Every finding on record at Avamere at Three Fountains

Based on observation, interview, and record review it was determined the facility failed to ensure a community use glucometer was cleaned with EPA (Environmental Protective Agency) approved disinfectant for 1 of 4 Halls, (Hall 2) reviewed for infection control. This placed residents at risk for cross contamination. Findings include: The facility's 10/2025 Glucometer Cleaning policy revealed staff were to clean glucometers with a bleach germicidal wipe or equivalent. On 7/7/26 at 7:46 AM Staff 3 (LPN) was observed to clean a community used glucometer with an alcohol pad. Staff 3 was stopped prior to entering another resident's room. Staff 3 stated he always used the alcohol pads to clean the glucometers. Staff 3 identified the following residents who had CBG checks for Hall 2: Residents 7, 13, 63, 68, 71, and 99. a. Resident 7 was admitted to the facility in 6/2026 with a diagnosis of diabetes. Resident 7's clinical record did not indicate she/he had a BBP (bloodborne pathogen). b. Resident 13 was admitted to the facility in 6/2026 with a diagnosis of diabetes. Resident 13's clinical record did not indicate she/he had a BBP. c. Resident 63 was admitted to the facility in 6/2026 with a diagnosis of diabetes. Resident 63's clinical record did not indicate she/he had a BBP. d. Resident 68 was admitted to the facility in 6/2026 with a diagnosis of diabetes. Resident 68's clinical record did not indicate she/he had a BBP. e. Resident 71 was admitted to the facility in 6/2026 with a diagnosis of diabetes. Resident 71's clinical record did not indicate she/he had a BBP. f. Resident 99 was admitted to the facility in 7/2026 with a diagnosis of diabetes. Resident 99's clinical record did not indicate she/he had a BBP. On 7/7/26 at 8:38 AM Staff 2 (DNS) stated staff were to use bleach wipes to clean the community use glucometers.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assisted with oral hygiene for 1 of 2 sampled residents (#81) reviewed for ADLs. This placed residents at risk for lack of oral care. Findings include: Resident 81 was admitted to the facility in 6/2026 with a diagnosis of a fracture. Resident 81's 6/29/26 admission MDS revealed she/he was cognitively intact and required assistance with ADLs including oral hygiene. Resident 81's 6/25/26 Care Plan indicated she/he required the assistance of one person for personal hygiene and mobility. On 7/6/26 at 3:02 PM Resident 81 stated since admission to the facility, staff did not provide her/him a toothbrush for oral care or offer to assist her/him with oral hygiene. During an observation on 7/7/26 at 4:08 PM with Staff 7 (CNA) Resident 81's toothbrush was observed in its original plastic wrapper in a basin by her/his sink. Resident 81 stated she/he had a bed bath today, but no one offered to help her/him brush her/his teeth. On 7/7/26 at 4:36 PM Staff 8 (CNA) stated she was Resident 81's assigned CNA on 7/7/26, day shift. Staff 8 stated Resident 81 had a toothbrush by her/his room sink but she did not assist Resident 81 with oral care during the morning shift. On 7/9/26 at 11:56 AM Staff 2 (DNS) stated residents were to be offered oral care at least two times a day, in the morning and in the evening.

Based on observation, interview and record review it was determined the facility failed to obtain physician orders for use and maintenance of a CPAP (Continuous Positive Airway Pressure) for 1 of 3 sampled residents (#76) reviewed for hospice and respiratory care. This placed residents at risk for improper air support. Findings include:Resident 76 was admitted to the facility in 6/2026 with diagnoses including sleep apnea (temporary cessation of breathing during sleep) and stroke.There was no documentation in the admission MDS, or the care plan to indicate plan Resident 76 utilized a CPAP (Continuous Positive Airway Pressure; a machine that uses mild air pressure to keep breathing airways open).Random observations from 7/6/26 through 7/10/26 on day and evening shifts revealed Resident 76 had a CPAP in her/his room on her/his nightstand.On 7/6/26 at 12:50 PM, Resident 76 stated she/he had a friend bring the CPAP to the facility a day after admission on [DATE], but staff did not clean the mask or tubing daily and the mask did not fit well.On 7/8/26 at 8:18 AM, Staff 13 (CNA) stated she was aware Resident 76 had a CPAP but she did not clean the mask or hose. On 7/8/26 8:20 AM, Staff 14 (CNA) stated she was aware Resident 76 had a CPAP since admission and washed the mask one time. On 7/8/26 at 8:31 AM, Staff 10 (RN) stated she was aware Resident 76 had a CPAP and filled the chamber with water a few times but did not clean the mask or tubing.On 7/8/26 at 2:38 PM Staff 9 (LPN Resident Care Manager) confirmed Resident 76 did not have an order for the CPAP or for the cleaning and caring of the CPAP equipment.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was provided accommodations for activities for 1 of 1 sampled resident (#81) reviewed for activities. This placed residents at risk for lack of meaningful engagement. Findings include: Resident 81 was admitted to the facility in 6/2026 with a diagnosis of a fracture. Resident 81's 6/29/26 admission MDS revealed she/he was cognitively intact, and her/his hearing was Highly impaired. Resident 81 was assessed to not use hearing aids. Resident 81's 6/29/26 Activity Profile revealed she/he liked to watch older television shows. Resident 81's 6/25/26 through 7/7/26 Self Directed Activity form revealed she/he watched television on 7/2/26. During observations on 7/7/26 at 10:38 AM, 7/7/26 at 1:42 PM, 7/7/26 at 3:37 PM, 7/8/26 at 8:13 AM, and 7/8/26 at 11:32 AM Resident 81 was observed in bed with her/his eyes shut and her/his television was not on. On 7/6/26 at 2:16 PM Resident 81 stated she/he could not hear the television when she/he wanted to watch it. On 7/8/26 at 8:48 AM Staff 4 (LPN Resident Care Manager) stated if a resident was hard of hearing and wanted to listen to the television, the facility asked the family to bring in a headset for the resident's use. On 7/8/26 at 8:52 AM Staff 5 (Social Services) stated Resident 81 was very hard of hearing and staff had to stand really close to her/his right ear to communicate. Staff 5 stated she was not aware Resident 81 had concerns related to listening to the television. On 7/8/26 at 11:40 AM Staff 18 (Activity Director) stated Resident 81 resided on the skilled unit and residents who resided on the skilled unit were usually in the facility for a short period of time. Staff 18 stated Resident 81 preferred to stay in her/his room. Staff 18 also stated she did not offer Resident 81 a headset so she/he could hear the television. On 7/8/26 at 11:50 AM Staff 6 (Social Services) stated if a resident was hard of hearing the facility provided headsets so they could watch and hear their television. On 7/8/26 at 12:04 PM Staff 2 (DNS) stated the facility should have provided headsets for residents who could not hear the television.

Based on observation and interview it was determined the facility failed to ensure furniture was in good repair for 1 of 1 facility reviewed for physical environment. This placed residents at risk for an unhomelike environment. Findings include: During an observation on 7/9/26 at 2:03 PM with Staff 19 (Maintenance Director) the armchairs in rooms 10, 16, 18, 42, and 44 were observed to have torn fabric with exposed cloth material on the armrests. The torn material on the chairs was at least one inch in diameter. The general sitting area by the front entrance had two chairs with multiple cracks in the synthetic leather on the seat covering exposing the cloth material and one armchair with missing synthetic leather exposing cloth material. Staff 19 stated the furniture was not in good repair. Staff 18 stated staff were to notify maintenance when furniture was ripped. Staff 19 stated he was not notified of the torn furniture. On 7/9/26at 12:56 PM Staff 1 (Administrator) stated if there were tears in the furniture staff were to remove the furniture.

Based on observation, interview, and record review it was determined the facility failed to ensure transmission-based precautions were followed, surfaces were sanitized and linen was properly transported for 3 of 5 halls reviewed for infection control precautions. This placed residents and staff at risk for cross-contamination. Findings include: The 12/29/21 facility Categories of Transmission-Based Precautions instructed staff: -to wear an isolation gown that was securely tied around the staff's neck and back when entering a COVID-19 positive room on special droplet precautions. -to use dedicated, non-critical resident equipment (stethoscopes) when possible to prevent cross-contamination. The 1/2025 Resident Line Listing Report, COVID-19 indicated 19 residents tested positive during the month including 9 residents who tested positive on 1/13/25. The 1/9/25 Attention Staff: PPE (Personal Protective Equipment) Donning and Doffing Education and Reminders instructed staff to remove their N-95 (droplet protection mask) and eye protection after exiting a COVID-19 positive resident room and replace with a new N-95 mask and eye protection after hand hygiene was performed. 1. On 1/14/25 at 9:21 AM room [ROOM NUMBER] was observed to require special droplet precautions. Staff 34 (LPN) exited room [ROOM NUMBER], wore a N-95 mask and face shield out of room [ROOM NUMBER] and hung a contaminated stethoscope on the room door handle towards the hall. Staff 34 did not change her N-95 mask or face shield and removed the stethoscope from the door handle to sanitize the stethoscope without sanitizing the door handle. On 1/14/25 at 9:33 AM room [ROOM NUMBER] was observed to require special droplet precautions. Staff 35 (RN) entered the room and wore a face shield and N-95 mask. On 1/14/25 at approximately 9:38 AM Staff 35 exited room [ROOM NUMBER] and did not change her N-95 mask or face shield. Staff 35 stated she worked in the facility three days and was instructed to wear a N-95 mask and face shield at all times while in the facility with no further instructions. A surveyor directed Staff 35 to read the PPE instructions on the outside of room [ROOM NUMBER]. Staff 35 read the instructions and left to obtain clarification from Staff 34 without changing her N-95 mask or face shield. On 1/14/25 at 9:39 AM Staff 38 (CMA) was observed to exit room [ROOM NUMBER], performed hand hygiene and touched the contaminated door knob. Staff 38 stated he was unaware the door knob was contaminated. On 1/14/25 at 9:50 AM Staff 34 acknowledged she did not change her N-95 mask or face shield as expected and droplet precaution rooms needed a clean area outside the rooms to sanitize equipment and prevent cross-contamination. On 1/14/25 at 10:05 AM Staff 37 (Housekeeping Director) stated housekeeping staff were not instructed to removed their N-95 masks or face shield when they exited rooms on droplet precautions. On 1/14/25 at 11:00 AM Staff 4 stated she was made aware of the breach in infection control standards when staff exited rooms on droplet precautions and the lack of clean surfaces to ensure proper sanitation of equipment. Staff 4 acknowledged an immediate in-service for staff related to infection control expectations was necessary. 2. The 1/2014 Departmental (Environment Services)-Laundry and Linen facility procedure instructed staff to ensure hygienically clean linen by covering clean linen carts. On 1/15/25 at 12:26 PM Staff 36 (Laundry) was observed to deliver personal laundry on a cart near Rooms 59 to 60 without a cover. Staff 36 stated I always deliver this way with no cover. Staff 36 indicated residents' personal laundry did not need a cover and she left residents' personal laundry uncovered and hanging outside rooms on droplet precautions. On 1/15/25 at approximately 1:00 PM Staff 37 (Housekeeping Director) acknowledged linen was to remain covered when in the hall. On 1/16/25 at 8:34 AM Staff 2 (DNS) confirmed the expectation was for all linen carts to be covered when in the hall whether clean linen was general or personal. 47001 3. On 1/12/25 at 8:28 AM Staff 27 (CNA) was observed exiting a room on COVID 19 precautions. Staff 27 removed a surgical mask which covered an N-95 mask, Staff 27 did not remove the N-95 mask. Staff 27 stated she was trained to cover the N-95 with a surgical mask when entering a COVID 19 precaution room and then remove the surgical mask upon exit. She was not trained to remove the N-95 mask and replace it with a new N-95 mask. On 1/15/25 at 11:35 AM Staff 4 (LPN Infection Preventionist) stated when staff exit a room on COVID 19 precautions, they are expected to remove all PPE, including the N-95 mask, and replace it with a new N-95 mask. 4. On 1/13/25 at 9:04 AM Staff 31 (CNA) was observed sitting on a bed in a room on Enhanced Barrier Precautions (EBP) without wearing a gown. Staff 31 stated the resident was on EBP and she should have put on a gown before sitting on the resident's bed. On 1/15/25 at 11:35 AM Staff 4 (LPN Infection Preventionist) stated when staff are caring for a resident on EBP or touching the resident's bed, they are expected to wear a gown and gloves. 5. On 1/14/25 at 3:16 PM Staff 28 (CMA) was observed changing her N-95 mask after exiting a room on COVID 19 precautions. Staff 28 was observed removing her dirty N-95 mask and without completing hand hygiene, putting on a clean N-95 mask. Staff 28 stated she should have used sanitizer after she removed the dirty N-95 mask. On 1/15/25 at 11:35 AM Staff 4 (LPN Infection Preventionist) stated staff are expected to sanitize their hands as soon as the N-95 mask comes off their face.

Based on interview and record review it was determined the facility failed to ensure CNA staff had 12 hours of annual in-service training for 2 of 5 sampled CNAs (#s 17 and 18) reviewed for staffing. This placed residents at risk for a lack of quality care. Findings include: 1. Staff 17's (CNA) training and in-service logs revealed he received 6.75 of 12 required training hours. The 6.75 hours did not include dementia training. On 1/15/25 at 10:48 AM staff 17 acknowledged he did not get the 12 hours of training completed, including dementia training. On 1/15/25 at 10:45 AM and 11:04 AM Staff 2 (DNS) verified Staff 17 worked more than one year in the facility and Staff 3 (Assistant DNS) acknowledged Staff 17 did not have his 12 hours of training in the last one year. Staff 3 sated she and the resident care managers were to monitor the in-service training hours. 2. Staff 18's (CNA) training and in-service logs revealed she received 10.25 of 12 training hours in the last one year. On 1/15/25 at 10:45 AM and 11:04 AM Staff 2 (DNS) verified Staff 18 worked more than one year in the facility and Staff 3 (Assistant DNS) acknowledged Staff 18 did not complete her 12 hours of training in the last one year. Staff 3 sated she and the resident care managers were to monitor the in-service training hours. On 1/15/25 at 10:59 AM a call was placed to Staff 18. A return call was not received.

