. Review of R10's physician's orders [REDACTED]. R10's physician ordered Calcium Citrate 400 mg twice a day for a [DIAGNOSES REDACTED]. Additionally, on 7/27/11, R10's physician ordered Vitamin D3 50,000 units 2 tabs every month for osteoporosis. The admission Minimum Data Set (MDS) assessment, dated 7/13/11, coded R10 as requiring extensive assistance of 2 persons for transfer and bed mobility. Additionally, the MDS indicated the BIMS (Brief Interview Mental Status) score equaled 11, moderate cognitive impairment. Review of the ADL Care Plan, initiated on 7/11/11, failed to include that R10's transfer status required extensive assistance of 2 or more persons. Additionally, despite an OT evaluation, dated 7/7/11, which noted that the resident was dependent for transfer using a hoyer lift, the care plan failed to have this intervention of the hoyer lift until 7/21/11 the day after R10 sustained a left hip fracture during transfer with 1 assist without the use of the hoyer lift. Review of the Point Click Care computer program task list failed to note that R10 had a, "Special Need: Hoyer Lift for all transfers" which included Nursing Assistant and RN/LPN until the intervention was initiated on 7/21/11, the day after R10's fracture. Review of the 7/11 Point Click Care computer program of Interventions/Tasks in the area of transfers, revealed that the facility failed to transfer R10 consistently with a 2 person assist and there was no indication on this task report that a hoyer lift was used. There were 9 times from 7/6/11 - 7/20/11 that R10 was incorrectly transferred with a 1 person physical assist. Even after the fracture, from 7/21/11 - 7/31/11 there were 6 times that R10 was incorrectly transferred with a 1 person physical assist. Review of the Nurses' Notes (NN) revealed a NN, dated 7/9/11 at 12:10 PM, that documented, "A/Ox3 (alert and oriented), 0 (no ) c/o (complaint of) pain, hoyer lift for transfers...". Also, a NN, dated 7/10/11 at 3:00 PM , that documented, "... resident requires total assistance with (2) people for ADLS (activities of daily living), bathing, toileting and transfers..." Additionally, there was a NN, dated 7/18/11 at 10:30 PM, that documented, "... hoyer lift for transfers..." Review of the Physical Therapy (PT) evaluation, dated 7/7/11, noted that R10 was dependent for transfers to bed and to chair/wheelchair. The summary and assessment of the evaluation stated, "Pt (patient) c (with) lengthy medical hx (history) following a hospitalization for heart failure. Pt has been non ambulatory for - (approximately) 4 years c mobility provided by power chair. Pt has < (decreased) trunk strength and transfer ability. PT to address pt's transfers and bed mobility". Review of the Occupational Therapy (OT) evaluation, dated 7/7/11, noted that R10 was dependent for transfers requiring maximum assistance. The summary and assessment of the evaluation stated, "Pt has < (decreased) strength overall. He is dependent to txfer (transfer) into w/c (wheelchair) using a hoyer lift ..." On 1/6/12, in an interview with E10 (Occupational Therapist) and E11 (COTA, Rehab Team Leader) E10 confirmed that R10 was dependent for transfer into a wheelchair using a hoyer lift. E10 was asked how and whether this information was provided to nursing? E10 stated that often aides will come and ask him how to transfer a resident but he did not remember any specific aides coming to him with transfer questions for R10. E11 stated that in general the nursing staff is communicated with and then the information is put on the 24 hour report. Additionally, E11 stated that for the safety of both the resident and the staff if a 2 person assist is required for transfer, then the mechanical lift is needed. However, review of the 7/7/11 PT and OT physician orders [REDACTED]. Review of the Mechanical Lift policy/procedure, dated 3/2010, noted, "Purpose: to move immobile or obese patients for whom manual transfer poses potential for staff or patient injury ... Although one person can operate most models of hydraulic lifts, it's advisable to have two staff members present to stabilize and support the patient". Review of the facility incident report, dated 7/20/11, and the subsequent investigation, revealed that the summary of the alleged incident included, "Resident is