Every finding on record at Avamere Crestview of Portland

Based on observation, interview and record review it was determined the facility failed to ensure medications were properly labeled and expired medications were removed from the cart immediately for 3 of 5 sampled medication carts reviewed for medication. This placed residents at risk for receiving expired medications. Findings include: The facility's 1/2025 Medication Storage/Storage of Medication policy instructed facility staff to immediately remove from stock outdated medications and note the date insulin vials and pens were first used.On 2/11/26 at 12:45 PM the 30/40 hall medication cart was observed to have the following:- One bottle of Fish oil 1000 mg with an expiration of 12/2025- One bottle of Aspirin 325mg with an expiration of 10/2025On 2/11/26 at 12:45 PM Staff 21 (CMA) confirmed the expired dates on the medications and stated they should have been removed and destroyed.On 2/11/26 at 1:14 PM the treatment cart number two was observed to have the following:- One vial of Humalog (insulin) without an open date written on it. The 7/2023 manufacturer's instructions revealed the medications should not be used past 28 days from the open date.- One tub of Eucerin lotion with no expiration date on the container.- One tub of Cetaphil lotion with no expiration date on the container.On 2/11/26 at 1:14 PM Staff 22 (LPN) confirmed the open date was missing on the insulin vial and the expiration dates were missing on the two lotions. She stated the insulin should have an open date but was unsure how long insulin could remain in use. On 2/11/26 at 1:30 PM the station three cart was observed to have the following:- One box of Nystatin powder (antifungal medication) with the expiration date of 12/2024On 2/11/26 at 1:30 PM Staff 14 (RN) confirmed the expiration date, removed the medication from the cart, and stated it would be destroyed. On 2/12/26 at 10:06 AM, Staff 2 (DNS) confirmed open dates should have been written on insulin vials and the medication carts should be checked for regularly before administering medication, powders, and other medications were not expired.

Based on observation, interview and record review it was determined the facility failed to obtain consent, assess, monitor and reevaluate a resident for a wheelchair seatbelt for 1 of 1 sampled resident (#60) reviewed for restraints. This placed residents at risk for being restrained. Findings include:Resident 60 was admitted to the facility in 9/2021 with diagnoses including cerebral palsy (a group of life-long neurological disorders appearing in infancy or early childhood that affect movement, muscle tone, posture and balance), stroke, dementia and muscle weakness. Resident 60's 1/17/26 Quarterly MDS indicated the resident used a wheelchair and no restraints were used. Review of Resident 60's clinical record revealed no documentation to indicate the resident was assessed, care planned or monitored for the use of the wheelchair seatbelt. There was no evidence a physician order was obtained, and the risks and benefits of the wheelchair seatbelt were not reviewed with the resident or resident representative since 9/3/24. Resident 60's care plan did not include the use of a wheelchair seatbelt. Observations conducted from 2/9/26 through 2/12/26 between the hours of 8:30 AM and 1:09 PM revealed when Resident 60 was in her/his wheelchair, the resident always had her/his wheelchair seatbelt fastened. On 2/9/26 at 9:49 AM, Resident 60 stated she/he always used her/his wheelchair seatbelt to prevent her/him from falling from the wheelchair. On 2/11/26 at 8:46 AM, Staff 5 (CNA) stated Resident 60 used her/his wheelchair seatbelt to feel more secure when sitting in her/his wheelchair. On 2/11/26 at 9:18 AM, Staff 6 (CNA) stated Resident 60 was supposed to have her/his wheelchair seatbelt fastened when she/he was up in her/his wheelchair and the resident used her/his wheelchair seatbelt to help her/him from sliding down in the wheelchair. 2/11/26 at 12:06 PM, Staff 14 (RN) stated Resident 60 used a wheelchair seatbelt because her/his oxygen fluctuated and Resident 60's wheelchair seatbelt was used to keep her/him in the wheelchair. She reported we usually do a restraint assessment, have a physician's order and care plan the use of a wheelchair seatbelt but was unsure if this was completed for Resident 60. 2/11/26 at 12:25 PM, Staff 3 (RNCM) confirmed Resident 60 used the wheelchair seatbelt and verified there was no physician order, safety device assessment and consent, monitoring or care planning completed for the resident's use of the wheelchair seatbelt. Staff 3 stated her expectations were to have a physician's order in place, a safety device and consent assessment completed quarterly to ensure it was safe for Resident 60 to use the wheelchair seatbelt and care plan interventions established regarding use of the wheelchair seatbelt.

Based on interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 5 sampled residents (#3) reviewed for unnecessary medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include:The facility's Self-Administration of Medications policy, dated 2/2021, indicated the following: -Residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe for the resident to do so. -The interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Resident 3 was admitted to the facility in 6/2025 with diagnoses including fracture of the fourth lumbar vertebra (a break in the bone of the lower spine often causing severe pain or nerve damage). Resident 3's 12/23/25 Significant Change MDS indicated the resident had no cognitive impairment. An 8/11/25 physician order indicated Resident 3 was prescribed melatonin at bedtime with instructions that staff may leave the medication at bedside for Resident 3 to take when ready. Resident 3's 1/2026 and 2/2026 TAR revealed the resident received melatonin each evening. A review of Resident 3's clinical record revealed no evidence a self-administration of medication assessment was completed.On 2/12/26 at 8:28 AM, Resident 3 stated she/he received melatonin at bedtime to help with sleep. Resident 3 stated sometimes when the medication was brought to her/him, she/he was not ready to take the medication, and staff left the medication for her/him to take at a later time. On 2/12/26 at 8:32 AM, Staff 13 (CMA) stated medications could be left at a resident's bedside if the resident was assessed and was determined to be safe to leave the medication. On 2/12/26 at 9:09 AM, Staff 4 (LPN Care Manager) stated Resident 3 did not always want to take her/his melatonin when it was brought to her/him, so she obtained a physician's order to leave the medication at the resident's bedside to take at a later time. Staff 4 stated she did not complete a self-administration of medication because it didn't trigger in her mind. Staff 4 stated she expected a self-administration of medication assessment be completed when residents had medication left at their bedside and acknowledged she should have completed a self-administration of medication assessment on Resident 3 prior to medications being left at the bedside. On 2/12/26 at 2:09 PM, Staff 12 (CMA) confirmed she left melatonin at Resident 3's bedside when the resident stated she/he was not ready to take the medication.