Based on interview and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for developing drug resident organisms. Findings include: Resident 24 was admitted to the facility in 2018 with a diagnosis of anxiety. Progress Notes revealed the following: -12/31/24 Resident 24 reported painful urination and Staff 6 (NP) was notified. Staff 6 provided orders for nursing staff to obtain a urine sample and a culture and sensitivity from Resident 24. -1/1/25 nursing staff obtained Resident 24's urine sample, sent it to the lab, and the results were pending. Resident 24's UA resulted on 1/2/25 and was reviewed by Staff 6 on 1/3/25. A hand written note on the lab form indicated Cipro (antibiotic) was ordered. A 1/3/25 Order Details revealed Staff 6 ordered Ciprofloxacin (generic name for Cipro) two times a day for six days. A 1/6/25 Antibiotic Time Out form revealed Resident 24 was administered Ciprofloxacin for a UTI for initial symptoms of burning with urination. After the start of antibiotics Resident 24 did not have a fever, signs of a UTI, a change in activity, or a change in appetite. The form indicated Staff 6 was notified of Resident 24's status and antibiotics were to be continued. On 1/14/25 at 10:01 AM Staff 4 (IP LPN) stated at times, depending on a resident's medical history and UTI symptoms, antibiotics were started before a urine culture was finalized. Staff were to obtain the culture results and communicate with the resident's medical provider if the course of treatment needed to the changed. Staff 4 stated Resident 24 was started on an antibiotic before the urine culture was completed. After Resident 24's urine culture was received staff reached out to Staff 6 because the lab indicated the sample was incorrectly obtained. Staff 6 was not available and did not see the results of the labs. Staff 4 stated she communicated with Staff 9 (LPN Resident Care Manager) to let her know Staff 6 was not available. Staff 4 stated she reached out out to Staff 5 (Resident 24's Physician) and Staff 5 instructed staff to continue the antibiotic because Staff 6 initiated the treatment. Staff 4 stated she did not document the conversation with Staff 5. On 1/14/25 10:37 AM Staff 5 stated she was not notified of Resident 24's urine test results and the lab's inability to run a urine culture. After review of Resident 24's urine results, Staff 5 stated nursing staff did not properly obtain a urine sample and a culture was not performed. If the UA and associated labs were provided to Staff 5 she would have stopped the antibiotics. Staff 5 also stated if Resident 24's only symptom was burning with urination she likely would not have started Resident 24 on antibiotics in the first place. On 1/14/25 at 11:39 AM Staff 9 stated she was aware nursing staff obtained a urine sample for Resident 24. Staff 9 stated she was notified of the lack of urine culture on day six of the prescribed antibiotic therapy. Staff 9 stated Resident 24's only symptom prior to starting the antibiotic was burning with urination. On 1/14/25 at 2:22 PM Staff 6 stated Resident 24 had a UTI in 12/2024 and was prescribed an antibiotic based on the urine culture. At the end of 12/2024 when nursing staff reported Resident 24 had symptoms of a UTI she had staff obtain an UA and she started an antibiotic which would be susceptible to the organisms which were identified in Resident 24's previous urine culture. Staff 6 stated if she would have seen the results of the 1/3/2025 UA she would have stopped the antibiotics. On 1/14/25 at 2:56 PM, with Staff 2 and Staff 1, Staff 2 stated the facility follows IP protocols and staff were to reach out to the resident's medical provider within 72 hours after an antibiotic was initiated and a specimen culture resulted. Staff 2 stated there was a communication breakdown between Staff 6 and the nursing staff. Staff 2 stated if staff were not able to contact Staff 6 they should have communicated with Staff 5. Staff 2 stated Resident 24's antibiotic should have been stopped but was not.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed for self-administration of medications and physician orders were in place for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication-related consequences. Findings include: The 2001 Self-Administration of Medications facility policy indicated, as part of the comprehensive assessment, the interdisciplinary team was to assess each resident's cognitive and physical abilities to determine whether self-administration was safe and appropriate. Resident 13 was admitted to the facility in 9/2024 with diagnoses including cellulitis (bacterial infection) of right lower limb and peripheral vascular disease (reduced circulation of blood in veins). The 12/11/24 Quarterly MDS indicated Resident 13 was cognitively intact, had chronic pain and her/his pain occasionally interfered with her/his sleep and daily activity. The 12/11/24 Vitals and Pain Only Evaluation indicated Resident 13 received PRN pain medications and the resident did not feel her/his pain was an issue. The 1/2025 MAR and TAR revealed no orders for Biofreeze (topical pain relief) or Icy Hot (topical pain relief to treat minor muscle and joint pain). Review of Resident 13's clinical record revealed no assessment for the self-administration of medications. On 1/13/25 at 1:07 PM Staff 32 (CNA) stated Resident 13 had pain in her/his right knee and was observed by Staff 32 to self-administer topical pain medication which was provided by the resident's family. Staff 32 was aware orders for the topical pain medication should be in place and nurses informed. On 1/13/25 at 1:18 PM Resident 13 stated she/he had no unmanaged pain except in her/his knees which she/he addressed with the self-administration of topical pain creams. Resident 13 revealed tubes of Biofreeze and Icy Hot in her/his cabinet drawer at her/his bedside. On 1/14/25 at 12:33 PM Staff 16 (CMA) confirmed Resident 13's pain was addressed with PRN pain medications in addition to the Biofreeze the resident utilized for knee pain. Staff 16 indicated staff were aware Resident 13 self-administered her/his topical pain medication. On 1/14/25 at 2:27 PM Staff 10 (LPN) stated she was not aware any nurse was informed Resident 13 self-administered any topical pain medications and orders for the medications were not in place. On 1/15/25 at 2:52 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 13 was not assessed to self-administer her/his topical pain medication and orders for the medication were needed.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was provided restorative services for 2 of 2 sampled residents (#s 13 and 30) reviewed mobility. This placed residents at risk for decrease in range of motion. Findings include: A 7/2017 Restorative Nursing Services facility policy Interpretation and Implementation indicated restorative goals and objectives were to be individualized and outlined in the resident's plan of care to maintain dignity and self-esteem. 1. Resident 13 was admitted to the facility in 9/2024 with diagnoses including cellulitis (bacterial infection) of right lower limb and peripheral vascular disease (reduced circulation of blood in veins). The 12/11/24 Quarterly MDS indicated Resident 13 was cognitively intact, had chronic pain, weakness, deconditioning and was at risk for related declines. A 12/6/24 Restorative Program Referral indicated Resident 13 was to maintain her/his current level of functioning with the use of exercise bands as tolerated, stand tolerances in parallel bars and assistance to her/his wheelchair three to five days each week. The 1/7/24 revised care plan indicated Resident 13 was at risk for decreased mobility and was on a maintenance RA program. A 30 day look back of the Nursing Rehabilitation task indicated on 12/20/24 and 1/3/25 services were received by Resident 13 and on 12/27/24 the resident refused services. No additional RA hours were documented. The 12/28/24 and 1/11/25 Weekly Progress Notes by Staff 33 (RA) indicated Resident 13 did not received RA therapy. On 1/12/25 at 9:22 AM Resident 13 stated RA was available to assist with exercise bands for a period of time and then services stopped. Resident 13 indicated Staff 9 (LPN-Resident Care Manager) was notified of the concern. On 1/13/25 at 2:53 PM Staff 39 (PT Assistant) stated therapy would submit RA referrals to Staff 9 to implement. Staff 39 indicated there were times when Resident 13 refused RA services and refusals should be documented. On 1/13/25 at 3:19 PM Staff 9 acknowledged Resident 13 received limited RA services during the last 30 days. On 1/14/25 at 12:06 PM Staff 33 stated she was unable to provide RA services for residents from 12/23/24 through 12/28/24 and during the last seven days because she was scheduled to work as a CNA. On 1/15/25 at 2:52 PM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Assistant DNS) stated the facility attempted to schedule RA staff daily but acknowledged, since 12/2024, RA services had not occurred as expected due to lack of available CNAs. 2. Resident 30 was admitted to the facility in 10/2024 with diagnoses including diabetes and cellulitis (bacterial infection) of right lower limb. The 11/3/24 Admission MDS indicated Resident 30 was cognitively intact, was at risk for falls, required one staff to assist with mobility using her/his front wheel walker and received no RA services. A 11/23/24 Restorative Program Referral indicated Resident 30 was to maintain her/his current level of function with assisted use of her/his front wheel walker or exercise equipment as tolerated utilizing seated exercises, knee marches, ball squeezes and light hip exercise two to three times each week. The 12/7/24 revised care plan indicated Resident 30 had a RA program related to her/his risk for decreased mobility. A 30 day look back of the Nursing Rehabilitation task indicated on 12/17/24 and 12/25/24 RA services were received by Resident 30. No additional RA hours were documented. The 12/7/24 Weekly Progress Notes by Staff 33 (RA) indicated Resident 30 received one day of RA therapy. The 1/11/25 Weekly Progress Notes by Staff 33 (RA) indicated Resident 30 received no RA services during the week. On 1/14/25 at 12:06 PM Staff 33 stated Resident 30 asked her when RA would begin again and acknowledged the resident received limited RA services. On 1/14/25 at 3:10 PM Resident 30 stated she/he did not receive RA services for three weeks and they were to occur three times weekly. Resident 30 stated she/he voiced her/his concerns to Staff 9 (LPN-Resident Care Manager) who coordinated RA services but RA services were not provided. Resident 30 believed her/his legs were more stiff and painful due to the lack of RA services. On 1/15/25 at 9:13 AM Staff 17 (CNA) stated Resident 30 requested RA services for her/his leg pain and because only RA staff were permitted to provide RA services, he was only able to assist Resident 30 with walking while in her/his room. On 1/15/25 at 1:16 PM Staff 9 confirmed Resident 30 complained about the lack of RA services and acknowledged Resident 30 was a prime candidate for RA services because of her/his high level of function which was important to maintain. Staff 9 stated the facility should have daily RA services available in order to meet the RA schedule of Resident 30. On 1/15/25 at 2:52 PM Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Assistant DNS) stated the facility attempted to schedule RA staff daily but acknowledged, since 12/2024, RA services had not occurred as expected due to the lack of available CNAs.

Based on interview and record review it was determined the facility failed to ensure the resident was free from a significant medication error for 1 of 3 sampled residents (#101) reviewed for medications. As a result, Resident 101 was hospitalized for a drug overdose. Findings include: On 8/30/23 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined significant medication errors were found. An interview on 3/28/24, with Staff 1 (Administrator) and Staff 2 (DNS) revealed the facility's plan of correction included the following: -Staff education completed for all CMAs and LPNs on Administering Medications Policy, 7 Rights of Medication Administration, 5 Ways to Identify Residents and medication pass audit. -DNS completed Education with the responsible nurse. -DNS or designee will conduct random audits of CMAs or LNs weekly for completing seven rights of medication administration and how to identify residents for four weeks, then at least monthly for three months. Resident 101 was readmitted to the facility in 8/2023, with diagnoses including recent placement of a cardiac pacemaker (implanted medical device that generates electrical pulses to chambers of the heart), respiratory failure, and end stage kidney disease with dialysis (clinical purification of blood). A Facility Reported Incident indicated on the evening of 8/16/23, Resident 101 received ten medications prescribed for Resident 106. Resident 101 was administered the following medications: -Advair (a steroid medication), -Clozaril (an antipsychotic medication), -Olanzapine (an antipsychotic medication), -Metformin (an anti-diabetic medication), -D-Mannose (a UTI prevention medication), -Flomax (an alpha blocker medication), -Combivent (a beta 2-adrenergic agonist medication), -Tylenol (an analgesic medication), -Vitamin C and Systane eyedrops. The report indicated the medications were given by Staff 6 (LPN) just after 7:00 PM. The report indicated Staff 6 realized he had administered the wrong medications to Resident 101 and the resident had a decrease in her/his level of consciousness. The physician was notified and the resident was sent out to the hospital on 8/17/24 at 1:09 AM. A Facility Discharge Summary dated 8/17/23, indicated the resident was transferred to the hospital after she/he was given medications belonging to another resident at the bedtime medication pass on 8/16/24. The diagnosis was accidental overdose. The resident's condition on discharge was noted as poor. A Hospital Emergency Department Triage Note dated 8/17/23 at 1:18 AM, indicated Resident 101 received her/his own prescribed medications as well as ten medications from another resident at the facility. The facility monitored and became concerned when the resident became A&O x 0 (alert and oriented times zero or the lowest level of consciousness) when she/he was normally A&O x 4 (alert and oriented to person, place, time, and event). A Hospital History and Physical dated 8/17/23, indicated on arrival the resident had an altered mental status related to an unintentional drug overdose. The plan was to address the acute encephalopathy (alteration of mental status due to systemic factors) due to the drug overdose. While at the nursing facility the resident was administered the following medications: metformin 2,000 mgs (an antidiabetic medication), clozapine 175 mgs (an antipsychotic medication), Olanzapine 5 mgs (an antipsychotic medication) and seven other medications prescribed to another resident. The clinical impression included metformin and an antipsychotic overdose. On 8/17/23 the resident also became severely hypotensive (low blood pressure), lost consciousness and became unresponsive. On 8/18/23 the resident had severe hypotension (shock), hypokalemia (low potassium critical for proper functioning of cells, particularly heart muscle cells), and lethargy. The resident was transferred to the ICU (Intensive Care Unit). On 3/28/24, Staff 1 (Administrator) provided the facility's Accident Incident Manual - Medication Error Check List which indicated Staff 6 failed to: -Ask the resident to state their name. -Use the picture identifier, the name plate on the resident's door or any other acceptable identifier prior to administering the medications to Resident 101. On 3/29/24 at 8:15 AM, Staff 6 (LPN) stated he gave Resident 101 ten medications prescribed for Resident 106 shortly after 7:00 PM. Staff 6 stated while giving Resident 101 she/he stated this was a lot of medications. Staff 6 stated he did not follow up on the remark. Staff 6 stated it was a lapse in his practice for not verifying the correct resident before administering the medications. Staff 6 stated he also went back and gave Resident 101 her/his prescribed medications after being aware of his initial medication error. The resident received mirtazapine (an antidepressant medication), Eliquis (a blood thinner medication), vitamin D and artificial tears eye drops. Medication documentation indicated the resident received those medications at 8:30 PM which was after the 7:00 PM medication error and she/he was also administered nitroglycerin (heart medication) at 10:39 PM. Staff 6 stated, I should have checked with someone before giving her/him additional medications on top of the incorrect medications. I just used my nursing judgement. On 4/1/24 at 1:40 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 6 made a significant medication error which resulted in Resident 101 being hospitalized . Staff 1 acknowledged Staff 6 did not follow protocol for the safe administration of medications and failed to contact the physician prior to administering additional medications to Resident 101. Staff 1 also confirmed Staff 6 failed to provide appropriate documentation in the medical record for the other resident whose medications were administered to Resident 101.

Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards for 1 of 7 sampled residents (#101) reviewed for significant medication error. As a result, Resident 101 experienced a decline in condition and required hospitalization for a drug overdose. Findings include: On 8/30/23 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined Staff 6 failed to adhere to professional standards of practice for medication administration. An interview on 3/28/24, with Staff 1 (Administrator) and Staff 2 (DNS) revealed the facility's plan of correction included the following: -Staff education completed for all CMAs and LPNs on: Administering Medications Policy, 7 Rights of Medication Administration, 5 Ways to Identify Residents and medication pass audit. -DNS completed education with the responsible nurse. -DNS or designee will conduct random audits of CMAs or LNs weekly for completing the seven rights of medication administration and how to identify residents for four weeks, then at least monthly for three months. [NAME] 851 045 0050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling. (c) Be knowledgeable of the professional nursing practice standards applicable to LPN practice and adhere to those standards. [NAME] 851 045 0070 Conduct Derogatory to the Standards of Nursing (4)Conduct related to communication: (a)Failure to accurately document nursing interventions and nursing practice implementation. (b)Failure to document nursing interventions and nursing practice implementation in a timely, accurate, thorough, and clear manner. This includes failing to document a late entry within a reasonable time period. (c)Entering inaccurate, incomplete, falsified, or altered documentation into a health record or agency records. This includes but is not limited to: Failing to communicate information regarding the client's status to other individuals who are authorized to receive information and have a need to know. (8)Conduct related to other federal or state statute or rule violations: (q) Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 101 was readmitted to the facility in 8/2023 with diagnoses including recent placement of a cardiac pacemaker (implanted medical device that generates electrical pulses to chambers of the heart), respiratory failure and end stage kidney disease with dialysis (clinical purification of blood). A Facility Reported Incident indicated on the evening of 8/16/23, Resident 101 received ten medications prescribed for Resident 106. Resident 101 was administered the following medications: -Advair (a steroid medication), -Clozaril (an antipsychotic medication), -Olanzapine (an antipsychotic medication), -Metformin (an anti-diabetic medication), -D-Mannose (a UTI prevention medication), -Flomax (an alpha blocker medication), -Combivent (a beta 2-adrenergic agonist medication), -Tylenol (an analgesic), -Vitamin C and, -Systane eyedrops. The report indicated the medications was given by Staff 6 (LPN) just after 7:00 PM. The report indicated Staff 6 realized he had administered the wrong medications to Resident 101 and the resident had a decrease in her/his level of consciousness. The physician was notified and the resident was sent out to the hospital on 8/17/24 at 1:09 AM. A Hospital History and Physical dated 8/17/23, indicated on arrival the resident had an altered mental status related to an unintentional drug overdose. The plan was to address the acute encephalopathy (alteration of mental status due to systemic factors) due to the drug overdose. While at the nursing facility the resident was administered the following medications: metformin 2,000 mgs (an antidiabetic medication), clozapine 175 mgs (an antipsychotic medication), Olanzapine 5 mgs (an antipsychotic medication) and seven other medications prescribed to another resident. The clinical impression included metformin and an antipsychotic overdose. On 3/29/24 at 8:15 AM, Staff 6 stated he gave Resident 101 ten medications prescribed for Resident 106. Staff 6 stated while giving Resident 101 the medications, she/he stated this was a lot of medications. Staff 6 stated he did not follow up on Resident 101's statement. Staff 6 stated it was a lapse in his practice for not verifying the correct resident before administering the medications. Staff 6 stated he realized later he had made the mistake. Staff 6 stated he also went back and gave Resident 101 her/his prescribed medications after being aware of his initial medication error. The resident received mirtazapine (an antidepressant medication), Eliquis (a blood thinner medication), vitamin D and artificial tears eye drops. Medication documentation indicated the resident received those medications at 8:30 PM which was after the 7:00 PM medication error and she/he was also administered nitroglycerin (heart medication) at 10:39 PM. Staff 6 stated, I should have checked with someone before giving her/him additional medications on top of the incorrect medications. I just used my nursing judgement. On 4/1/24 at 1:40 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed Staff 6 made a significant medication error, which resulted in Resident 101 being hospitalized . Staff 1 acknowledged Staff 6 did not follow protocol for the safe administration of medications and failed to contact the physician prior to administering additional medications to Resident 101. Staff 1 also confirmed Staff 6 failed to provide appropriate documentation in the medical record for the other resident who's medications were administered to Resident 101. Refer to F760

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of their narcotic medications for 3 of 3 sampled residents (#s 103, 104 and 105) reviewed for drug diversion. This placed residents at risk for unmet medication care needs. Findings include: On [DATE], the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined three incidents of misappropriation of resident's narcotic medication were found. An interview on [DATE], with Staff 1 (Administrator) and Staff 2 (DNS) revealed the facility's plan of correction included the following: -Staff 7 (RCM/LPN) began Investigation immediately upon being informed of the missing medications and Staff 8 was put on administrative leave. -All staff with access to medication carts were drug screened. -All discarded medications were destroyed. -Access to medication carts was minimized during the investigation. -All narcotic books (ledgers) were audited. -No residents were negatively impacted by the missing medications. -Missing medications were reported to physician, State Agency, and Law Enforcement Agency on [DATE] and [DATE]. -Staff 8 (LPN) was suspended pending the investigation and later terminated. -Staff education completed for all CMAs and LPNs on fully completing each section of the narcotic books and on the narcotic destruction process. Training included: Narcotic Books and Page Transfer In-service, Controlled Substance Log Book, Shift Audit Record, Example Documentation, Pharmacy: Pulling Controlled Medications from the Cubex Machine. -Any narcotic discrepancies are to be reported immediately to nurse management. -Carts checked at least weekly for discontinued narcotics. -DNS or designee to audit all med carts weekly for narcotic destruction needs. -DNS or designee will audit up to three narcotic books weekly for accuracy for four weeks, then monthly for three months, until substantial compliance was met. On [DATE] at 3:42 PM Staff 1 and Staff 2 were notified of past non-compliance. 1. Resident 103 was admitted to the facility in ,d+[DATE], with diagnoses including palliative care (end of life) and chronic pain. An Incident Report dated [DATE] indicated Staff 3 (CMA) reported to Staff 4 (RCM/LPN) her concern of missing narcotics during her narcotics count. Staff 4 reviewed the medication destruction logs and found the missing medication card of oxycodone (a narcotic pain medication) had been signed to another page in the facility's Narcotic Book with a different medication and resident name on the card. A search was conducted but staff were unable to find the missing medication card. A review of the facility's Narcotic Log Book indicated a page was initiated on [DATE] for Resident 103's narcotic pain medication (oxycodone). Resident 103 received her/his medication twice on [DATE] and once on [DATE]. The bottom of the page indicated the balance of the medications were transferred to Unit I, Book 80, page 125, with a balance of 27 tablets. The new page was backed dated [DATE]. The balance transfer date on the page was prior to the dates any medication was administered. The signature on the page was identified by the facility as a forgery. A facility investigation document dated [DATE] by Staff 2 (DNS), indicated the day shift CMA remembered counting a page (in the narcotic book) for a recently deceased resident but the corresponding card of narcotics was not in the medication cart. The card was unable to be located by staff. The destruction logs were checked by the RCM and she found the page of oxycodone had been signed as if transferred to another page in the narcotic book but that page had a different medication and resident's name on it. On [DATE], two additional cards of oxycodone were identified to be missing from another cart. An investigation for narcotic diversion was started. Law enforcement and the state agency were notified. On [DATE] at 2:15 PM, Staff 1 (Administrator) acknowledged the misappropriation of medications had occurred. 2. Resident 104 was admitted to the facility in ,d+[DATE], with diagnoses including fractured leg and chronic pain. An Incident Report dated [DATE], indicated Staff 5 (CMA) notified a RCM she felt there were missing narcotics from her medication cart. Staff 5 went page by page through the narcotic book and identified missing medication. One missing card of oxycodone was found previously for another resident and two missing cards of oxycodone were found to be missing for Resident 104. A review of the facility's Narcotic Log Book indicated pages were initiated on [DATE] and [DATE] for Resident 104's PRN narcotic pain medication (oxycodone). Resident 104 received her/his last medication from the [DATE] card on [DATE] and from the [DATE] card on [DATE]. The bottom of the page indicated the balance of the medications were transferred to other books and pages which were found to already have entries for other residents. The balance transfer dates on the pages were illegible. The signature on the page was identified by the facility as a forgery. The facility investigation dated [DATE], indicated the resident received her/his last dose of the medication on [DATE] when she/he had out patient surgery. The RCM found two pages of the narcotic book had been signed as if the medications were transferred to another page but those pages had different medications and residents on them. The two cards in question were not accounted for anywhere in the books or in the facility. The missing medications identified were noted to be discontinued medications. An audit of the narcotic books in use showed no further concerns. Law enforcement and the state agency were notified. On [DATE] at 2:15 PM, Staff 1 (Administrator) confirmed the misappropriation of medications had occurred. 3. Resident 105 was admitted to the facility in ,d+[DATE] with diagnoses including traumatic brain injury and neuralgia (shock-like pain that follows the path of a nerve). A Facility reported incident dated [DATE], indicated a CMA reported a narcotic was signed out of the narcotic book after a medication count was completed and after the keys were handed off. The signature in the book appeared to be forged. No adverse effects were noted as a result of the potential misappropriation. The facility determined a dose of Resident 105's oxycodone was signed out of the narcotic book at 6:20 PM on [DATE] and was not documented on the eMAR, and the resident did not receive the dose of the medication at 6:20 PM. Staff were unable to find the missing dose of medication and misappropriation of property was not ruled out. Facility staff noted the medication was similar, and the signature on the narcotic book page resembled the signatures identified in their previous drug diversion investigation opened on [DATE]. On [DATE] at 2:15 PM, Staff 1 (Administrator) acknowledged the misappropriation of medication had occurred. Staff 1 also stated Staff 8 was the only one with keys to the cart during the timeframe the narcotic went missing.

Based on interview and record review it was determined the facility failed to ensure sanitation protocols were followed for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses. Findings include: The 8/2023 High Temperature Dish Machine Log revealed from 8/4/23 through 8/21/23 during breakfast all final rinse water temperatures were below 180 degrees. The lunch period dish machine temperatures revealed only on 8/10/23, 8/16/23 and 8/21/23 were the required 180 degree final rinse water temperature for sanitation achieved. No corrective action notes were found for any dish machine temperatures that were out of range. On 8/21/23 at 12:26 PM Staff 9 (Dietary Aide) stated he believed any dish machine final rinse temperature above 175 degrees was acceptable and thought management monitored the High Temperature Dish Machine Log for out of range dish machine temperatures. On 8/21/23 at 12:56 PM Staff 8 (Dietary Manager) stated she regularly walked through the kitchen to ensure the dish machine was working, had knowledge staff recorded the dish machine temperatures without correct verification, acknowledged she did not address the out of range dish machine temperatures for the dish washer properly, and could not confirm the final rinse temperatures for the dish machine were consistently met. There were no resident food-related illnesses during this time frame.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for COVID-19 testing for 1 of 3 treatment carts, vital sign equipment sanitation for 1 of 4 halls (40's Hall), wound care for 1 of 2 sampled residents (#32) reviewed for pressure ulcers and catheter care for 1 of 1 sampled resident (#40) reviewed for catheters. This placed residents at risk for infections. Findings include: 1. On 8/23/23 at 2:38 PM Staff 12 (CNA) was observed to check vital signs in room [ROOM NUMBER], then walk across the hall to room [ROOM NUMBER] to check vital signs. Staff 12 was asked what she used to sanitize the equipment for room [ROOM NUMBER] and 66. She stated she used alcohol wipe prep pads. On 8/23/23 at 2:45 PM Staff 25 (MDS Coordinator) acknowledged staff should always use an EPA (Environmental Protective Agency) approved sanitizer for sanitizing all equipment. Alcohol wipe prep pads are not an approved sanitizer for this purpose. 2. On 8/24/23 at 3:34 PM a random observation of a treatment cart in the 40's hallway revealed a used COVID-19 test on top of the treatment cart not covered. The COVID-19 test was positive. Staff 17 (LPN) acknowledged used COVID-19 tests should be covered and not left on top of a cart with multiple residents and staff in the area. 3. Resident 32 was admitted to the facility in 2022 with diagnoses including pain. On 8/24/23 at 9:25 AM Staff 13 (LPN) was observed to perform a dressing change on Resident 32. Resident 32 had two Stage 2 pressure wounds to her/his hip. Staff 13 donned clean gloves, removed the dirty dressing from the wound, did not change her gloves, cleaned the wound and prepared to apply Santyl (ointment to remove dead tissue from pressure ulcers) and calcium alginate (dressing used for wound repair) to the wound with dirty gloves. Staff 13 was stopped before she applied ointment and dressing. On 8/24/23 at 9:25 AM Staff 13 (LPN) acknowledged she did not change her dirty gloves before the wound was cleansed in preparation for the ointment and dressing. 26991 4. Resident 40 was admitted to the facility with diagnoses including bladder obstruction. On 8/21/23 at 4:44 PM Resident 40's catheter drainage bag was observed on the floor. Staff 21 (LPN) stated the catheter drainage bag should not be on the floor and should be elevated or placed on a barrier. On 8/22/23 at 1:53 PM Resident 40's catheter drainage bag was observed on the floor. On 8/22/23 at 2:01 PM Staff 22 (CNA) stated the catheter drainage bag should not be on the floor. On 8/24/23 at 9:28 AM Staff 25 (MDS Coordinator) acknowledged the resident's catheter drainage bag should not be on the floor.

Based on observation, interview and record review it was determined the facility failed to ensure automatic doors were functional for 1 of 1 non-smoking courtyard. This placed residents at risk for exposure to weather related elements and inability to re-enter the facility. Findings include: An estimate of repairs prepared on 4/21/23 revealed there were four operators (automatic door openers) recommended to be replaced associated with the doors to the non-smoking courtyard. On 8/22/23 at 6:08 PM Resident 125 stated the doors in the non-smoking courtyard did not work. It was the only area residents could go out and enjoy the fresh air. The other courtyard was where residents smoked. Resident 125 stated on two occasions she/he was assisted out to the non-smoking courtyard, but staff did not return to help her/him return into the facility. Resident 125 stated she/he fortunately had a cell phone to call the front desk for assistance. On 8/22/23 at 2:40 PM a tour of the non-smoking courtyard was conducted with Staff 1 (Administrator). The doors were not able to be opened with the automatic door opener and were heavy to pull. A sign was observed on the inside-facing surface of the non-smoking courtyard door indicating the courtyard was temporarily shut down for repair due to broken doors. A bolt was observed at the top of the door to prevent the door from manually being opened. On 8/22/23 at 9:27 AM Staff 5 (Maintenance Director) stated the facility called many companies to evaluate the courtyard door operators and the companies were not able to repair the brand of doors the facility had. The courtyard doors were broken for about three months. On 8/24/23 at 1:56 PM Staff 23 (Former CNA) stated she worked at the facility for approximately six years and the non-smoking courtyard doors were broken on and off during that period of time. The doors broke, were repaired, then broke again. The doors were really heavy and they were hard to open. One day she was at work and the front desk staff called and stated Resident 125 was outside in the non-smoking courtyard and was not able to open the doors. Resident 125 had a cell phone, called the facility's front desk staff, and Staff 23 opened the doors for the resident.

