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

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

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