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received showers and necessary care and assistance to maintain good grooming and hygiene for 2 of 3 sampled residents (#s 31 and 68) reviewed for ADLs. This placed residents at risk for lack of personal hygiene and dignity. Findings include: The facility's Activities of Daily Living policy, dated 7/2025, indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 1. Resident 68 was admitted to the facility in 3/2024 with diagnoses including spinal stenosis (narrowing of the spine) and diabetes. Resident 68's 3/17/24 care plan indicated the resident had mixed bowel and bladder incontinence. Resident 68's 12/21/25 Quarterly MDS indicated the resident had mild to moderate cognitive impairments and required partial to moderate assistance with showering. The 2/6/26 updated shower schedule indicated Resident 68 was scheduled for showers on Sunday and Thursday, evening shift. Resident 68's 1/12/26 through 2/13/26 shower task logs revealed the resident did not receive showers on the following days: -Thursday, 1/15/26. -Sunday, 2/8/26 and -Thursday 2/12/26. A review of Resident 68's Progress Notes from 1/15/26 through 2/13/26 revealed no evidence the resident was provided with additional showering opportunities if showering was refused, or the resident's shower was not provided. Observations conducted from 2/9/26 through 2/13/26 between the hours of 8:21 AM and 2:49 PM revealed Resident 68 wore the same gray sweatpants each day. The resident wore the same dirty, white T-shirt until 2/12/26. Her/his hair appeared greasy and uncombed. On 2/9/26 at 9:59 AM and 2/13/26 at 8:13 AM, Resident 68 stated she/he did not receive showers as scheduled. Resident 68 stated on 2/8/26, she/he was supposed to receive a shower, staff said she/he would be showered but no staff came back so she/he missed her/his shower. Resident 68 also stated her/his shower was not provided on 2/12/26 and guessed staff forgot again. On 2/11/26 at 8:49 AM and 9:14 AM, Staff 5 (CNA) and Staff 6 (CNA) stated Resident 68 did not refuse showers. Staff 6 stated when showers were missed, she reported the missed shower to the charge nurse and would try to provide the resident a shower later that day or the next day. On 2/11/26 at 9:37 AM, Staff 14 (RN) stated residents were assigned specific days for showering and if a resident refused, she would talk with the resident to provide risk and benefits of not showering and try to see if they would accept a bed bath. Staff 14 stated there was an option for PRN showers if a resident refused or missed a shower and somehow the shower was made-up. On 2/11/26 at 12:38 PM, Staff 8 (CNA) stated Resident 68 required one-person assistance with showering, showered twice a week and always accepted showers. Staff 8 stated if a resident refused or missed a shower, she reapproached them two or three times, documented the number of times the resident was approached then filled out a form that was given to the charge nurse. Staff 8 stated if a resident missed a shower, they usually had to wait until their next scheduled shower day unless staff was able to complete a PRN shower another day. On 2/12/16 at 9:26 AM, Staff 3 (RNCM) stated residents were scheduled for showers at least twice a week or more, if they preferred. Staff 3 reviewed Resident 68's shower task logs and progress notes and acknowledged the resident missed scheduled showers and the missed showers were not made-up. Staff 3 stated Resident 68 accepted showers and her expectations were Resident 68's missed showers should have been made-up. 2. Resident 31 was admitted to the facility in 1/2025 with diagnoses including congestive heart failure and chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen into the bloodstream.) A review of Resident 31's 6/6/25 Annual MDS revealed she/he had severe cognitive impairment and required substantial assistance with personal hygiene tasks. Resident 31's care plan dated 7/2/25 revealed she/he required one person assistance with combing hair and shaving for personal hygiene. On 2/9/26 at 12:14 PM Resident 31 was observed to have excessive visible facial hair and hair that appeared matted, tangled, and secured in a knotted ponytail. Resident 31 stated she/he was unable to shave and comb her/his hair independently because she/he was not able to lift her/his shoulders. On 2/10/26 at 12:41 PM Staff 18 (CNA) stated Resident 31 was total care and staff provided all care for the resident. Staff 18 acknowledged Resident 31's facial hair and the presence of a large knot in the resident's hair. Staff 18 stated the knot made hair care difficult and indicated the resident's hair was hard to wash and comb due to the condition. On 2/10/26 at 1:43 PM Staff 19 (LPN) acknowledged Resident 31 had excessive facial hair and a significant knot in her/his hair. Staff 19 stated Resident 31 was not care planned for grooming related to facial hair or interventions to address the knot in her/his hair. On 2/10/26 at 1:55 PM Staff 4 (LPN Care Manager) stated residents who required assistance with ADLs should receive assistance as needed. Staff 4 indicated she was aware Resident 31 had excessive facial hair and a knot in her/his hair. Staff 4 acknowledged Resident 31 had not consistently received grooming and hygiene care in accordance with her/his needs. On 2/10/26 at 2:07 PM Staff 2 (DNS) acknowledged the resident was observed with excessive facial hair and a large knot in her/his hair. Staff 2 stated staff were responsible for providing personal hygiene and grooming in accordance with the resident's care plan.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 2 of 3 sampled residents (#s 35 and 43) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Program, dated 11/2025, indicated the following: -The Activities Program is provided to support the well-being of resident and to encourage both independence and community interaction. -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. -Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. -Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interest of each resident. 1.Resident 43 was admitted to the facility in 1/2026 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 43's 2/2/26 admission MDS indicated the resident was cognitively intact. The MDS also indicated having books, newspapers and magazines to read, being around animals, going outside to get fresh air when the weather was good, and participating in religious services or practices were very important activities to the resident. Resident 43's Activity Profile, initiated on 2/5/26, was reviewed. The Activity Profile contained the resident's name and date of birth ; the remainder of the assessment was incomplete. The record lacked documentation of the resident's activity preferences, interests, customary routines, or individualized needs, preventing the development of a person-centered activity plan. Resident 43's 2/10/26 Activity Care Plan revealed the following: -The resident preferred self-directed activities. -The resident's interests were news and sports. A review of Resident 43's Activity Task Records from 1/27/26 through 2/13/26 revealed the resident participated in one group activity on 2/7/26 and received one-to-one activities on 1/28/26, 2/2/26 and 2/7/26. Observations of Resident 43 from 2/9/26 through 2/13/26 from 8:00 AM to 4:00 PM revealed the resident was in her/his room in bed or sitting in her/his wheelchair. No books, magazines, newspapers were visible in the resident's room. On 2/11/26 at 3:17 PM Resident 43 was observed watching television in her/his room. Resident 43 stated activities were not offered to her/him and indicated she/he would participate in group activities if staff invited her/him. An activity calendar was observed taped to the wall in the resident's room. Resident 43 stated the print was too small to read from a distance. Resident 43 further stated she/he was not informed of the Bible Study held on 2/11/26 at 10:30 AM and stated she/he would have attended if she/he were aware of the activity. On 2/12/26 at 12:29 PM, Staff 8 (CNA) stated Resident 43 spent the majority of her/his time in her/his room in bed. Staff 8 stated she was unaware of any activities or resident preferences and indicated the resident did not participate in social outings. Staff 8 reviewed Resident 43's Kardex (bedside care plan) and confirmed there was no documented information to guide staff regarding the resident's activity interests or preferences. On 2/12/26 ats1:47 PM, Staff 16 (CNA) stated Resident 43 had not participated in group activities and she was unaware of the resident's preferences. Staff 16 reviewed Resident 43's Kardex and confirmed there was no documented information to guide staff regarding the resident's activity interests or preferences. On 2/13/26 at 9:01 AM Staff 4 (LPN Care Manager) stated it was her expectation Resident 43's interests and preferences would be identified upon admission and addressed in a comprehensive care plan. Staff 4 acknowledged Resident 43's interests and preferences were not identified on the resident's care plan. On 2/13/26 at 9:45 AM Staff 2 (DNS) stated the facility was responsible for determining each resident's activity interests and incorporating them into the care plan. Staff 2 confirmed Resident 43 did not have documented interests and preferences and acknowledged activities had not been individualized for the resident. 