Based on observation, interview and record review it was determined the facility failed to accurately assess pressure ulcers for 1 of 3 sampled residents (#10) reviewed for pressure ulcers. This placed residents at risk for inaccurate treatment. Findings include: Resident 10 was admitted to the facility in 2023 with diagnoses including malnutrition. A 1/12/23 care plan indicated Resident 10 had potential/actual impairment to skin integrity. On 6/22/23 the care plan indicated Resident 10 had new MASD (moisture associated skin damage) to her/his coccyx (tail bone) and sacrum (near the lower back and spine). The 7/24/23 through 8/22/23 Skin and Wound Evaluation Reports, including photos, indicated Resident 10 had MASD and IAD (incontinence associated dermatitis) on her/his sacrum with 80 percent slough (yellow/white material in the wound bed). Based on reviewed photos, the assessments inaccurately described the wounds. On 8/24/23 at 9:59 AM Staff 13 (LPN) was observed to perform a dressing change. The coccyx/sacral area had three open areas with slough in all three. The wounds were observed to be unstageable pressure ulcers (full thickness skin loss in which the base of the ulcer is obscured by slough). On 8/24/23 at 10:41 AM Staff 3 (LPN Resident Care Manager) acknowledged the wounds should have been assessed as unstageable pressure ulcers and the assessments were not accurate.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 1 of 2 sampled residents (#54) reviewed for nutrition. This placed residents at risk for unsafe medication administration. Findings include: Resident 54 was admitted to the facility in 2023 with diagnoses including seizures. An 8/11/23 Admission MDS and associated CAAs revealed Resident 54 was cognitively impaired and required assistance of one staff to eat meals. On 8/22/23 at 2:05 PM Resident 54 was observed in bed with her/his eyes open. A clear plastic medicine cup containing a pink, large flat tablet was observed on the bedside table and was within reach of the resident. On 8/22/23 at 2:09 PM the surveyor showed Staff 3 (LPN Resident Care Manager) the tablet on Resident 54's bedside table and Staff 3 stated the resident was not assessed to self-administer medications and medications were not to be left at the bedside.

Based on interview and record review it was determined the facility failed to ensure care plans were revised for 1 of 2 sampled residents (#54) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 54 was admitted to the facility in 2023 with diagnoses including seizures. An 8/11/23 Admission MDS and associated CAAs revealed Resident 54 was cognitively impaired and required assistance of one staff to eat meals and had difficulty swallowing. A Care Plan initiated 8/8/23 revealed the resident had impaired swallowing with risk for aspiration (food or fluid enters the airway during swallowing) and required one to one supervision with meals. On 8/22/23 at 2:05 PM Resident 54 was observed in bed with her/his eyes open, a water pitcher was on the bed-side table and the pitcher was within reach of the resident. Staff was not in the room with the resident. A sign was observed above the resident's bed titled Aspiration Precautions. The amount of supervision with meals was marked 1:1 supervision. On 8/22/23 at 2:09 PM Staff 3 (LPN Resident Care Manager) stated the resident was no longer at risk for aspiration and the one to one supervision was due to her/his inability to physically feed her/himself and the care plan was not up-to-date. On 8/22/23 at 2:33 PM Staff 15 (Therapy Directory) stated speech therapy worked with Resident 54 and Staff 15 verified there were no current aspiration concerns, but the resident required one to one supervision to ensure she/he was able to bring food to her/his mouth.

Based on observation, interview and record review it was determined the facility failed to provide a meaningful activity program for 3 of 4 sampled residents (#s 40, 48 and 54) reviewed for activities. This place residents at risk for lack of social interaction and isolation. Findings include: 1. Resident 40 was admitted to the facility in 2020 with diagnoses including dementia. A 7/15/23 Annual Preference for Routine and Activities form revealed Resident 40 was able to answer the questions. The resident indicated it was very important to her/him to do her/his favorite activities which included listening to music. The resident indicated it was somewhat important to be around pets and groups of people. A 7/17/23 Annual MDS and associated CAAs indicated the resident had impaired cognition, was able to make her/his needs known and required time to respond. A Care Plan revised on 7/25/23 revealed the resident liked to watch the Lone Ranger, listen to country and soft music and liked some sensory activities (blocks). Staff were to invite the resident to activities of interest, provide a calendar and in-room materials as indicated (the type of materials was not specified). A 7/26/23 through 8/23/23 Self Directed Activity log, included listening to music and being around pets. There were no activities documented in the log. A 7/26/23 through 8/23/23 Group Activity log revealed the resident was not offered to attend any activities. A 7/26/23 through 8/23/23 One to One Activity log revealed the resident had two interactions. On 8/23/23 At 3:07 PM Staff 16 (CNA) stated Resident 40 did not participate in activities. The resident did not like the sensory blocks and did not like to be with others. On 8/23/23 at 3:24 PM Staff 14 (Activity Director) stated a calendar was provided to all residents and they checked with residents to see if they wanted to attend activities. CNA staff were also to check with residents see if they wanted to attend an activity. The activity staff tried to provide one to one activities for residents with dementia. Staff 14 stated they had pet visits at least five days a week. Staff 14 acknowledged there were not very many documented activities provided as offered for Resident 40. On 8/24/23 at 9:23 AM Staff 18 (CNA) stated Resident 40 usually just slept in her/his room. At times staff offered to take the resident to activities and/or provided the resident a magazine to look at. The resident usually watched television. 2. Resident 54 readmitted to the facility in 8/2023 with diagnoses including seizures. A Care Plan initiated 6/2023 revealed the resident liked to watch game shows, play bingo, be outside, and spend time with family and pets. Staff were to invite the resident to activities of the resident's preference. An 8/6/23 Preferences for Routine and Activities form revealed the resident was able to answer the questions and it was very important for the resident to listen to music, be around pets, go outside, participate in religious activities and do her/his favorite activities. An 8/11/23 Admission MDS and CAAs revealed the resident had a cognitive decline, was alert, able to make needs known, and direct her/his care. The resident was dependent on staff for transfers out of bed. Activity documentation from 8/2/23 through 8/23/23 revealed the resident had three one to one visits and was offered to attend one group activity. There was no indication the resident was offered pet therapy. Observations revealed on 8/21/23 at 1:05 PM Resident 54 was in bed with her/his eyes shut. The television was off and there was no music playing in the background. On 8/21/23 at 2:45 PM Resident 54 stated she/he liked to play board games. On 8/23/23 at 3:34 PM Staff 14 (Activity Director) stated a calendar was provided to all residents and they checked with residents to see if they wanted to attend activities. CNA staff were also to check with residents see if they wanted to attend an activity. The activity staff tried to provide one to one activities for residents with dementia. Staff 14 stated they had pet visits at least five days a week. Staff 14 stated Resident 54 was provided in-room bingo and should have a bingo card on a clipboard in her/his room. The facility just had a pet visit and the resident should have been visited. Staff 14 acknowledged there were not many documented activities provided as offered for Resident 54. On 8/23/23 at 4:13 PM with Staff 16 (CNA), a BINGO form on a clip board was not observed in Resident 54's room. 41455 3. Resident 48 was admitted to the facility in 2021 with diagnoses including dementia and lung cancer. A 9/7/22 revised care plan indicated to invite Resident 48 to activities of interest, and she/he liked the outdoors and to watch news and western shows. The 5/30/23 Annual MDS indicated Resident 48's cognition was moderately impaired, she/he had no physical limitations to her/his lower extremities and was not transferred out of her/his bed during the review period. The 7/22/23 through 8/21/23 Task Activity: One on One indicated on 7/31/23 Resident 48 received passive interaction. No additional activities were documented during the period. On 8/21/23 at 5:10 PM Resident 48 was observed in bed and stated she/he knew it took effort to get her/him out of bed but wanted support to get up depending on the activity. On 8/22/23 at 11:39 AM Staff 12 (CNA) stated Staff 10 (Activity Assistant) at times went into Resident 48's room and did not stay long. On 8/23/23 at 10:43 AM Staff 10 stated she relied on CNA staff to motivate Resident 48 to get out of bed and the resident often refused or slept. Staff 10 stated she visited Resident 48 monthly when she dropped off the monthly activity calendar and acknowledged more frequent interactions with Resident 48 would be beneficial. On 8/23/23 at 11:14 AM Staff 14 (Activity Director) stated residents with dementia needed daily interaction and acknowledged once a month activity for Resident 48 and was not sufficient.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 2 of 3 sampled residents (#s 3 and 11) reviewed for accidents. Resident 3 fell out of bed and sustained a right [CONDITION(S)]. Findings include: 1a. Resident 3 admitted to the facility in 2020 with diagnoses including dementia and a stroke. A comprehensive care plan dated 8/18/20 and revised on 3/4/21 indicated Resident 3 was a high fall risk related to a history of falls. Staff were directed to check on Resident 3 frequently when she/he was in bed and the bed was to be in a lowered position with fall mats on each side of the bed. A soft touch call light was to be within reach at all times. An Incident Report initiated on 3/5/21 revealed the following: -Resident 3 had an unwitnessed fall in her/his room. The resident was laying on her/his back on the floor and holding onto her/his right hip. Resident 3 was unable to move her/his right leg and the right foot was externally rotated. Resident 3 was sent to the hospital for evaluation. -Staff 17 (CNA) stated she laid Resident 3 down in bed at approximately 7:30 PM because she/he was tired. Staff 17 stated at approximately 8:30 PM she saw the resident sitting up in her/his bed and the bed was in a low position. She stated she knew the resident's bed was to be in the lowest position and to make sure her/his call light was within reach. Staff 17 stated she did not know Resident 3 was supposed to have fall mats on both sides of her/his bed. She indicated she did not see the fall mats in the room. Staff 3 stated she thought she had reviewed all her residents' care plans except for Resident 3's care plan. -Staff 7 (RN) stated she entered Resident 3's room to administer medication to her/his roommate and found Resident 3 laying on the floor on her/his back. The bed was in a low position and the resident was holding onto her/his right hip stating, my hip hurts. Staff 7 completed her assessment; pain was noted to the right upper hip, Staff 8 (RCM-LPN) was notified, and the resident was sent out to the hospital. -Staff 7 and Staff 8 noticed Resident 3 had a fall mat on the right side of her/his bed but there was no fall mat on the left side of the bed which was folded in half and was between the nightstand and the wall. -An x-ray from the hospital revealed a right [CONDITION(S)] was sustained. -Abuse and neglect were ruled out. On 9/7/21 at 9:38 AM Staff 7 stated Resident 3 was not alert and only oriented to herself/himself. Staff 7 stated she entered Resident 3's room on 3/5/21 to administer medications to her/his roommate and found Resident 3 on the floor. She noticed Resident 3's right leg was rotated externally, and she could not touch her/his right hip area because of pain, and the resident kept saying that hurts. Staff 7 stated she noticed there were no fall mats on one side of her/his bed. Staff 7 stated Staff 17 did not place fall mats down on 3/5/21 in the evening when putting the resident to bed. Resident 3 was sent out to the hospital because she/he fractured her/his right hip. On 9/7/21 at 9:53 AM Staff 17 stated she cared for Resident 3 on 3/5/21 when Resident 3 was found on the floor in her/his room. She stated Resident 3 was a fall risk and her/his bed was supposed to be in the lowest position and fall mats were to be placed on both sides of her/his bed. Staff 17 stated she did not look at her/his care plan and did not see the fall mats in Resident 3's room. Staff 17 stated she heard the resident yelling and when she entered the room Staff 7 was already in the room. On 9/8/21 at 10:17 AM Staff 8 stated Staff 7 called her into Resident 3's room on 3/5/21 and the resident was on the floor holding onto her/his right hip. Staff 8 stated the resident was unable to move her/his right leg, was in pain and her/his right foot was pointed outwards. Staff 8 stated they kept the resident on the ground, and she/he was transported to the hospital. Staff 8 stated Staff 17 did not follow the care plan because Resident 3 did not have a fall mat in place on the side of the bed she/he fell out of and Staff 3 stated she did not look at the care plan and did not see the fall mats in the resident's room. b. An observation on 9/2/21 from 1:30 PM through 3:00 PM revealed Resident 3 was laying on his back, asleep in bed. The bed was approximately two in a half feet from the ground, and there were no fall mats in place but were leaned up against the wall in her/his room. A comprehensive care plan dated 8/18/20 and revised on 3/4/21 indicated Resident 3 was a high fall risk related to a history of falls. Staff were directed to check on Resident 3 frequently when she/he was in bed and the bed was to be in a lowered position with fall mats on each side of the bed. A soft touch call light was to be within reach at all times. On 9/2/21 at 11:46 AM Staff 10 (CNA) stated Resident 3 was a fall risk and when she/he was in bed staff should ensure the bed was in the lowest position and fall mats were in place on both sides of her/his bed. On 9/2/21 at 2:55 PM Staff 16 (Nursing Assistant) stated Resident 3 was a fall risk and when the resident was in bed. The bed should be in the lowest position with fall mats down on both sides of the bed. Staff 16 stated she reviewed the care plan at the beginning of her shift to know what the resident care needs were. On 9/2/21 at 3:21 PM Staff 12 (Social Service) entered Resident 3's room and acknowledged her/his bed was not in the lowest position and her/his fall mats were leaned up against the wall. On 9/2/21 at 5:04 PM Staff 8 (RCM-LPN) stated she expected all CNAs to review the care plan and the Kardex (a form utilized by CNAs to provide information related to ADL care for residents). Staff 8 stated she expected CNAs to ensure Resident 3's bed was in the lowest position with fall mats in place on the floor on each side of the bed. 2. Resident 11 admitted to the facility in 11/2020 with diagnoses including dementia and anxiety. A revised comprehensive care plan dated 11/25/20 indicated Resident 11 was a high fall risk related to dementia and anxiety. Resident 11 was a two-person assist using a gait belt with a slide board for transfers. An Incident Report initiated on 8/12/21 revealed the following: -Staff 22 (LPN) was called into Resident 11's room. The resident was sitting on the floor at the foot of her/his bed between the bed and the wheelchair. Staff 23 (CNA) stated she was assisting the resident with the slide board and the board tilted, which caused the resident to slide to the edge of the bed. Staff 23 grabbed the resident's gait belt and eased her/him to the floor. -Staff 22 assessed Resident 11 and she/he was not injured. Staff 23 indicated she did not review the care plan and thought the resident was a one person assist for transfers. -Staff 8 (RCM-LPN) completed the investigation and indicated Staff 23 did not follow the care plan because Resident 11 was a two person assist with a slide board for transfers for safety and weakness. Abuse and neglect were ruled out. On 9/2/21 at 11:48 AM Staff 10 (CNA) stated Resident 11 was alert to herself/himself and could answer simple questions. Staff 10 stated the resident was a fall risk and was a two-person assist using a gait belt for transferring her/him from the bed to a wheelchair. On 9/7/21 at 3:47 Staff 23 stated she cared for Resident 11 on 8/12/21 and thought the resident was a one-person transfer with the use of a slide board. Staff 23 stated the resident was not injured, she/he slid to the edge of her/his bed during the transfer, and she was able to assist Resident 11 down to the floor. Staff 23 stated she should have reviewed the resident's care plan. On 9/8/21 at 10:17 AM Staff 8 stated on 8/12/21 Staff 23 did not follow or check the care plan regarding Resident 11's transfer status.