a bilateral lower leg amputee. He was in the shower chair in his room. He was lifted by nursing assistant to be placed into bed. His left part of his leg came in contact with the bed and nursing assistants (sic) leg during transfer. He heard Pop, Pop, Pop and felt pain. He told the nursing assistant who then went and got the nurse. Xray revealed Left intertrochanteric fracture. Left femur with osteoporosis. Resident was sent to emergency room , but returned without treatment. Name (R10's physician) spoke with (name) Orthopedist who saw resident in ER. (Name), Orthopedist told (name of R10's) doctor that there was (sic) no corteses (sic) left and that the bone was hollow. No surgery was done as there would be nothing for the hardware to adhere too (sic)." On 1/6/12, in an interview with E2 (DON), she stated that the summary was from a telephone conversation with E18 (CNA) and a direct conversation with R10. The investigative statement of E13 (RN), dated 7/20/11, included, "...Resident stated to writer that after his shower the CNA was lifting him back into bed - he stated CNA was lifting him by holding him underneath his arm - and he stated he 'did not use the lift' . Resident stated - as my body hit the mattress of the bed - I heard 'Pop-Pop-Pop' and then had pain in my left leg. Writer informed resident that we would make him and wife aware of x-ray results as soon as we received them.-Resident could not remember the name of the CNA when asked." On 1/6/12, in a telephone interview with E18, he stated that he remembered R10. On 7/20/11, when the fracture occurred to R10's left hip during a transfer, E18 stated that it was the first time that he had provided care to R10. E18 stated that according to the CNA Kardex that R10 needed total care in bathing. He stated that the Kardex did not specify use of a machine for transfers but that the resident was listed as total care/dependence. E18 stated that on 7/20/11 that he lifted up R10 by himself and placed him in a shower chair. After the shower, E18 again picked up R10 from the shower chair by himself to transfer him back to bed. He stated that R10's arms were around his neck and that E18's arms were around the resident's waist. Upon transfer back to bed, R10 complained of pain in the left leg. E18 stated that he did not tell the nurse at first that he had transferred R10 back to bed by himself by lifting/picking him up. Review of a follow up Xray of the left hip, dated on 8/12/11, revealed the following results, "There is a left intertrochanteric fracture with modest displacement and angulation, without callus formation compared to 7/20/11. The joint shows no dislocation. Pubic rami are intact. Osteoporosis is present". The PT discharge summary, dated 7/27/11, noted, "Pt. (patient) d/c'd (discontinued/discharged ) p (after) family training today c (with) hoyer lift. Pt's. spouse displayed competance (sic) with same. Pt. this past week c no progress whatsoever and in fact very limited 2 (secondary to) new L (left) hip area fx (fracture) and limitation c tx (treatment) only from 'waist up' per MD new orders. Pt. doesn't tolerate even UE TE's (upper extremity therapeutic exercises) 2 pain L leg despite pain meds given. Pt.(sic) very medically compromised as well as cardiovascularly compromised. Pt is d/c'd to restorative nurse program and has been instructed on these abdominal, UE TE's". The facility failed to ensure that the resident remained free from accident hazards and that the resident received adequate supervision and assistive devices to prevent accidents. The facility failed to have an adequate system to communicate R10's transfer needs as assessed by PT and OT and nursing departments to the CNAs who were providing direct care to R10. Subsequently, the facility failed to implement R10's transfer status of extensive assistance of 2 persons with use of a hoyer lift for transfer. R10 was incorrectly transferred when E18 picked him up by himself to transfer R10 from a shower chair to bed and sustained a fractured left hip. On 1/6/12, in an interview with E2, she stated that both E18 and R10 agreed that the resident's left leg came in contact with the bed/edge of the bed and mattress and the CNA's leg during the incorrect transfer and that was how the fracture occurred due to osteoporosis.