2. Resident 35 was admitted to the facility in 7/2024 with diagnoses including post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening or traumatic events that causes persistent symptoms, such as flashbacks, nightmares and severe anxiety). Resident 35's 7/7/25 Significant Change in Status MDS revealed the resident was severely cognitively impaired and the resident's preferred activities included keeping up with the news and having books, newspapers and magazines available to read. Resident 35's 7/22/25 Activity Care Plan revealed the following:-The resident preferred to self-initiate and direct activities. -The resident's self-directed activity pursuits included television, music, bingo and current events. -Staff were to provide the resident with self-directed material as needed/requested. -The resident enjoyed watching the news and football on television. -The resident was not interested in reading. A review of Resident 35's Activity Task Logs from 1/19/26 through 2/13/26 revealed the resident did not participate in a reading activity. Random observations of Resident 35 from 2/9/26 through 2/11/26 between 8:16 AM to 4:04 PM revealed the resident to be in the dining room or in her/his room both awake and asleep. The resident's television played cartoons, and no books, newspapers or magazines were available for the resident to read. On 2/10/26 at 9:50 AM, Witness 1 (Family Member) stated Resident 35 had become less responsive over the past year but still enjoyed watching television. Witness 1 stated he preferred the resident avoid news programming even though it was a preference as it triggered the resident's PTSD. Witness 1 stated Resident 35 liked to watch nature shows and would not choose to watch cartoons. On 2/11/26 at 8:16 AM, Resident 35 was observed in her/his room in her/his wheelchair. Resident 35 stated watching cartoons was a waste of time, and she/he preferred to watch mysteries and studies. Resident 35 was unable to answer additional questions regarding her/his activity preferences and interests. On 2/11/26 at 3:25 PM, Staff 10 (CNA) stated Resident 35 spent most of her/his day sleeping or watching television in her/his room outside of mealtimes. Staff 10 stated the resident enjoyed watching sports on television, was unsure if she/he liked cartoons, and she/he required staff assistance to use the television remote. Staff 10 stated he did not know if the resident liked to read but he could find activity preference information in the resident's care plan. On 2/11/26 at 3:32 PM, Staff 23 (CNA) stated Resident 35 spent her/his time either sleeping or watching television in her/his room. Staff 23 stated she did not really know what the resident liked to watch on television and was unsure of other activity preferences. On 2/11/26 at 3:50 PM, Staff 27 (CNA) stated Resident 35 liked to watch westerns and old television shows. Staff 27 stated the resident never requested to watch cartoons on television. On 2/12/26 at 9:03 AM and 12:38 PM, Staff 24 (CNA) stated Resident 35 enjoyed watching music and sports on television and did not seem to care too much for watching cartoons. Staff 24 stated the resident enjoyed reading books and newspapers. Staff 24 further stated the resident was unable to initiate activities and additional activity preferences were found in the resident's care plan. On 2/12/26 at 9:31 AM and 12:41 PM, Staff 5 (CNA) stated Resident 35's television was on a lot, but he was not sure what the resident liked to watch. Staff 5 stated the resident was unable to self-initiate activities and required staff assistance to change the channel on the television and to turn it on-and-off. Staff 5 stated the resident enjoyed reading the newspaper, Staff 26 (Activity Director) was responsible for distributing newspapers to residents, and he had never seen Resident 35 offered the newspaper. On 2/12/26 at 11:15 AM, Staff 25 (RN) stated he was unsure of Resident 35's television preferences, but they could be found in the resident's care plan. On 2/12/26 at 12:18 PM, Staff 7 (Social Services Director) stated Resident 35 spent her/his day watching television. Staff 7 stated South Park (an adult animated sitcom) was the only cartoon Resident 35 enjoyed. Staff 7 stated Staff 26 was responsible for distributing newspapers, she did not know if Resident 35 enjoyed reading the newspaper, and she could not recall the last time she saw the resident with a newspaper. Staff 26 was not available for an interview. On 2/12/26 at 1:03 PM, Staff 1 (Administrator) acknowledged Resident 35's activity care plan was in need of revision as the resident was no longer able to self-initiate activities. Staff 1 stated television programming should be selected according to resident preference, and she/he acknowledged that cartoons were not Resident 35's preference. Staff 1 further stated newspapers were delivered to the facility four days a week and should be distributed to residents with an expressed interest.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed care plans related to fall safety for 3 of 3 sampled residents (#s 3, 6 and 35) reviewed for falls. This placed residents at risk for continued falls and potential injury. Findings include: The facility's Falls and Fall Risk Managing policy, dated 10/2025, indicated the following: -Based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with the input of the provider, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 1. Resident 3 was admitted to the facility in 6/2025 with diagnoses including fracture of the fourth lumbar vertebra (a break in the bone of the lower spine often causing severe pain or nerve damage). Resident 3's Morse Fall Scale (an evidence-based assessment of a resident's fall risk) completed on 7/25/25, 8/12/25, 9/5/25, 9/15/25, 10/29/25, 12/1/25, 12/9/25, 12/15/25, 12/22/25 and 2/5/26 indicated the resident was at high risk for falling. Resident 3's 12/23/25 Significant Change MDS indicated the resident had no cognitive impairment, was dependent for toileting, required partial to moderate assistance to come to a standing position from sitting to standing, required partial to moderate assistance for transferring to and from a bed to a chair or wheelchair and Resident 3 had two or more falls since admission or prior assessment. Resident 3's Fall CAA indicated the resident had several falls since admit due to loss of balance and getting up unassisted. Resident 3 was cooperative with care and utilized her/his call light. Current interventions included ensuring the call light and grabber were within reach. Resident 3's fall investigations for the past six months revealed the resident experienced the following falls: -8/11/25;-9/4/25; -10/12/25;-10/29/25;-11/14/25;-11/30/25;-12/9/25;-12/15/25 and-12/19/25. Resident 3's fall care plan indicated the resident was at risk for falls due to weakness, impulsivity, mixed incontinence, known to self-transfer, need for assistance and history of falls. The following care plan interventions were in place: -Keep bed in low position except during care. Initiated 6/10/25. -call, don't fall sign in resident's line of sight. Initiated 8/12/25. -Ensure grabber is within the resident's reach. Initiated 12/22/25. -Falling star program to alert staff of high risk for falls. A management risk form was completed which allowed the resident to keep her/his door shut due to noise. Initiated 9/5/25 and revised on 1/16/26. Observations from 2/9/26 through 2/13/26 revealed the following: -2/9/26 at 9:22 AM, Resident 3's bed was in the high position, her/his grabber was on a dresser which was in the corner, across the room, out of reach of the resident. No call, don't fall sign was posted in the resident's room. There was no yellow falling star sign posted outside the room, by the resident's door nameplate. -2/10/26 at 12:56 PM, 2:41 PM and 3:33 PM, Resident 3's bed was in the high position, her/his grabber was on a dresser which was in the corner, across the room, out of reach of the resident. No call, don't fall sign was posted in the resident's room. There was no yellow falling star sign posted outside the room, by the resident's door nameplate. -2/11/26 at 8:26 AM, 1:02 PM and 2:22 PM, Resident 3's bed was in the high position, her/his grabber was on a dresser which was in the corner, across the room, out of reach of the resident. There was no yellow falling star sign posted outside the room, by the resident's door nameplate. There was no call, don't fall sign posted in the resident's room until the 1:02 PM observation. During the 8:26 AM observation, Staff 5 (CNA) came into Resident 3's room to bring her/him a menu, Resident 3's bed was in the high position, and Staff 5 did not offer to lower the resident's bed to a low position. -2/11/26 at 11:05 AM and 12:01 PM, Resident 3 was in the dining room with no grabber available to