Based on interview and record review it was determined the facility failed to administer medication with timely provision of food for 1 of 1 sampled resident (#81) reviewed for [MEDICAL TREATMENT]. Resident 81 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 50. Findings include: Resident 81 admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] indicated Resident 81 was cognitively intact, was diabetic, received insulin injections and required [MEDICAL TREATMENT]. A physician order [REDACTED]. In an interview on 1/10/19 at 1:16 PM Resident 81 stated on 1/9/19 at around 4:30 PM she/he was administered her/his evening insulin by Staff 18 (RN) and no meal was delivered timely to her/his room. Resident 81 indicated she/he had became symptomatic of [DIAGNOSES REDACTED] due to her/his evening meal not being delivered timely and she/he started to sweat, was weak and not feeling well in general. Resident 81 stated she/he called for help and requested to get some peanut butter and orange juice from Staff 21 (LPN). Resident 81 indicated Staff 21 tested her/his blood sugar level at around 6:30 PM and it was 50. Resident 81 further stated she/he did not get her/his meal until after 7:00 PM. A review of Resident 81's clinical record revealed no documentation regarding Resident 81 having a low blood sugar or becoming symptomatic of [DIAGNOSES REDACTED] on 1/9/19. The only documentation found was on the 1/2019 TAR which indicated on 1/9/19 at 4:30 PM [MEDICATION NAME] was administered to Resident 81. On 1/10/19 at 4:50 PM Staff 3 (LPN/Resident Care Manager) was asked about Resident 81 having a low blood sugar the evening of 1/9/19. Staff 3 was unaware of the incident. She reviewed the clinical record and could not locate any documentation regarding the 1/9/19 incident. When asked what her expectations were regarding the administration of [MEDICATION NAME] she indicated staff should administer the [MEDICATION NAME] only 15 to 30 minutes prior to a meal being served so it would absorb in the resident's system quickly and to ensure residents would not become hypoglycemic. In an interview on 1/10/19 at 7:07 PM Staff 18 stated he administered Resident 81's insulin around 5:00 PM on 1/9/19. Staff 18 indicated dinner was to be delivered shortly after he administered the insulin but the meal was not timely. In interviews on 1/10/19 at 7:34 PM and on 1/14/19 at 7:11 PM Staff 21 indicated she started her shift at 6:00 PM and Staff 27 (LPN) was in training with her. Staff 21 was given report and indicated once report was completed around 6:30 PM or 6:40 PM Staff 21 and Staff 27 started rounds down the hall while discussing medication pass when she heard Resident 81 call out that her/his blood sugar felt low. This was one hour and 40 minutes after her/his [MEDICATION NAME] was given. Staff 21 and Staff 27 entered Resident 81's room and the resident was sweating. The resident requested some peanut butter and orange juice. Staff 21 checked Resident 81's blood sugar, the result was 50 and then provided her/him the snack. Staff 21 indicated Resident 81 did not get her/his dinner until after 7:00 PM. She further indicated due to Resident 81 getting her/his [MEDICATION NAME] early and not getting her/his meal on time caused in Resident 81's blood sugar to drop and Resident 81 to become symptomatic of [DIAGNOSES REDACTED]. In an interview on 1/15/19 at 10:37 AM Staff 3 acknowledged Staff 18 administered insulin without timely provision of food on 1/9/19 in the evening and the resident became hypoglycemic. Staff 3 further indicated when speaking with Staff 18 and Staff 21 they indicated that the incident could have gone horribly wrong if Resident 81 was unable to call out for assistance.

Based on interview and record review it was determined the facility failed to ensure facility staff adhered to standards of practice regarding medication administration for 1 of 1 sampled resident (#81) reviewed for [MEDICAL TREATMENT]. Resident 81 experienced symptoms associated with a low blood sugar level of 50. Findings include: Oregon Administrative Rule [PHONE NUMBER] - Conduct Derogatory to the Standards of Nursing is defined as: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (3) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment; (4) Conduct related to communication: (f) Failing to communicate information regarding the client's status to members of the health care team in an ongoing and timely manner as appropriate to the context of care; (8) Conduct related to other federal or state statute or rule violations: (q) Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 81 admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] indicated Resident 81 was cognitively intact. The resident was diabetic, received insulin injections and required [MEDICAL TREATMENT]. A physician order [REDACTED]. In an interview on 1/10/19 at 1:16 PM Resident 81 stated on 1/9/19 at around 4:30 PM she/he was administered her/his evening insulin by Staff 18 (RN) and no meal was delivered timely to her/his room. Resident 81 indicated she/he had became symptomatic due to her/his evening meal not being delivered timely and started to sweat, was weak and not feeling well in general. Resident 81 stated she/he called for help and requested some peanut butter and orange juice from Staff 21 (LPN). Resident 81 indicated Staff 21 took her/his blood sugar at around 6:30 PM and it was 50. Resident 81 further stated she/he did not get her/his meal until after 7:00 PM. A review of Resident 81's clinical record revealed no documentation regarding Resident 81 having a low blood sugar or becoming symptomatic on 1/9/19. The only documentation found was on the (MONTH) 2019 TAR which indicated on 1/9/19 at 4:30 PM [MEDICATION NAME] was administered to Resident 81. On 1/10/19 at 4:50 PM Staff 3 (LPN/Resident Care Manager) was asked about Resident 81 having a low blood sugar on the evening of 1/9/19. Staff 3 was unaware of the incident. She reviewed the clinical record and could not locate any documentation regarding the 1/9/19 incident. When asked what her expectations were regarding the administration of [MEDICATION NAME] she indicated staff should administer the [MEDICATION NAME] only 15 to 30 minutes prior to a meal being served so it would absorb in the resident's system quickly and to ensure the insulin was effective. In an interview on 1/10/19 at 7:07 PM Staff 18 (RN) stated he administered Resident 81's insulin around 5:00 PM on 1/9/19. Staff 18 indicated dinner was to be delivered shortly after he administered the insulin but the meal was not delivered timely. On 1/10/19 at 7:34 PM and 1/14/19 at 7:11 PM Staff 21 (LPN) indicated she started her shift at 6:00 PM and Staff 27 (LPN) was in training with her. Staff 21 was given report and indicated once report was completed around 6:30 PM or 6:40 PM Staff 21 and Staff 27 started rounds down the hall while discussing medication pass when she heard Resident 81 call out and said her/his blood sugar felt low. This was one hour and 40 minutes after her/his [MEDICATION NAME] was given. Staff 21 and Staff 27 entered Resident 81's room and the resident was sweating. The resident requested some peanut butter and orange juice. Staff 21 obtained Resident 81's blood sugar and indicated her/his blood sugar was 50 and provided her/him with a snack. Staff 21 indicated Resident 81 did not get her/his dinner until after 7:00 PM. She further indicated Resident 81 getting her/his [MEDICATION NAME] early and not getting her/his meal on time resulted in Resident 81 having a drop in her/his blood sugar and becoming hypoglycemic (low blood sugar). In an interview on 1/15/19 at 10:37 AM Staff 3 (LPN/Resident Care Manager) acknowledged Staff 18 administered the [MEDICATION NAME] without food on 1/9/19 in the evening and the resident became symptomatic. Staff 3 further indicated when speaking with Staff 18 and Staff 21 the incident could have gone horribly wrong if Resident 81 was unable to call out for assistance.

Based on observation, interview and record review it was determined the facility failed to ensure care planned safety interventions were in place and that a resident received adequate supervision to prevent elopements for 2 of 5 residents (#s 6 and 10) reviewed for safety. This put residents at risk for potentially avoidable accidents. Resident 6 sustained a fracture. Findings include: 1. Resident 6 was admitted to the facility in April 2017 with [DIAGNOSES REDACTED]. The resident's status sheet (CNA Care Plan) dated 4/17/17 indicated the resident had fall interventions including the bed in the lowest position and non-skid socks on when out of bed. The resident required one staff assistance for transfers, ambulation and bed mobility. The status form additionally noted at the end of the resident information that staff were to always use their gait belt when transferring a resident, unless the status form stated otherwise. A facility incident report dated 4/18/17 indicated the resident was lowered to the ground during a transfer in the bathroom. The resident stated she/he fell , had complaints of pain to the right knee and redness was noted. The resident further stated during the transfer the aide (Witness 9 Former Nurse's Aide) did not use a gait belt or get help when transferring the resident. The resident additionally sustained a skin tear to the right knee. The resident declined transport to the hospital, was transferred into bed and made comfortable. A portable x-ray was ordered on [DATE] with a fracture noted. The resident was medicated for pain and transported to the hospital. The incident investigation additionally indicated Witness 9 was suspended for not using a gait belt during the transfer. Nursing progress notes indicated a mobile x-ray came to the facility on [DATE] and it was determined the resident had a femur fracture. The resident was sent to the hospital for evaluation and did not return to the facility. Three attempts between 1/17/18 and 1/18/18 were made to reach witness 9 (Former Facility Nurses Aide) with no return calls received. Interview on 1/17/18 at 9:20 am Staff 2 (DNS) indicated Witness 9 was a pretty new aide but was not afraid to ask for help and asked for assistance previously. Witness 9 was shown earlier in the day how to transfer Resident 6 using a gait belt. Staff 2 stated a one-person transfer was appropriate but a gait belt should have been in place. The facility policy was to have a gait belt in place unless the resident was care planned not to. Interview on 1/17/18 at 12:20 pm Staff 4 (LPN Care Manager) indicated the aide was new, went through training and did not indicate she needed any further information. Staff 4 stated after the fall Witness 9 said she was not comfortable with transferring the resident alone. All residents who require transfer assistance should have a gait belt in place unless it was care planned otherwise. A gait belt should have been in place at the time Resident 6 was transferred. 2. Resident 10 was admitted to the facility in November 2017 with [DIAGNOSES REDACTED]. An elopement risk evaluation on 11/18/17 indicated the resident was a low risk for wandering. The resident's 11/25/17 MDS indicated the resident required supervision for dressing, toileting, bed mobility and transfers. The resident required limited assistance to walk in the room, the corridor and for locomotion off the unit. The resident was assessed to have a 13 out of 15 on the brief interview for mental status review which indicated the resident was cognitively intact. The resident's care plan dated 11/29/17 indicated the resident was a high risk for elopement related to a [MEDICAL CONDITION] and agitated behaviors. The resident frequently removed the wander guard and tried to elope. Interventions were noted as check wander device, determine reasons for wanting to leave and develop activity plan/interventions. The resident was a moderate fall risk, resistive to treatment/care and at risk for injury due to [MEDICAL CONDITION] activity. Frequent checks were not listed on the care plan. The resident status form (CNA Care Plan) dated 1/12/18 indicated the resident had a subdural hemorrhage, non-skid socks to be on when out of bed, check wander guard placement daily. Frequent checks were not listed on the status form. Nursing progress notes for November 2017 through January 2018 showed the resident was alert and oriented x 2-3 with intermittent confusion. Additional nursing notes in December showed the resident was alert and oriented x 3-4, (Alert and oriented times 4 means alert/oriented to person, place, time and situation). The resident walked around the facility and would remove the wander guard from her/his body. The resident inconsistently utilized her/his walker for ambulation. A nursing progress note dated 12/14/17 indicated the resident was found walking up the hall from the assisted living facility with a half case of beer in her/his hands. The resident allowed the beer to be locked up at the nurse's station. The resident stated she/he did not leave the facility and go buy the beer but a friend came and gave it to her/him. The resident did not seem to have went outside as her/his hands and clothing were warm. The resident had removed her/his wander guard. A nursing progress note dated 12/20/17 at 2:04 pm indicated the resident was found wandering. The wander guard was reapplied and the resident was informed not to leave the facility due to safety concerns. The resident stated understanding. An incident investigation dated 12/20/17 indicated the resident was observed crossing the street from the therapy gym. The licensed nurse found the resident at the market across the street from the facility. The resident was escorted back to the facility and her/his wander guard was replaced. The resident stated she/he knew she/he was not supposed to leave the facility but no one was available to help her/him to the store. The resident was placed on frequent safety checks. No additional information was noted related to interventions to help prevent further exits. A nursing progress note dated 1/11/18 at 1:07 pm indicated the resident exited the facility through the attached assisted living facility and was walking down the street. Two staff were sent to assist the resident back to the facility. The resident fell on the way back to the facility with staff and sustained a skin tear to the left elbow. The resident had removed her/his wander guard and it was replaced to the right ankle. A facility incident investigation dated 1/11/18 at 11:00 am indicated the resident stated the facility was a prison and has attempted to elope frequently. Today the resident exited the facility through the attached assisted living facility entrance. Staff from the assisted living facility notified the nursing facility of the resident's exit. The investigation further indicated the wander guard was in place around 9:00 am, the resident removed the wander guard and was later walking down the sidewalk. The resident was very confused and forgets she/he has been living at the facility for decreased cognition. The resident was on frequent safety checks. The resident stated she/he wanted to go to the market across the street. The resident was allowed to make a purchase at the market but upon return tripped over one of the staff's shoes and fell . No additional information was noted related to interventions to help prevent further exits. Multiple observations of the resident between 1/16/18 and 1/18/18 showed the resident would ambulate around the facility, primarily near the front of the building and her/his room. The resident's mood varied with some occasions more agreeable to staff and visitor interactions and other occasions very agitated with any redirection. The resident spent several hour periods of time in her/his room then would spend time out and about near the soda machine, back hallway and front of the facility near the business office. The resident was observed near doors but not attempting to exit through the doors. Interviews conducted 1/16/18 through 2/7/18 between 9:15 am and 4:30 pm showed: Staff 4 (LPN Care Manager) indicated the resident could be very sneaky. The resident would watch for staff to go on break and then try to go out of the facility. Posted signs did not help deter the resident nor did reminders not to leave the facility. Staff 4 stated the wander guard was started after the resident was found returning from the assisted living facility on 12/14/17, frequent checks were initiated because of the 12/201/7 exit. Staff 4 further indicated the resident frequently made statements such as she/he was an adult and knew what she/he was doing. The resident inconsistently utilized her/his walker, frequently removed the wander guard and while appeared alert the resident did not consistently remember things such as where her/his room was. The staff were to frequently check on the resident. Staff 4 stated the timeframe for frequent checks was not specifically outlined but the goal was every 10-20 minutes. Staff 2 (DNS) indicated the resident removed the wander guard frequently and staff would reapply. She was not certain the resident would be safe on own to walk to the store. Staff 2 stated the resident would not walk in front of a car but she was not confident the resident would be safe on the uneven surfaces or remembering to come back to the facility. The resident was alert enough to answer questions and in the moment, understood why she/he should not go out but Staff 2 was not convinced the resident retained the information. Staff 2 further stated the wander guard was put in place within a few days of admission not because of an exit; the frequent checks were started right away as well. Staff 2 indicated frequent checks meant knowing the resident's location at all times but staff were not directed with a specific timeframe but understood to check on the resident often. Staff 10 (CNA) indicated she was new to working with the resident but was told the resident was a wanderer. The resident got up and around on her/his own and if she saw the resident leave her/his room she tried to direct the resident towards the specific thing she/he was seeking or back to her/his room. Staff 10 stated she would check on the resident at least every hour unless the floor was crazy then it might be longer. Staff 10 was asked if she would be checking on the resident more often when she knew the resident wandered and required frequent checks to which she replied probably. Staff 15 (CNA) indicated the resident liked to get up and around and would try to leave the facility. The resident had not exited for Staff 15 but she heard report about other times the resident had left the facility. Staff 15 stated she checked on the resident at least every hour but she normally tried to be present in the hall throughout the shift watching all residents. Staff 11 (CNA) indicated she checked on the resident at least every 20 minutes. The resident frequently removed the wander guard and wouldn't always let them put it back on. Staff 11 stated the resident was smart and would watch for quiet moments or when staff were busy in an area and then head for a door. She believed the resident understood what was told to her/him but the resident chose to do what she/he liked anyway. Staff 11 further indicated very recently she heard the resident tell the nurse that (she/he) isn't stupid (she/he) knows what exits (she/he) can get out of. The resident was fast when she/he decided to leave and would get upset when staff intervened. Resident 10 indicated she/he preferred when the bedroom door was closed. The resident stated she/he did not need a babysitter here and the staff bugged her/him too much. The resident further stated she/he could go out on her/his own, always has, not a prisoner.