her/him. -2/12/26 at 8:32 AM and 11:55 AM, Resident 3's bed was in the high position, her/his grabber was on a dresser which was in the corner, across the room, out of reach of the resident. There was no yellow falling star sign posted outside the room, by the resident's door nameplate. -2/13/26 at 8:29 AM, Resident 3's bed was in the high position. There was no yellow falling star sign posted outside the room, by the resident's door nameplate. On 2/9/26 at 1:22 PM, 2/11/26 at 8:18 AM and 1:03 PM, 2/12/26 at 8:32 AM and 11:55 AM, Resident 3 reported she/he experienced several falls since her/his admission. Resident 3 stated she/he used to have a yellow falling star sign outside of her/his door, but she/he did not want to have the room door left open because of the screamer and the guy next door who yelled frequently and the next thing I know the yellow sign was gone. Resident 3 stated she/he did not know where her/his grabber was, but she/he was supposed to use the grabber if something fell on the floor because one of her/his falls happened when she/he bent over to pick up an item that fell on the floor. Resident 3 stated staff often left her/his bed in the high position after completing care and a call, don't fall sign used to be posted in her/his other room but was not in her/his current room, which she/he was in for the past several months. On 2/11/26 at 1:03 PM, Resident 3 stated someone posted a call, don't fall sign on the wall when she/he was out of the room. On 2/11/26 at 8:33 AM, Staff 5 stated Resident 3 had a few falls. He stated the resident's fall interventions consisted of staff reminding the resident to use her/his call light and checking on the resident since her/his door was always closed. On 2/11/26 at 9:20 AM, Staff 6 (CNA) stated all residents determined to be at high risk for falling, had yellow signs with a star on it posted outside their doors and that is how we know which residents are considered high fall risks. Staff 6 reported Resident 3's bed should always be in the low position and her/his call light within reach. Staff 6 was not aware of additional fall precautions for Resident 3. On 2/11/26 at 12:44 PM, Staff 8 (CNA) stated she learned Resident 3 was at high risk for falling when the resident recently mentioned it during care. Staff 8 reported residents at high risk for falling had a yellow falling star sign posted outside their doors to alert staff of the resident's high fall risk and some residents had call, don't fall signs visible in their rooms to help them remember they needed assistance when transferring. Staff 8 was unsure of Resident 3's specific fall precautions. On 2/11/26 at 3:18 PM, Staff 10 (CNA) stated Resident 3 was considered at high risk for falling and had a yellow falling star sign outside her/his door. Staff 10 went to Resident 3's room and confirmed there was no falling star sign present. Staff 10 was unaware of Resident 3's specific fall precautions with the exception of reminding her/him to utilize the call light. On 2/12/26 at 8:32 AM, Staff 13 (CMA) stated residents who were at risk for falling had a yellow sign outside of their door. Staff 13 went to Resident 3's room and confirmed the resident's grabber was on a dresser which was in the corner, across the room, out of reach of the resident and there was no yellow sign outside of Resident 3's door. Resident 3 reported to Staff 13 that staff often left her/his bed in the high position after providing care and the call, don't fall sign had not been posted since she/he moved rooms several months ago, until 2/11/26. Staff 13 confirmed Resident 3's bed was supposed to be in the low position. On 2/12/26 at 8:53 AM, Staff 3 (RNCM) stated Resident 3 had several falls in the past few months, was considered a high fall risk and the resident's primary fall interventions included keeping the bed in the lowest position except during care, having her/his grabber within reach and having a call, don't fall sign posted. Staff 3 reported Resident 3's yellow falling star sign was removed because the resident wanted her door closed at all times, so the resident no longer met the criteria for the falling star program. Staff 3 confirmed there was no call, don't fall sign posted in the resident's room but she placed one in Resident 3's room, yesterday. Staff 3 stated her expectations were staff needed to provide fall interventions as care planned. 2. Resident 6 was admitted to the facility in 3/2024 with diagnoses including repeated falls. Resident 6's 10/21/25 At Risk for Falls Care Plan revealed the resident's bed was to be kept in a low position at all times outside of when care was provided. Resident 6's 1/29/26 Fall Risk Evaluation revealed the resident was at high risk to fall. Resident 6's 2/3/26 Quarterly MDS revealed the resident was cognitively intact and did not have a fall since her/his prior assessment. On 2/11/26 at 11:42 AM, Resident 6 was observed in her/his bed asleep. The resident's bed was positioned between knee-to-waist height. Staff 15 (Infection Preventionist), Staff 14 (RN) and Staff 4 (RNCM) were present in the resident's room assisting the resident's roommate. No staff were observed to encourage Resident 6 to lower her/his bed. On 2/11/26 at 12:44 PM, Staff 28 (CNA) stated Resident 6 was at risk to fall as she/he liked to lean over the side of the bed a lot. Staff 28 stated the resident's bed should always be in the lowest position. On 2/12/26 at 8:42 AM, Resident 6 was observed in her/his room in bed. The resident's bed was at waist height. Staff 5 (CNA) lowered the resident's head of bed per the request of the resident and exited the room without assisting or encouraging the resident to lower the rest of her/his bed. On 2/12/26 at 8:55 AM, Staff 24 (CNA) stated Resident 6 was at risk to fall. Staff 24 stated interventions to prevent resident falls were found in the resident's care plan, and Resident 6's bed was to be in a low position when occupied because of her/his history of falls. On 2/12/26 at 9:24 AM, Staff 5 stated he was not aware of any interventions to prevent falls for Resident 6 outside of encouraging her/him to wear non-skid socks or shoes when transferring. Staff 5 stated he preferred to keep Resident 6's bed at waist height. On 2/12/26 at 11:12 AM, Staff 25 (RN) stated Resident 6's bed was to be kept in the lowest position when occupied as she/he had a history of a fall. Staff 25 observed Resident 6 in bed and confirmed the resident's bed was at waist height. Staff 25 further stated the resident's bed was a little high and he would want it lower. On 2/12/26 at 1:47 PM, Staff 4 stated Resident 6's bed should be kept in a low position when occupied. Staff 4 further stated staff should encourage the resident to lower her/his bed when observed to be in a high position as the resident was able to independently use her/his bed remote. 3. Resident 35 was admitted to the facility in 7/2024 with diagnoses including history of falls. Resident 35's 10/20/25 At Risk for Falls Care Plan revealed the resident's bed was to be kept in a low position at all times outside of when care was provided. Resident 35's 1/5/26 Fall Risk Evaluation revealed the resident was at high risk to fall. Resident 35's 1/7/26 Quarterly MDS revealed the resident was severely cognitively impaired and experienced a fall since her/his prior assessment. On 2/9/26 at 10:20 AM, 2:13 PM and 3:36 PM, Resident 35 was observed in her/his room in bed. The bed was positioned at waist height. On 2/11/26 at 3:25 PM, Staff 10 (CNA) stated Resident 35 was at risk to fall and her/his bed height should be on the lower side. On 2/11/26 at 3:32 PM, Staff 23 (CNA) stated Resident 35 was not considered at risk to fall, she did not know if the resident experienced any falls, and she did not know what height the resident's bed should be kept at when she/he was in bed. On 2/12/26 at 9:03 AM, Staff 24 (CNA) stated Resident 35 fell a couple of times in the past, and as a result, the resident's bed was to be kept in a low position. On 2/12/26 at 9:31 AM, Staff 5 (CNA) stated Resident 35's bed should be kept in the lowest position as she/he will try to crawl out of bed when anxious. On 2/12/26 at 11:15 AM, Staff 25 (RN) stated Resident 35 was considered at risk to fall and her/his bed should be kept in a low position when occupied. On 2/12/26 at 1:47 PM, Staff 4 (RNCM) stated Resident 35 had a history of falls, and her/his bed was to be kept in the lowest position. Staff 4 stated the resident's bed should not be at waist height when occupied.