1. Based on interviews and record review it was determined the facility failed to provide adequate supervision to prevent accidents for 1 of 5 sampled residents (#86) for whom incidents or accidents were reviewed. Resident 86 sustained a painful fracture after the resident's leg/foot was caught during a transfer. Findings include: Resident 86 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan, with an initiation date of 8/22/12, indicated the resident was totally dependent on staff for bed mobility, positioning, transfers and dressing with one person assistance. The resident was noted to be cognitively impaired and used non-verbal communication. Staff were to anticipate the resident's needs. Staff were to watch for all non-verbal indicators of pain and notify the licensed nurse immediately, assess for pain every shift and PRN, report to RNCM and physician with any new onset of discomfort. The resident was transferred with the assistance of one staff person and a stand-pivot transfer prior to her/his leg fracture. The resident was a two person Hoyer transfer after readmission in January 2013. A facility incident investigation dated 12/28/12 indicated the resident's right knee was swollen with increased pain the morning of 12/26/12. The investigation included an interview with Staff 7 (CNA) who indicated the resident was transferred multiple times during the day on 12/25/12 and during one of the transfers the resident's right foot caught on the wheelchair. Staff 7 did not report the incident because the resident did not have any complaints of pain. An X-ray was completed on 12/27/12 and found the resident had a right displaced femur fracture. The resident was sent to the hospital for treatment on the afternoon of 12/27/12. Electronic MAR (eMar) notes dated 10/21/12 through 11/24/12 indicated the resident had no signs of pain and no pain medication was administered. No eMar notes were recorded between 11/24/12 and 12/25/12. On 12/25/12 at 4:53 pm an eMar note indicated the resident exhibited non-verbal signs of pain and the resident was given two tablets of Tylenol. Additional eMar notes dated 12/25/12 at 8:01 pm indicated the resident was medicated for pain. On 12/26/12 at 6:32 am two tablets of Tylenol were given for knee pain, as the resident was moaning and crying out when touched. The resident was given two tablets of Tylenol every four hours for complaints of knee pain until discharge on [DATE]. The NNs dated 12/26/12 at 9:46 pm indicated the resident's right knee was swollen, painful and had a faint bruise. The on call physician was notified and ordered the area be iced, elevated and the knee X-ray on 12/27/12. The resident was to be monitored and sent to the emergency room if the knee became reddened, more painful or swollen. Nurses' notes dated 12/27/12 at 11:11 am indicated a final X-ray report was received and showed a displaced distal femur fracture. The resident's knee continued to be swollen and painful with no redness noted. The resident was given PRN Tylenol for comfort. An additional note at 9:53 pm indicated the resident was transferred to the hospital for evaluation and treatment. Interviews conducted on 2/13/13 and 2/14/14 between 7:30 am and 4:00 pm showed: On 2/13/13 at 3:35 pm Staff 7 (CNA) indicated 12/25/12 was a normal day. The resident got up for both meals, he toileted the resident once and provided incontinent care in bed as well. Staff 7 could not remember any incidents while he transferred the resident on 12/25/12. Staff 7 indicated if something did happen he was not sure if he would have reported it if the resident did not seem hurt. It would depend on the severity of what happened. On 2/13/13 at 2:51 pm Staff 2 (DNS) said he completed the investigation related to Resident 86's knee. Staff 7 (CNA) told Staff 2 during an interview the residents foot caught on the wheelchair during one of the transfers, he could not say what transfer or when during the day. Staff 2 said since the resident did not show signs of pain he did not investigate further. Staff 2 stated when they looked at the timeline the incident occurred on the day shift as the resident did not get up on the night shift. 2. Based on observation, interview and record review it was determined the facility failed to assess 2 of 5 sampled residents (#s 325 and 51) who were reviewed for smoking safety. This placed the individual resident's safety at risk as well as the safety of others. Findings include: Resident 323 was admitted to the facility in February 2013 for therapy and nursing services related to a fractured leg. On 2/12/13 at 1:04 pm Resident 323 was in the courtyard smoking alone. This surveyor approached the resident and Staff 21 (CNA) followed to explain to the resident she/he could not smoke alone. Resident 323's chart included a blank smoking assessment. On 2/13/13 at 2:47 pm Staff 43 (Social Services) and Staff 13 (RNCM) said if residents were assessed to be independent smokers they had to leave the facility out the front door to smoke. If they smoked in the courtyard staff were required to sit with the resident whether they were assessed to be independent or not. On 2/15/13 at 3:15 pm Staff 1 (Administrator) and Staff 2 (DNS) said they they had not addressed the smoking policy. b. Resident 51 was admitted to the facility in early February 2013 with [DIAGNOSES REDACTED]. The facility's Nursing Admission assessment dated [DATE] stated the resident did not smoke. A facility nursing note dated 1/9/2013 indicated Resident 51 was alert, confused at times and the resident made, "no attempts to smoke inside the building." On 2/14/13 at 2:40 pm Resident 51 and another resident were observed coming in from the courtyard after smoking. When Resident 51 was asked if she/he was a smoker the resident replied, "yes." Resident 51's smoking assessment was dated 2/14/13. On 2/15/13 at 3:15 pm Staff 1 (Administrator) and Staff 2 (DNS) said they had not addressed the smoking policy.

1. Based on observation, interview and record review it was determined the facility failed to provide pain medications timely for 2 of 3 residents (#315 and 320) reviewed for pain control or to follow physician orders [REDACTED]. This resulted in untreated pain for residents 315 and 320 and risk of complications related to [MEDICAL CONDITION] for resident 95. Findings include: a. Resident 315 was admitted to the facility in late January 2013 with [DIAGNOSES REDACTED]. The facility's Pain assessment dated [DATE] indicated Resident 315 reported a pain level of at "8" (on a scale of 00-10). According to the assessment, the resident reported the pain was daily and caused loss of sleep and the resident was observed to have pain behaviors. Facility notes from a care conference on 2/7/13 revealed pain was a considerable issue for the resident. The comprehensive assessment dated [DATE] indicated the resident was alert and oriented and self-directed care. Resident 315's February 2013 Physician order [REDACTED]. The resident's February eMAR reflected the resident received long acting pain medication twice a day and [MEDICATION NAME] PRN (narcotic pain medication) four to six times daily as ordered. On 2/12/13 at 9:09 am Resident 315 was sitting on the side of the bed grimacing. The resident was waiting for a pain pill requested half an hour previously. At 9:15 am the resident had not received any pain medication. The PRN request sheet confirmed Resident 315 requested pain medication at 8:30 am. At 9:11 am Staff 5 (CMA) said she was rushing due to the acuity on the hall and would get to the resident as soon as she could. At 9:25 am, 55 minutes after the request, Staff 5 brought Resident 315 the pain medication. At 9:30 am an OT staff person entered the room for the resident's therapy. Resident 315 said, due to pain, there was no way she/he could go to therapy that morning. On 2/14/13 at 11:02 am Staff 5 (CMA) was returning from lunch and stated, while she was away, Resident 315 requested pain medication at 10:40 am. Staff 5 said the medication was not given while she was away. She said Staff 40 (LPN) covered for her. At 11:10 am Staff 5 was unable to access the pain medication for Resident 315 due to the eMAR being locked until the order was verified by the LN (Staff 40). Staff 5 left to find the LN to verify the orders. At 11:20 am Staff 40 entered the orders into the computer. Staff 40 said he was aware of the pain medication request and said it had not been, "that much time." Staff 40 said he knew the CMA would return at 11:00 am. At 11:27 am Resident 315 was sitting on the side of the bed. The resident said staff promised pain medications would not be late again. The resident said it had been 50 minutes and the pain level was an 8 or 9. At that time Staff 5 entered room with pain medication for Resident 315. On 2/15/13 at 3:15 pm Staff 1 (Administrator) and Staff 2 (DNS) were informed of the lack of timely pain medication for Resident 315 on two occasions. They said they were aware of the issues. b. Resident 320 was admitted to the facility in February 2013 for rehabilitation following surgical repair of a [MEDICAL CONDITION]. The resident also had [DIAGNOSES REDACTED]. A pain assessment dated [DATE] indicated Resident 320 complained of frequent pain, daily, that interfered with ADLs and sleep. The resident rated the pain as a "10" on a scale of 00 - 10. An MDS dated [DATE] identified pain as an issue for the resident and indicated the facility would proceed to care plan. A CAA dated 2/14/13 identified acute hip/incision pain following surgery as well as underlying chronic pain involving [MEDICAL CONDITION] and arthritis. The resident's medications included [MEDICATION NAME] (for pain and depression) and [MEDICATION NAME] (for [MEDICAL CONDITION] pain) as well as PRN [MEDICATION NAME] (a narcotic pain medication) and [MEDICATION NAME] (a narcotic-like pain medication). The CAA indicated the resident expressed perception of "10/10 pain at times, when walking down the hallway ... Staff will (continue) to assess for verbal and non verbal indicators of pain. Any concerns with pain (management) are reported to RCM/MD." No temporary/admission care plan was found for Resident 320. A comprehensive care plan in the electronic record dated 2/12/13 did not address pain. On 2/11/13 at 1:34 pm Resident 320 complained about waiting too long for pain medication. At 1:55 pm the resident complained pain medication was overdue and should have been given at 1:30 pm. At 2:00 pm on 2/11/13 Staff 27 (CMA) stated Resident 320 was medicated for pain at 12:30 pm. Review of the facility narcotic record book revealed the resident had an an order for [REDACTED]. The last dose signed out for the resident was at 10:30 am on 2/11/13. Staff 27 checked the e-MAR and verified the resident's last dose was given at 10:30 am and the resident was due for another dose. On 2/19/13 at 11:30 am Resident 320 was observed in bed with the lights off in the room. The resident stated she/he was very painful and the pain medication was not effective. Resident 320 stated, "they (the facility) ran out over the weekend. No one ever asks what level my pain is ... the therapists do but the nurses don't. I need my pain medication increased. I don't know who to tell." Review of the MAR for February 2012 revealed Resident 320 routinely used [MEDICATION NAME] every three to four hours while awake, taking between five to seven doses each day. Staff documented it was effective. The resident's last dose of [MEDICATION NAME] was given at 8:56 pm on the night of 2/18/13. On 2/19/13 at 11:44 am Staff 5 (CMA) stated the report she received was that a prescription renewal was sent to the pharmacy to be delivered as soon as possible. Staff 5 was told the prescription ran out and the attending physician was on call at the hospital and not on call at the facility. The facility was eventually able to reach the physician and a prescription had been sent. On 2/19/13 at 12:43 pm Staff 26 (RN) stated he believed a request for a renewal of the resident's [MEDICATION NAME] was faxed to the physician over the weekend but the facility did not received a reply. A fax dated 2/19/13 pertaining to the need for a new prescription for the [MEDICATION NAME] was found on the desk at the nurses' station. No other documentation of attempts to reach the physician regarding a prescription renewal were found. On 2/19/13 at 12:52 pm a delivery from the pharmacy arrived without medication for Resident 320. The pharmacy was notified. On 2/19/13 at 1:30 pm Staff 2 (DNS) and Staff 13 (RNCM) confirmed the facility did not call or fax the physician on Friday 2/15/13. The nursing staff thought the resident had enough [MEDICATION NAME] to last through Monday 2/18/13. An unsuccessful attempt to reach the physician was made on 2/18/13. After the pharmacy was called at 1:00 pm on 2/19/13, Resident 320's [MEDICATION NAME] was delivered and the resident received a dose at 1:25 pm, over 16 hours from the resident's last dose. c. Resident 95 was a new admission to the facility with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. The order start date was 9/18/12 and continued through the resident's final discharge on 11/6/12. Review of the weight flow sheets, NN, CNA assignment sheets, treatment sheets and dietary information for September, October and November 2012 showed 11 days without documented weights. Ten of the days were from September 2012 and one from October 2012. In an interview on 2/14/13 at 1:14 pm Staff 11 (Assistant Resident Care Manager/LPN) indicated there was no other location the missing weights would be. 2. Based on observation, interview and record review it was determined the facility failed to assess and monitor an access site, communicate with the [MEDICAL TREATMENT] center and set-up transportation for 1 of 1 sampled resident reviewed for [MEDICAL TREATMENT] (# 326). This placed residents at risk of undetected complications related to [MEDICAL TREATMENT] and increased anxiety when left without transportation. Findings include: The facility's Care of [MEDICAL TREATMENT] Resident Guidelines indicated that on admission the Licensed nurse (LN) would review [MEDICAL TREATMENT] needs and update the MAR and TAR with the [MEDICAL TREATMENT] schedule and times. The LN was to initiate a [MEDICAL TREATMENT] care plan with the type of [MEDICAL TREATMENT], access site,and any pertinent information. The access site was to be evaluated for infection, patency and bleeding and documented on the TAR every shift. The LN was to verify transportation had been set up and initiate transportation as needed. Medications were be administered prior to departure unless otherwise ordered. Nursing staff were to send a [MEDICAL TREATMENT] communication form to the [MEDICAL TREATMENT] center each time a resident was scheduled for [MEDICAL TREATMENT]. The center completed the top portion and nursing staff were to complete the bottom portion upon return to the facility. A copy of the form was sent to [MEDICAL TREATMENT] and kept in the resident's record. Resident 326 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Nursing Admission assessment, dated 2/11/13 did not include an assessment of the resident's [MEDICAL TREATMENT] location or condition. Resident 326's February TAR had no evidence that the each shift monitored the access site for patency, bleeding or infection.. Resident 326's Admission Care Plan, undated, did not include any information related to the resident being on [MEDICAL TREATMENT], the [MEDICAL TREATMENT] schedule, or care and treatment for [REDACTED]. On 2/14/13 at 10:00 am Staff 13 (RNCM) was informed of the lack of [MEDICAL TREATMENT] information on the assessments and care plan and agreed the access site needed to be assessed. Staff 13 was unaware of a communication form to send with the resident to [MEDICAL TREATMENT]. On 2/14/13 at 9:40 am Resident 326 was waiting at the door with a boxed lunch. Resident 326 said she/he had [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. The resident said last Tuesday the ride was late and caused her/him to be late for [MEDICAL TREATMENT]. The resident said it disrupted the [MEDICAL TREATMENT] schedule the rest of the day. Resident 326's physician orders [REDACTED]. On 2/14/13 at 9:45 am Resident 326 said she/he needed to take the [MEDICATION NAME] binder before she/he ate lunch and needed PRN pain medication. The resident said she/he was not given any medication to take to [MEDICAL TREATMENT]. At 9:55 am the resident was becoming more anxious about getting to the [MEDICAL TREATMENT] center by 10:30 am. Staff 41 (RN) was asked to check the transportation status for Resident 326. Staff 41 said the facility van could not transport residents to [MEDICAL TREATMENT]. Staff 41 called the transport company to see if they were on the way. At 10:13 am Staff 41 told Resident 326 a transport bus was called and was on the way. The resident said the appointment was in seven minutes. On 2/14/13 at 10:35 am Staff 5 (CMA) said there was an order to send with Resident 326 any medications needed while at [MEDICAL TREATMENT]. Staff 5 said she gave the prepackaged medications to Staff 40 (LPN). At 10:36 am Staff 40 said he did not give the medications to Resident 326 prior to leaving because he was not able to find the resident before the resident left. On 2/14/13 at 4:32 pm Resident 326 returned from [MEDICAL TREATMENT]. The resident said there was no transport company ride when she/he was ready to leave. The facility van was there for another resident and the facility told the driver to also return Resident 326 to the facility. Resident 326 said there was no communication form given to her/him to carry back and forth. On 2/14/13 at 4:55 pm Staff 13 (RNCM) said when a resident first arrived to the facility the admitting nurse was responsible to fill out transportation forms for Staff 42 (scheduling coordinator) who notified nursing if the facility could transport or not. On 2/15/13 RNCM 8:56 am Staff 43 (Social Services) said the transportation for [MEDICAL TREATMENT] options were very limited and the facility van was not often available. Staff 43 said the hospital staff told the resident transportation would be provided, but that was only for Medicaid recipients. The resident should have been informed upon arrival about transportation. On 2/15/13 at 3:15 pm Staff 1 (Administrator) and Staff 2 (DNS) discussed the lack of coordination with [MEDICAL TREATMENT] services for Resident 326. They said the facility would assure transportation was available for [MEDICAL TREATMENT] residents. 3. Based on observation, interview and record review it was determined the facility failed to follow the care plan related to behaviors resulting in a skin tear for 1 of 3 sampled residents (#98) for whom non-pressure related wounds were reviewed. This placed residents at increased risk for skin injury during routine care. Findings include: Resident 98 was admitted to the facility during 2011 with [DIAGNOSES REDACTED]. The 8/5/12 care plan, with last revision date of 2/12/13, noted the resident would periodically resist care. An intervention, dated 8/5/12, directed staff to stop giving care when the resident was upset and attempt again when the resident was calm. On 2/12/13 at 9:41 am, steri-strips were observed on the top of the resident's left hand. The 2/14/13 Incident Investigation noted during the night of 2/10/13, the resident became combative when staff cleaned and repositioned her/him. The resident sustained [REDACTED]. On 2/15/13 at 10:10 am, Staff 12 (RNCM) stated on 2/10/13 staff were trying to do catheter care and the resident resisted. While resisting care, the resident hit her/his hand on the mobility bars on the side of the bed which resulted in the skin tear. On 2/19/13 at 3:20 pm, the failure to follow the care plan was reviewed with Staff 2 (DNS). No additional documentation was provided.

1. Based on interview and record review it was determined the facility failed to obtain timely treatment for [REDACTED].#86) who experienced accidents. Resident 86 was found to have a painful displaced femur fracture which had initial symptoms identified on 12/25/12 night shift and was not treated until the evening of 12/27/12. Findings include: According to Oregon State Board of Nursing "Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] (1)(a) Advocates for the client's right to receive appropriate care ...(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering ..." According to Oregon Standards and Authorized Duties for Certified Nurses Assistants [PHONE NUMBER] "Conduct Unbecoming a Nursing Assistant (3)(g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriate person in a timely manner." Resident 86 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan, with an initiation date of 8/22/12, indicated the resident was totally dependent on staff for bed mobility, positioning, transfers and dressing with one person assistance. The resident was noted to be cognitively impaired and used non-verbal communication. Staff were to anticipate the resident's needs and watch for all non-verbal indicators of pain. The licensed nurse was to be notified of pain indicators immediately, assess for pain every shift and PRN, report to RNCM and physician with any new onset of discomfort. The resident was transferred with the assistance of one staff person and a stand pivot transfer prior to her/his leg fracture. The resident was a two person Hoyer transfer after readmission in January 2013. A facility incident investigation dated 12/28/12 indicated the resident's right knee was swollen with increased pain the morning of 12/26/12. The investigation included an interview with Staff 7 (CNA) who indicated the resident was transferred multiple times on 12/25/12 and during one of the transfers the residents right foot caught on the wheelchair. Staff 7 did not report the incident because the resident did not have any complaints of pain. An X-ray was completed on 12/27/12 and found the resident had a displaced femur fracture to the right leg. The resident was sent to the hospital for treatment on the afternoon of 12/27/12. The facility NN dated 10/31/12 through 12/25/12 indicated the resident was stable with no complaints of pain and no falls. Electronic MAR (eMar) notes dated 10/21/12 through 11/24/12 did not include signs of pain or pain medication administered. No eMar notes were recorded between 11/24/12 and 12/25/12. On 12/25/12 at 4:53 pm an eMar note indicated non-verbal signs of pain and the resident was given two tablets of Tylenol. Additional eMar notes dated 12/25/12 at 8:01 pm indicated two additional tablets of Tylenol were given. On 12/26/12 at 6:32 am two tablets of Tylenol were given for knee pain, as the resident was moaning and crying out when touched. At 7:59 am the resident no longer complained of pain. The resident was given two tablets of Tylenol every four hours for complaints of knee pain until discharge to the hospital on [DATE]. The NN dated 12/26/12 at 9:46 pm indicated the resident's right knee was swollen, painful and had a faint bruise. The on-call physician was notified and ordered the area be iced, elevate the leg and X-ray the knee on 12/27/12. The resident was to be monitored and sent to the emergency room if the knee became reddened, more painful or swollen. The NN dated 12/27/12 at 11:11 am indicated a final X-ray report was received and showed a displaced distal femur fracture. The resident's knee continued to be swollen and painful with no redness noted. The resident was given PRN Tylenol for comfort. An additional note at 9:53 pm indicated the resident was transferred to the hospital for evaluation and treatment. An X-ray report of the leg/knee on 12/27/12 showed an acute oblique displaced [MEDICAL CONDITION] femur. The final result was noted as a fracture of a major long bone. The results were faxed to the facility on [DATE] at 11:22 am. The resident's November 2012 MAR indicated [REDACTED]. The December 2012 MAR indicated [REDACTED]. Interviews conducted on 2/13/13 and 2/14/14 between 7:30 am and 4:00 pm showed: Staff 7 (CNA) indicated 12/25/12 was a normal day for Resident 86. The resident was up for both meals, he toileted the resident once and provided incontinent care in bed as well. Staff 7 stated the resident required total assistance for her/his care. Staff 7 rolled the resident while she/he was in bed to provide care. The resident did not cry out or seem to be in pain. The resident did not normally have pain. Staff 7 stated if the resident was painful she/he would twitch, flail arms, moan or even cry. Sometimes the signs the resident was in pain were very subtle so staff had to watch closely as the resident was not verbal. Staff 7 could not remember any incidents while he transferred the resident on 12/25/12, he did not remember reporting anything during the investigation or problems with the resident's leg being twisted or caught. Staff 7 indicated if something did happen he was not sure if he would have reported it if the resident didn't seem hurt, it would depend on the severity of what happened. Staff 14 (CNA) indicated she worked with the resident on evening shift 12/25/12. Resident 86 was dependent for care and normally did not have signs of pain. Staff 14 stated while she turned and changed the resident in bed the resident said "ow ow." Staff 14 went to the medication aide and Staff 9 (LPN) to see if the resident had any pain medication and to advise of the resident's pain. Staff 14 indicated staff had to go slow with the resident to keep her/him calm and relaxed. The evening was otherwise normal, she did not notice the resident's knee looking out of the ordinary but she did not really look at the resident's knee during care. Staff 9 (LPN) indicated she worked the evening shift of 12/25/12. Staff 14 (CNA) asked her if the resident had anything for pain because the resident seemed painful during transfer. Staff 9 evaluated the resident as she/he was already up in the wheelchair and did not notice anything out of the ordinary. Staff 9 stated it was not common for the resident to have pain or show signs of pain. Staff 9 indicated if a painful area was touched on the resident she/he would say, "ow," might grimace or cry out. Staff 9 further indicated she completed a full evaluation after the resident was in bed, turned her/him, moved the leg a bit but did not see anything of concern. There was slight swelling of the knee noted but no other sign of an issue. Staff 9 did not believe she reported anything to the next shift as she attributed the pain to the resident's stiffness. Staff 15 (LPN) indicated she was first made aware of the resident's knee by Staff 16 (CNA) on the night shift of December 25th/26th. Staff 15 was told the resident's knee was swollen and the resident had increased pain. When she evaluated the area it was not red, not hot to the touch and was slightly swollen below the knee. Staff 15 did could not feel any fluid around the knee. The resident showed signs of pain and was grimacing when turned. The resident did not get up or move on her/his own and was not active during night shift so Staff 15 was not sure if the swelling was within the resident's norm. The resident remained the same throughout the shift and Staff 15 passed the information on in report. Staff 15 indicated the resident was not usually painful. She had not seen the resident ever grimace like she did that night, "clearly the resident was in pain." Staff 16 (CNA) indicated he worked with the resident on the night shift that started 12/25/12. While doing his rounds he turned the resident side to side for care and the resident cringed. Staff 16 looked closer and when he touched the resident's leg she/he winced and "kind of tried to protect the leg," it was obvious the resident was in pain. The resident's leg was swollen but not discolored. The nurse (Staff 15-LPN) checked the resident. Anytime they tried to move or touch the resident's leg, the resident showed signs of pain. Staff 16 indicated the resident did not normally have pain and usually rested comfortably through the night. The resident did not move on her/his own, she/he could move arms and hands somewhat but did not move her/his legs. Staff 16 stated the resident had not fallen during his shift nor had he heard about any previous incidents. Staff 16 did not transfer the resident out of bed during the night shift, all the care he provided was while the resident was in bed. Staff 6 (RN) did not remember a lot about the resident's leg, but was the evening charge nurse on 12/26/12 and 12/27/12. Staff 6 stated the leg was maybe a little swollen. The resident didn't act like she/he was in pain unless the leg was moved. The resident was not really verbal, could not move on her/his own and did not usually have any signs of pain. Staff 6 stated she sent the resident out early in the evening shift, sometime before dinner on 12/27/12. Staff 6 couldn't say why she did not have the resident X-rayed or sent to the hospital on [DATE]. On 2/14/13 at 2:10 pm Witness 5 (Family) indicated they arrived for a visit on 12/26/12 around 5:00 pm and the resident was still in bed. Witness 5 was told by Staff 6 the resident's knee was injured and she/he could not get out of bed. Staff 6 advised Witness 5 that an X-ray could not be done until the following day because the mobile service was closed. Witness 5 indicated he was shown the resident's leg. Staff 6 gently lifted the blanket up off the resident's leg and the resident began to shake and twitch. Witness 5 further indicated the resident seemed to be in extreme pain and he did not understand why the resident was not evaluated until the following day. Witness 5 stated the resident did not seem painful as long as she/he was totally still and there was no manipulation of the leg. The area above and on the resident's knee was very red and very swollen, it did not look at all like the resident's normal condition. When the X-ray was completed on 12/27/12 it showed a fracture. Staff 8 (LPN) indicated she worked with the resident during the day on 12/27/12. Resident 86 showed signs of pain, cried out and moaned when her/his leg was touched. The resident did not typically verbalize pain, might answer yes/no questions or say "ow." Staff 8 stated staff watched the resident for non verbal signs and normally the resident did not show signs of pain. Staff 8 indicated the resident's knee was swollen and "angry red." The rest of the resident's body looked normal. The swollen red knee was not a common problem for the resident. There had been no falls or accidents reported. Staff 8 stated an X-ray was obtained on the morning of 12/27/12. The results were received early in the afternoon and showed a fracture. Staff 8 could not say why she did not send the resident out prior to the X-ray or immediately after results were received that confirmed a fracture was present. 2. Based on interview and record review it was determined the facility failed to complete admission care plans sufficient to meet residents' needs for 5 of 17 residents (#s 313, 316, 317, 319, 320 and 324) for whom admission care plans were reviewed. This placed residents at risk for un-met needs. Findings include: a. Resident 319 was admitted to the facility in February 2013 for rehabilitation. The resident's [DIAGNOSES REDACTED]. On 2/11/13 at 3:26 pm Staff 13 (RNCM) stated the resident was admitted to the facility with an indwelling urinary Foley catheter due to pain and mobility impairment. physician's orders [REDACTED]. A Bowel and Bladder evaluation dated 2/8/13 concluded Resident 319 was a good candidate for bladder retraining. On 2/14/13 at 12:55 pm Resident 319 described being occasionally incontinent prior to hospitalization but was looking forward to the removal of the catheter. The resident stated facility staff cared for it each shift and Resident 319 understood it was temporary until mobility improved. An undated temporary admission care plan for Resident 319 in the Licensed Nurse (LN) book indicated only the presence of a Foley. The care plan did not define the size of the catheter, the volume of the balloon used to anchor the catheter in the bladder, bag care or specifics related to changing the catheter, tubing or bag. On 2/19/13 7:00 am Staff 33 (LPN) stated specifics about the catheter could usually be found on the Admission Nursing Data Base in the electronic chart. She was unable to find the admission data base in system for Resident 319. At 8:01 am on 2/19/13 Staff 11 (LPN) confirmed there were no orders on record for the catheter. Staff 11 stated there should be specific orders related to care and a plan for removal of the catheter prior to discharge. On 2/19/13 at 8:15 am Staff 13 (RNCM) agreed there were no orders related to the catheter and specific orders should be part of the care plan. b. Resident 320 was admitted to the facility in February 2013 for rehabilitation following a [MEDICAL CONDITION]. The resident's [DIAGNOSES REDACTED]. A pain assessment dated [DATE] indicated Resident 320 complained of frequent pain, daily, that interfered with ADLs and sleep. The resident rated the pain as a "10" on a scale of 00 - 10. Oral pain medication helped alleviate the pain. On 2/11/13 at 1:39 pm the resident complained of often waiting too long for pain medication. No admission/temporary care plan was found for Resident 320. At 12:20 pm on 2/19/13 Staff 13 (RNCM) stated Staff 26 (RN) remembered filling out an admission care plan, but was unable to find it. Staff 13 stated all skilled residents were to have nine basic care plans, including one for pain. c. Resident 324 was admitted to the facility during 2013 with [DIAGNOSES REDACTED]. The 2/6/13 Admission Nursing Summary noted the resident was considered at risk for falls and skin breakdown, had occasional pain and used oxygen (2 liter per minute by nasal cannula). The resident had upper and lower dentures, was occasionally incontinent of urine and experienced some confusion during the night. The resident had sustained a fractured nose, skin tears and extensive bruising from a fall prior to admission. Resident 324 had musculoskeletal impairment on one side and used a walker and wheelchair. The resident's clinical record did not contain a temporary care plan. There were no individualized interventions to address Resident 324's specific care needs. On 2/14/13 at 2:26 pm and 2/15/13 at 10:25 am, Staff 13 verified there was no temporary care plan prior to 2/14/13 (eight days after admission). Staff 13 stated she completed a temporary care plan for the resident after speaking with the surveyor on 2/14/13. d. Resident 316 was admitted to the facility during 2013 with [DIAGNOSES REDACTED]. The resident was admitted with orders for [MEDICATION NAME] (anticoagulant) and rehabilitation services. The 2/1/13 temporary care plan's sections related to continence, fall risk, anticoagulant therapy, nutrition (healing surgical incision) and potential for infection were blank. On 2/19/13 at 3:20 pm, the incomplete temporary care plan was reviewed with Staff 2 (DNS). No additional documentation was provided. e. Resident 317 was admitted to the facility during 2013 with [DIAGNOSES REDACTED]. The resident had orders for continuous oxygen use, [MEDICATION NAME] (corticosteroid) and rehabilitation services secondary to a fall at home prior to admission. The 2/1/13 Temporary Care Plan sections for continence, pain and fall risk were blank. The section regarding oxygen use noted the resident's O2 sats were taken every shift but didn't address the continuous oxygen use, concentrator, tubing, and nasal cannula care. The Temporary Care Plan section noted the resident had fragile skin but didn't address the resident's use of [MEDICATION NAME] which made the resident prone to bruising. Periodic observations of the resident revealed the resident wore a nasal cannula, had a concentrator next to the bed and long oxygen tubing to allow the resident movement around the room. The resident had multiple discolored areas up and down the arms with skin tears on right and left arms. The resident's incomplete Temporary Care Plan was discussed with Staff 2 (DNS) on 2/19/13 at 3:20 pm. No additional documentation was provided. Resident 313 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The resident's Admission Care Plan dated 2/4/13 did not contain documentation of the resident's fall potential, nutritional status or whether the resident was continent of bowel and bladder. The resident's care plan did not address the areas of circulation, or infection. On 2/15/13 at 12:00 pm Staff 11 (LPN/ Assistant RCM) stated the Admission Care Plan forms were filled out at the time the resident was admitted to the facility. Staff 11 viewed the resident's Admission Care Plan and agreed it was incomplete. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure the care plan was followed for the use of a self releasing seat belt (SRSB) for 1 of 3 sampled residents (#5) who had a fall. Resident 5 fell and sustained a hip fracture. Findings include: Resident 5 was admitted to the facility in Spring, 2012 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 6/20/12 assessed the resident as a high fall risk. The care plan interventions included the use of a self-releasing seat belt (SRSB) with the resident's wheelchair. The Resident Status Form (In-Room care plan) dated 10/3/12 directed staff to use an alarmed SRSB on the resident's wheelchair. The Incident Report dated 10/3/12 indicated a sensor alarm sounded and the resident's fall was witnessed. The report documented "staff" as a witness and not a specific name. The Progress Notes dated 10/3/12 indicated Staff 5 (LPN) performed Resident 5's assessment after the fall and there were no injuries noted. The notes dated 10/4/12 revealed the resident's right leg was painful, the physician ordered a portable right hip x-ray and the resident was hospitalized . The Final X-Ray Report dated 10/4/12 documented the resident had a right hip fracture. The hospital's History and Physical (H&P) dated 10/4/12 indicated the resident was hospitalized for [REDACTED]. The facility's Investigative Report dated 10/5/12 revealed Staff 13 (CNA) transferred the resident into a wheelchair without a SRSB on the night shift and reported off duty. The report indicated Staff 12 (LPN) witnessed the resident's fall. The documentation indicated the resident did not exhibit signs of pain until the following day and the physician ordered the resident's hospitalization . On 10/11/12 at 2:15 pm Staff 5 (LPN) indicated she assessed the resident after the resident's fall and there were no injuries noted. On 10/11/12 at 4:20 pm Staff 12 (LPN) stated he heard the resident's wheelchair sensor alarm sound, the resident stood up and fell to the floor on her/his "bottom." On 10/11/12 at 6:00 pm Staff 13 (CNA) stated she was assigned to the resident's care on 10/3/12 on the night shift. Staff 13 stated she took a sensor alarm off the resident's bed and placed it in the wheelchair near the resident's bed. Staff 13 indicated she transferred Resident 5 into the wheelchair with the seat sensor alarm and reported off duty. Staff 13 indicated she did not know Resident 5's SRSB was supposed to be used because she could not find the resident's care plan. On 10/12/12 at 11:00 am Staff 9 (RNCM) stated Staff 13 (CNA) transferred the resident into a wheelchair without a SRSB, the resident's right leg hurt the following day and the resident was hospitalized . On 10/12/12 at 12:12 pm Staff 15 (CNA) stated she worked the dayshift on 10/3/12, was assigned to Resident 5's care and did not see the resident prior to the resident's early morning fall. Staff 15 stated after the resident fell she noticed the wheelchair the resident had been sitting in did not have a SRSB. Staff 15 stated she looked at the pocket care plans when she worked and they were available. On 10/22/12 at 9:22 am Staff 1 (DNS) agreed Staff 13 (CNA) should have utilized Resident 5's SRSB prior to the resident's fall on 10/3/12.