Based on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 1 sampled resident (#35) reviewed for mood. This placed residents at risk for re-traumatization and decreased quality of life. Findings include:The facility's 8/2025 Trauma-Informed and Culturally Competent Care Policy instructed the following:-All residents were screened for possible exposure to traumatic events. -The initial screening was utilized to identify the need for further assessment and care.-Individualized care plans were developed to address past trauma in collaboration with the resident and family, as appropriate. -The care plan was to identify and decrease exposure to triggers that may re-traumatize the resident and incorporate language needs, culture, cultural preferences, norms and values. Resident 35 was admitted to the facility in 7/2024 with diagnoses including post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening or traumatic events that causes persistent symptoms, such as flashbacks, nightmares and severe anxiety). Resident 35's 7/4/24 Trauma Informed Care Evaluation completed by Staff 7 (Social Services Director) revealed the resident did not want to complete the assessment and/or stated she/he had not experienced trauma. Resident 35's 7/10/24 Trauma Care Plan revealed the following interventions to address the resident's PTSD:-Develop trust by being forthright with the plan of care, inform of intentions during interactions, do not startle, announce presence and tell the resident your name and why you were there. -Empowerment to achieve goal and focus on strengths. -If triggered, inform the nurse, keep a comfortable distance and do not encroach on personal space. Remind the resident she/he was safe, draw attention to environment and offer water. -Stop direct care if the resident was uncomfortable. Discuss action to be taken and allow the resident to attempt as desired. Offer assistance as needed. -Self-reported Trauma History Questionnaire was provided. Resident 35's 7/22/25 Activity Care Plan revealed the resident enjoyed listening to patriotic music, watching the news and she/he served in the military.Resident 35's 1/7/26 Quarterly MDS revealed the resident experienced severe cognitive impairment and had an active diagnosis of PTSD.Resident 35's 1/12/26 Social Service Quarterly Review revealed the resident experienced episodes of anxiety often for which she/he received psychotropic medications. On 2/9/26 at 10:20 AM, Resident 35 was observed in her/his room asleep in bed. Following the surveyor's knock on the door, the resident yelled out multiple times with her/his eyes closed but did not awaken.On 2/10/26 at 9:55 AM, Witness 1 (Family Member) stated Resident 35 experienced PTSD as a result of her/his military service. Witness 1 stated the resident had not slept well for decades as a result of the nightmares she/he experienced which centered around the resident's belief she/he was still in the war. Witness 1 stated it was helpful for staff to enter the resident's room quietly as she/he startled with louder noises. Witness 1 stated Resident 35's trauma triggers also included listening to the news, any discussion about war or the military and seeing her/his military uniform. Witness 1 stated he had not spoken to anyone at the facility about Resident 35's specific trauma triggers because staff were aware of the resident's military background and had access to the resident's health records. On 2/11/26 at 3:25 PM, Staff 10 (CNA) stated Resident 35 experienced anxiety when she/he turned from side-to-side in bed. Staff 10 stated he was unaware of the resident's trauma history or of any potential trauma triggers but stated this information could be found in the resident's care plan.On 2/11/26 at 3:32 PM, Staff 23 (CNA) stated she was unaware of Resident 35's service in the military and did not know if conversations about the military were appropriate to have with the resident. Staff 23 stated resident-specific trauma triggers were found in the resident's care plan. On 2/12/26 at 9:03 AM, Staff 24 (CNA) stated Resident 35 had high anxiety, confusion and delusions, and any task, even a simple task such as washing the resident's face caused her/him anxiety. Staff 24 stated she was able to minimize the resident's anxiety when she explained every step of the task to the resident, took her time with the resident and reminded her/him she was not out to get [her/him]. Staff 24 stated she avoided conversations about the military and war with the resident because they definitely caused anxiety and scared the resident. Staff 24 stated she was unsure if watching the news triggered the resident's PTSD but she would look in the resident's care plan to find this information in addition to other resident-specific trauma triggers.On 2/12/26 at 9:31 AM, Staff 5 (CNA) stated he was not sure what caused Resident 35's anxiety, but he did know the resident was in the military and fought in a war. Staff 5 stated the resident woke up scared at least weekly talking about being in the military and being tortured. Staff 5 stated he did not approach the resident when she/he was resting or appeared asleep because when he did, the resident would wake up, believe she/he was in the military and yell and jump, even with a gentle tap to wake up. Staff 5 stated the resident previously requested medication to help with her/his feelings of anxiety but no longer did so on account of her/his decline in cognition. Staff 5 further stated he was unsure if military movies or watching the news would trigger the resident, but he would look in the resident's care plan to find additional trauma triggers. On 2/12/26 at 11:15 AM, Staff 25 (RN) stated Resident 35 experienced a lot of PTSD. Staff 25 stated the resident experienced nightmares about her/his war experience. Staff 25 stated he tried to create a supportive environment for the resident when she/he experienced a nightmare, which did not seem to help but did not exacerbate the resident's anxiety around her/his PTSD. Staff 25 stated he was unsure if resident-specific trauma triggers were listed in the care plan. On 2/12/26 at 12:18 PM, Staff 7 stated she completed the initial trauma evaluations for all residents in order to get an understanding of resident-specific traumas, triggers and potential coping strategies that she included in the residents' care plans. Staff 7 stated she completed a generalized care plan for residents with a diagnosis of PTSD who declined to complete the initial trauma evaluation. Staff 7 stated she completed Resident 35's initial trauma evaluation. Staff 7 stated she was aware the resident served in the military, but she was unable to get a clear understanding of the resident's trauma from the resident. Staff 7 stated she did not reach out to the resident's family to get a more thorough understanding of the resident's trauma and potential trauma triggers. Staff 7 stated she was unaware the resident experienced nightmares as a result of her/his past trauma and was unsure if conversations about her/his military service or watching the news were potential trauma triggers. On 2/12/26 at 1:03 PM, Staff 1 (Administrator) stated she expected residents with a diagnosis of PTSD or a history of trauma to have care plans that included resident-specific trauma triggers and interventions. Staff 1 stated Resident 35's trauma care plan was general and did not include specific trauma triggers, interventions or activities to avoid.