Based on observation, interviews and record review it was determined the facility failed to provide ongoing assessment and treatment for 1 of 4 sampled residents (# 1) who had wounds. Resident 1 identified at high risk for skin breakdown, experienced the recurrence of an unstageable (deep tissue) wound and additional Stage II-III wounds that were untreated. Findings include: Resident 1 admitted to the facility in September 2010 with [DIAGNOSES REDACTED]. According to the admission medical records the resident admitted to the facility with a Stage II ulcer on the right heel. According to the facility Weekly Wound Progress Record dated 4/11/11 the right heel wound was determined to be "closed, no redness and treatment resolved." On 9/12/11 Resident 1 was admitted to a local hospital due to multiple medical problems. The hospital admission progress notes and photos dated 9/12/11 identified several wounds. The resident's right heel was described as "round hard dry black with 1.5 inch circumference, left lateral foot had a 1.5 inch diameter and 0.5 inch diameter blisters, multiple open areas on coccyx Stage II-III." Resident 1 re-admitted to the facility on [DATE]. The September 2011 annual MDS indicated the resident was dependent from staff for all ADLs. The resident required extensive assistance from staff for eating and propelling her/his wheelchair. Resident 1 was non-ambulatory and incontinent. The 6/15/11 and 9/14/11 Braden Scale assessment tool for pressure sore risk factors indicated Resident 1 was considered to be high risk for skin breakdown. The Ulcer Risk Evaluation dated 6/15/11 indicated the summary/plan was, "at risk, has psoriasis all over body, preventative measures and treatment care planned." On 9/14/11 the summary/plan indicated, "continues to be at risk due to immobility, large patchy areas of psoriasis, dependent for repositioning and mobility, continue with current treatment and plan of care." The comprehensive care plan dated 6/24/11 included a Wounds/Decubitus Ulcers Temporary Care Plan, dated 8/23/11 due to an identified scab on the resident's right second toe and scab on the right lower calf. There was no mention of other wounds or past wounds. The weekly CNA Skin Inspection Sheet (showers) dated 7/25/11 indicated a "scab" was present on the resident's right heel. The 8/25/11, 9/4/11 and 9/8/11 shower sheets indicated no new skin issues. The Treatment Records (TARs) from June 2011 through September 12, 2011 were reviewed. No treatment or monitoring was listed for the resident's right heel. On 10/6/11 at 1:10 pm, Staff 2 (RNCM) stated Resident 1 had severe psoriasis that was the source of her/his wounds. Staff 2 stated the resident had no other wounds before going to the hospital on [DATE], other than a toe with a scab. Staff 2 stated she had been the resident's care manager for a couple of months. Staff 2 was asked if the RNCMs did weekly wound rounds, she stated they rely on the charge nurses to tell them if a resident has a wound, rounds were done only on known wounds. Staff 2 stated when the nurses were applying the resident's psoriasis cream "they should be looking at everything." Staff 2 stated the CNAs check the residents skin on shower days and report any skin conditions to the charge nurse. Staff 2 stated she was was not aware the resident had several wounds when she/he left the facility and admitted to the hospital. Staff 2 and the nurse surveyor reviewed the shower audits she had supplied. The CNA shower audits were dated 4/21/11 (dressing on right heel), 6/2/11 (look at resident's right heel, RNCM wrote "no issue nothing"). Staff 2 was shown the shower audit dated 7/25/11 with right heel "scab" identified. The next available shower audit was 8/25/11 (nothing new), 9/4/11 (nothing) , 9/8/11 (no new issues). Staff 2 had no further audits or information to provide. On 10/6/11 at 2:05 pm, Staff 13 (CNA) stated she had occasionally provided showers for Resident 1 and confirmed she filled out the audit on 8/25/11. Staff 13 stated she remembered seeing a black sore on the resident's heel for a long time, but could not remember when. On 10/6/11 at 3:30 pm, with the resident's permission this nurse surveyor observed the dressing changes. Staff 1 (DNS), Staff 2 (RNCM), Staff 12 (RNCM) and Staff 7 (LPN) were present to observe and document the condition of the resident's wounds. The resident's right heel measured 2.5 cm x 2.5 cm round with dry black eschar, left lateral foot had two dry black areas that measured 2.4 cm x 1.5 cm and 1.2 cm x 0.7 cm. The resident's coccyx was dark red with multiple small open areas present. The hospitals re-admission prescribed treatment for [REDACTED]. On 10/7/11 at 10:50 am, Staff 5 (CNA) stated he had frequently cared for Resident 1 during the last year. Staff 5 stated before the resident went to the hospital she/he wore soft boots on both feet. Staff 5 stated the resident had a blackened right heel for a long time. "(She/He) admitted from another facility with it last year." Staff 5 stated the resident's coccyx would open and close and the nurses did the treatment. Staff 5 stated he had not given Resident 1 a shower or filled out a shower audit form. On 10/7/11 at 11:10 am, Staff 6 (LPN) stated she did not remember seeing the wound on the resident's right heel or left foot before the hospital however, she had seen the wounds since the resident readmitted to the facility from the hospital. Staff 6 stated she had "not seen any previous or current documentation of the wounds, just the order on the TAR." Staff 6 stated the usual procedure for a wound was, a weekly wound tracking sheet would be initiated, measurements weekly and the information went to the RNCM. Wound sheets were updated each Monday either on day or evening shift, when the treatment was ordered. On 10/7/11 at 11:40 am, Staff 8 (LPN) stated he knew there had been a treatment for [REDACTED]. Staff 8 stated the resident had worn the soft boots for a long time, but did not know the resident had any wounds on her/his feet and the resident's coccyx was "only excoriated." Staff 8 stated he was the nurse that sent the resident to the hospital on [DATE] due to a rapid change in condition. On 10/7/11 at 2:00 pm, Staff 12 (RNCM) stated she used to be Resident 1's care manager. The resident had a long history of a wound to the right heel. The resident was seen by a podiatrist and a wound clinic. Staff 12 stated she was the nurse that resolved the treatment in April when the wound healed. The resident continued to wear the soft boots and was not aware the wound had reappeared. Staff 12 was unable to provide any further documentation after the wound was considered healed, or evidence that ongoing monitoring was provided for the high risk resident. On 10/7/11 4:05 pm, Staff 9 (RN) stated she had not seen any wounds on the resident's feet, the resident had the boots on and stated she was working the night shift before the resident admitted to the hospital. On 10/7/11 at 4:15 pm, Staff 7 (LPN) stated she applied the resident's psoriasis cream on the evening shift but did not know the resident had wounds on her/his feet. Staff 7 stated she had not seen the resident's heel without the boots, they were always on. According to the facility's Skin Program Guideline the RCM or designee will evaluate any impaired skin integrity and document in the medical record...weekly skin checks are completed on all residents by licensed staff, during routine care and by the CNA. The Licensed Nurse will be notified of alterations in skin identified during routine care...The facility will maintain a weekly Wound/Pressure ulcer log and a Non-Pressure log which when completed will be distributed to DNS, Administrator... On 10/7/11 at 4:30 pm, Staff 4 (Interim Administrator) and Staff 1 (DNS) were informed there was no evidence that ongoing weekly wound tracking was done for Resident 1 after the heel wound was considered resolved, even though the resident was considered high risk. Three nurses completed the re-admission skin assessment when the resident returned from the hospital and no wound record was initiated. No current tracking could be located. Staff 4 and Staff 1 stated they were currently reviewing the wound identification and tracking process with the RNCMs.