Based on observation, interview, and record review, it was determined the facility failed to ensure a medication error rate of less than five percent. There were 2 errors out of 25 medication administration opportunities, resulting in an 8% error rate. This placed residents at risk of receiving a sub-therapeutic medication dose and reduced medication efficacy. Findings include:The 2020 insulin NPH (Humulin N) KwikPen Manufacturer Instructions For Use and the 2014 insulin aspart FlexPen Manufacturer Patient Fact Sheet - How To Use FlexPen indicated the insulin pens should be primed with two units of insulin prior to each administration to ensure the correct dose was delivered.Resident 9 was admitted to the facility in 1/2026 with diagnoses including aftercare following a liver transplant. Resident 9's 1/26/26 admission MDS indicated the resident was cognitively intact.Resident 9's 2/2026 Physician Orders included the following:- insulin NPH (an intermediate-acting medication for diabetes) 100 units/ml inject 21 units in the morning.- insulin aspart (a fast-acting medication for diabetes) 100 units/ml 15 units before meals. - insulin aspart 100 units/ml 4 units with meals per sliding scale.On 2/10/26 at 7:32 AM Staff 17 (LPN) administered insulin NPH and insulin aspart to Resident 9 and did not prime the insulin pens prior to administration.On 2/10/26 at 7:32 AM Staff 17 acknowledged they did not prime the insulin pens prior to administration and expressed they were not aware priming was required. 02/11/2026 8:15 AM Staff 2 (DNS) was notified Resident 9's insulin pens were not primed prior to administration. Staff 2 stated they expected all nursing staff to prime insulin pens prior to administering insulin.

Based on observation, interview and record review it was determined the facility failed to provide appetizing and palatable food for 1 of 2 sampled residents (#43) reviewed for food. This placed residents at risk for unmet nutritional needs and poor intake. Findings include: The facility's Food and Nutrition Services Policy, dated 10/2017, indicated the following: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Resident 43 was admitted to the facility in 1/2026 with diagnoses including stroke and dysphagia (difficulty swallowing). On 2/9/26 at 2:17 PM, Resident 43 stated she/he was on a puree diet, and it was yuck, everything was bland, and the potatoes tasted like powder.A review of the 2/11/26 lunch menu revealed the facility was to provide: [NAME] herbed baked chicken, roasted red potatoes, cauliflower au gratin, dinner roll with margarine, pumpkin cake with whipped topping and beverage.On 2/11/26 at 11:34 AM kitchen meal service was observed. Staff prepared rosemary herbed chicken, roasted red potatoes, cauliflower au gratin, dinner roll with margarine and pumpkin cake with whipped topping were observed to be served. The chicken appeared overcooked. A test tray was requested.On 2/11/26 at 1:38 PM, the test tray for puree diets was sampled with the following findings:-rosemary herbed chicken was bland in taste and lacked visual appeal.-cauliflower au gratin was bland in taste and lacked identifiable characteristics.-dinner role was doughy and lacked visual appeal.-pumpkin cake with whipped topping was bland in taste and lacked visual appeal. On 2/12/26 at 11:45 AM, a test tray for puree diets was sampled with the following findings:-braised roast pork was bland and was not identifiable by taste.-garlic green beans were bland. -dinner role was doughy and lacked visual appeal.-sherbet cup was bland with no flavor. On 2/12/26 at 11:54 AM, Staff 1 (Administrator) was asked to test the meal. Staff 1 stated the braised roast pork did not taste consistent with the menu item and stated the green beans were not identifiable by taste. Staff 1 further stated the meal presentation was not good and indicated it was her expectation for residents to be informed of the food items served. On 2/13/26 at 7:43 AM Resident 43 stated the breakfast meal was bland, stated she/he was unable to identify the scrambled eggs, and stated the biscuits and gravy tasted like cornmeal mush, resulting in the resident not consuming the biscuits and gravy. On 2/13/26 at 7:57 AM Staff 20 (Dietary Manager) stated she was aware concerns existed with the appearance of puree diets and acknowledged puree meals did not always present well. Staff 20 stated it was the facility's responsibility to ensure meals were palatable and visually appealing. Staff 20 acknowledged the kitchen needed to improve puree meal quality, including flavor and presentation.

Based on observation and interview it was determined the facility failed to follow proper infection control precautions for 1 of 1 sampled resident (#40) reviewed for catheter care and while handling clean laundry for 1 of 1 laundry areas. This placed residents at risk for cross contamination and risk of infection. Finds include: According to the Center for Disease Control and Prevention: Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. B.2: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 1. Resident 40 admitted to the facility in 9/2022 with diagnoses including a urinary tract infection. On 9/11/2024 at 12:14 PM Resident 40 was observed to ambulate independently in his/her wheelchair as his/her catheter bag dragged on the ground. On 9/11/2024 at 12:17 PM Staff 2 (DNS) confirmed catheter bags should not drag on the ground. 2. On 9/12/2024 at 2:06 PM Staff 19 (Housekeeping) was observed to push an uncovered rolling rack of clean resident clothing down the hall. The rack was left unattended in a crowded hallway as Staff 19 delivered clothing items to resident rooms. On 9/13/2024 at 1:00 PM Staff 19 stated the rolling rack used to deliver clean resident clothing did not have a cover. On 9/13/2024 at 1:00 PM Staff 20 (Regional Housekeeping Manager) stated rolling racks used to return clean resident clothing should be covered.

Based on observation, interview and record review it was determined the facility failed to maintain a clean and sanitary environment in the facility's ice machine, dry storage, and dish drying area for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of potential infections related to foodborne pathogens and cross contamination. Findings include: 1. On 9/6/24 at 9:43 AM, the facility's ice machine was observed to drain onto the floor approximately six inches from the in-floor drain underneath the ice machine. The linoleum flooring under the ice machine was disintegrated and pulled away from the concrete floor. A puddle of brown, moldy water formed on the concrete floor and flowed underneath the linoleum and onto the floor around the ice machine and in the direct path to the walk-in freezer. A chunk of an unknown brown porous substance the approximate size of a baked potato was observed under the ice machine. Staff 10 (Dietary Manager) observed this, donned exam gloves and removed the item. She stated it looked like wadded up paper towels to collect the water under the machine. On 9/9/24 at 9:54 AM Staff acknowledged the presence of what appeared to be mold in the puddle under and adjacent to the ice machine. She stated it needed to be cleaned and the ice machine needed to drip into the in-floor drain. Staff 10 acknowledged the current condition was unsanitary and stated she expected the kitchen to be cleaned regularly to avoid the potential contamination of items in the walk-in freezer, dry storage and food prep areas. 2. On 9/9/24 at 10:05 AM the ice machine was observed to have a holster containing an ice scoop mounted on its left side. The ice scoop rested in an accumulation of water and a brown slimy substance inside the holster. Staff 10 (Dietary Manager) acknowledge the holster was not clean and stated the holster was to be cleaned daily for food safety. 3. On 9/9/24 at 10:08 AM the exit door adjacent to the dry storage area was observed to have a half-inch gap between the floor and the bottom of the door. Staff 10 stated kitchen staff kept the compost bins outside of this door at night and acknowledged the gap was sufficient for pests to enter the facility. She requested, Write it up so we can get it fixed. 4. On 9/9/24 at 10:13 AM a large drum fan was observed to blow on a wire shelving unit adjacent to the dishwashing station. The shelving unit contained recently-washed dishes, cookware and utensils. The grate covering the front of the fan was observed to have a large accumulation of fuzz, grime and dust which was blowing toward the drying dishes. On 9/9/24 at 10:15 AM Staff 22 (Dietary Aide) stated the fan was used during all shifts because the kitchen and dishwashing area were very hot. On 9/9/24 at 10:18 AM Staff 10 (Dietary Manager) acknowledged the presence of the fuzz, grime and dust on the fan. She stated it was not sanitary and needed to be cleaned. She stated she expected the fan to be cleaned regularly to avoid transferring potential contaminants to the clean dishes and cook areas.

Based on observation, interview, and record review it was determined the facility failed to provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being for 5 of 14 sampled residents (#s 7, 20, 34, 46 and 51) reviewed for behaviors, communication and sensory care, dental and PASARR. This placed residents at risk for unmet needs and decreased dignity. Findings include: The facility's 9/2004 Social Services Program Policy and Procedure revealed the following: -The social services program shall assist facility staff, family and friends of the resident to help meet the resident's personal and emotional needs. -Duties of the social services department include assessing the psychosocial and emotional needs of each resident, developing interventions to address residents' needs and preferences to ensure or enhance quality of life and dignity, making referrals as needed and documenting the outcomes and assisting each resident in obtaining appropriate clothing. 1. Resident 7 was admitted to the facility in 9/2020 with diagnoses including Post-traumatic stress disorder (PTSD). Resident 7's 9/24/20 Social History indicated the resident had a military history and she/he was exposed to Agent Orange (a chemical herbicide and defoliant) when she/he served in the Vietnam War. Resident 7's 8/11/24 Quarterly MDS revealed the resident was able to make her/himself understood and understand others without difficulty. No evidence was found in Resident 7's clinical record to indicate the resident's mental and psychosocial needs were comprehensively assessed, including an assessment of the resident's trauma and potential trauma triggers. On 9/11/24 at 10:58 AM Staff 5 (Social Services Director) stated she started completing trauma assessments for residents in 7/2024, and because Resident 7 admitted to the facility prior to this date, the resident's trauma was not assessed. On 9/13/24 at 12:45 PM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 2. Resident 34 was admitted to the facility in 10/2023 with diagnoses including Post-traumatic stress disorder (PTSD). Resident 34's 10/5/24 Social History indicated the resident was a Vietnam War Veteran and had a diagnosis of PTSD. Resident 34's 10/9/23 Admission MDS indicated she/he was visually severely impaired, experienced moderate difficulty hearing, was usually able to make her/himself understood to others, required substantial-to-maximal assistance for upper body dressing and was dependent on staff for lower body dressing. The MDS also indicated it was somewhat important to the resident to be able to choose what clothes she/he wanted to wear. A 4/7/24 Personal Inventory Record revealed the resident had one hat, one gray t-shirt, one pair of red sweats and one pair of shoes. On 9/9/24 at 12:36 PM Resident 34 was observed in her/his room in bed with the lights off dressed in a hospital gown. Resident 34 stated she/he suffered from PTSD as a result of her/his service in the Army. Resident 34 stated no one at the facility had ever discussed with her/him the cause of her/his PTSD or potential triggers for re-traumatization and she/he was interested in talking to someone. Resident 34 stated her/his hearing was fair and she/he had never been offered the opportunity to have an auditory consult or obtain a hearing device and stated she/he was interested in both. Resident 34 further stated it was not her/his preference to wear a hospital gown, staff did not offer to assist her/him to get dressed, she/had been told that she/he did not have any clothes and no one at the facility had ever offered to assist her/him to obtain clothing. At this time, the only clothing items present in the resident's closet were two pairs of pants. No evidence was found in Resident 34's clinical record to indicate an assessment of the resident's trauma was completed, a care plan was developed to address the resident's potential trauma triggers, an auditory consult, or resources to obtain a hearing aid or hearing appliance were offered to the resident or any attempt had been made to assist the resident to obtain clothing items. On 9/11/24 at 10:58 AM and 12:18 PM Staff 5 (Social Services Director) stated resident trauma assessments were to be completed at the time of admission for all residents, especially those residents with a diagnosis of PTSD. Staff 5 stated she started completing trauma assessments for residents in 7/2024, and because Resident 34 admitted to the facility prior to this date, she/he did not receive a trauma assessment. Staff 5 further stated she had not offered the resident an opportunity to have her/his hearing evaluated or assisted her/him to obtain clothing items. On 9/13/24 at 12:45 PM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 43690 3. Resident 51 was admitted to the facility in 6/2024 with diagnoses including Post-traumatic stress disorder (PTSD) and anxiety. Resident 51's 6/17/24 Admission MDS revealed the resident was able to make her/himself understood and understand others without difficulty. No evidence was found in Resident 51's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. On 9/11/24 at 10:58 AM Staff 5 (Social Services Director) stated resident trauma screenings were to be completed at the time of admission for all residents, especially those residents with a diagnosis of PTSD. Staff 5 stated she started completing trauma screenings for residents in 7/2024, and because Resident 51 admitted to the facility prior to this date, she/he did not receive a trauma screening. On 9/13/24 at 11:46 AM Staff 1 (Administrator) and Staff 16 (Regional Nurse Consultant) acknowledged the findings of this investigation. 50928 4. Resident 20 was admitted to the facility in 2016 with diagnoses including dementia. Resident 20's Social Determinants of Health assessment dated [DATE] indicated the primary language for Resident 20 was Laotian or Thai and the resident preferred to have an interpreter when communicating with physicians and health care staff. On 9/12/2024 at 11:40 AM Staff 5 (Social Services Director) stated she had not arranged or assisted to provide for communication needs through Resident 20's primary language. 5. Resident 46 was admitted to the facility in 5/2024 with a diagnosis including severe protein calorie malnutrition. On 9/10/2024 Resident 46 stated he wanted new dentures because it would make eating easier. On 9/11/2024 at 2:57pm Staff 5 (Social Services Director) stated she had not arranged or offered services to Resident 46 regarding her/his dental needs.

Based on interview and record review it was determined the facility failed to provide staff with appropriate competencies and skills to attain and maintain the highest practicable well-being for 1 of 1 sampled resident (#20) reviewed for communications and activities. This placed residents at risk for unmet needs. Findings include: The facility's 2/2022 Trauma-Informed and Culturally Competent Care policy indicated all staff received orientation and in-service training regarding cultural competency as an aspect of resident-centered care. Resident 20 was admitted to the facility in 7/2016 with diagnoses including dementia. On 9/11/2024 at 11:59 AM Staff 14 (CNA) stated he had been an employee at the facility for over a year and had not received any cultural competency training. On 9/12/2024 at 10:56 AM Staff 15 (CNA) stated she had been an employee at the facility for over [AGE] years and had never participated or completed any cultural competency training. On 9/13/2024 at 12:42 PM Staff 4 (Staffing Coordinator) stated she was unaware of any cultural competency training program at the facility. On 9/13/2024 at 2:06 PM Staff 1 (Administrator) was unable to provide documentation to indicate Staff 14, Staff 15 or Staff 4 received training in cultural competency.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 4 of 7 facility halls reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 9/9/24 through 9/13/24 identified the following issues: -Rooms 20, 23, 24, 27, 33, 35, 36, 38, 40, 45, 46, 49, 60, 61, 62, 64, 65, 66, 68 and 69 had resident doors with missing pieces of wood with sharp/jagged edges on the lower portions of the doors. -Rooms 61, 64, 65, 68, 69, 71 and 78 had walls where the in room sinks were with gouges along the walls, missing paint and exposed drywall. -room [ROOM NUMBER]-1 had a chunk of missing paint on the wall behind the resident bed. -room [ROOM NUMBER] had broken blinds and a jagged edge with missing paint and exposed drywall behind the resident door. -room [ROOM NUMBER]-1 had large scratches to the right of the head of bed and across the room from the foot of the bed. -room [ROOM NUMBER] had wall base peeling away from the wall next to the bathroom and the wall to the left of the resident door was gouged with missing paint, exposed drywall and had multiple missing chunks out of the blinds. -Carpet outside rooms [ROOM NUMBERS] was rippled approximately six feet by six feet causing a potential tripping hazard. -Carpet was pulled away from the wall base outside Rooms 17, 22, 23 and 46. -Carpet was pulled away from the wall base at nurses station 2 along with a sharp/jagged edges along the entryway with missing paint and exposed drywall. -Nurses station 1 had sharp/jagged edges along the lower portion of the entryway with pieces of wood that had separated. -The alcove adjacent to Hall 70 had two dirty light fixtures and two faux [NAME] chairs with exposed substrate fabric which was uncleanable and stained. -Blinds in the main dining room leading to the Activity Director's office had multiple missing and broken slats. -The entryway to the main dining room from the 300 Hall had a sharp/jagged wall edge with missing paint and exposed drywall approximately five feet up the wall. On 9/13/24 at 10:37 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.

Based on observation, interview and record review it was determined the facility failed to honor a resident's preference to get dressed for 1 of 4 sampled residents (#34) reviewed for ADLs. This placed residents at risk for lack of choices and self-determination. Findings include: Resident 34 was admitted to the facility in 10/2023 with diagnoses including blindness. Resident 34's 10/9/23 Admission MDS indicated she/he was severely visually impaired, usually able to make her/himself understood to others, required substantial-to-maximal assistance for upper body dressing and was dependent on staff for lower body dressing. The MDS also indicated it was somewhat important to the resident to be able to choose what clothes she/he wanted to wear. Resident 34's 7/15/24 ADL Self Performance Deficit Care Plan revealed the resident was totally dependent on staff to get dressed. On 9/9/24 at 12:24 PM and 9/10/24 at 1:21 PM Resident 34 was observed in bed and wore a hospital gown. Resident 34 stated it was not her/his preference to wear a hospital gown and staff did not offer to assist her/him to get dressed. On 9/11/24 at 9:19 AM Staff 14 (CNA) stated Resident 34 never refused when he offered to assist her/him to get dressed and the resident always wanted to wear pants. On 9/12/24 at 2:03 PM Staff 1 (Administrator) stated she expected staff to offer to assist residents to get dressed in the morning.

Based on interview and record review it was determined the facility failed to ensure a consent was obtained prior to administering antipsychotic medications to residents for 1 of 5 sampled residents(#24) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 24 was admitted to the facility in 7/2024 with diagnoses including fracture and dementia. Resident 24's 7/30/24 Physician Order indicated the resident was prescribed valproic (antipsychotic) for schizoaffective disorder. Resident 24's 8/2024 and 9/2024 MARs revealed the resident received valproic daily. Review of Resident 24's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of valproic. On 9/11/24 at 9:57 AM Staff 13 (RNCM) reviewed Resident 24's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of valproic and confirmed a consent was not obtained from Resident 24 or her/his representative prior to the resident starting the medication.

Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 4 sampled residents (#23). This placed residents at risk for lack of dignity. Findings include: Resident 23 was admitted to the facility in 3/2022 with a diagnosis of dementia. Resident 23's Annual MDS completed on 3/14/2024 indicated Resident 23 was significantly cognitively impaired. Resident 23's revised 8/16/2024 Care Plan indicated Resident 23 had meals served on Styrofoam dishware. On 9/9/2024 through 9/11/2024 between the hours of 11:49 AM and 1:15 PM Resident 23 was obseved to eat meals off of Styrofoam dishware. On 9/12/2024 at 10:20 AM Staff 18 (LPN) stated the facility had not attempted to implement alternatives such as plasticware. Staff 18 confirmed the loss of dignity related to residents eating from Styrofoam dishware. On 9/12/2024 at 11:00 AM Staff 10 (Dietary Manager) acknowledged the use of Styrofoam dishware was a dignity concern. On 9/13/2024 at 2:06 PM Staff 1(Administrator) acknowledged the use of Styrofoam dishware was a dignity concern.

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of abuse for 1 of 4 sampled residents (#267) reviewed for dignity. This placed residents at risk for abuse and neglect. Findings include: Resident 267 was admitted to the facility in 9/2024 with diagnoses including malignant brain cancer. A 9/9/24 Grievance communication Form stated Resident 267 had concerns related to her/his night shift CNA not being responsive to the call light and not friendly during care. The DNS and LPN Resident Care Manager spoke with Resident 267 and her/his family about the concerns and determined Resident 267 can be overstimulated by noise and her/his care plan was updated. The conclusion of the grievance stated the CNA would not be working with Resident 267 anymore. On 9/10/24 at 10:00 AM Resident 267 stated on her/his first night in the facility there was a night shift CNA who did not take care of her/him and took her/his call light away. Resident 267 stated she/he called her/his brother to get assistance. Resident 267 was tearful when she/he described the night. A 9/10/24 Admission MDS indicated Resident 267 had mild cognitive impairment. On 9/12/24 at 10:17 AM Staff 12 (LPN Resident Care Manager) stated she became aware of Resident 267's concerns through his/her brother. Staff 12 stated she spoke with Resident 267 with Staff 2 (DNS). Resident 267 stated the CNA was slow to respond to her/his call light and was not friendly. Staff 12 stated Resident 267's care plan was updated after talking with the family and the CNA was not coming back to the facility. When asked about the CNA taking Resident 267's call light, Staff 12 replied she thought the call light was taken away to provide care and then given back to Resident 267. On 9/12/24 at 11:03 AM Staff 2 (DNS) stated Resident 267 made a compliant about the night shift CNA on 9/6/24. Staff 2 stated she and Staff 12 spoke with Resident 267 and her/his family and she/he stated the CNA made her/him feel uncomfortable. Staff 2 stated Resident 267 likes interactions to be quiet and soft and this CNA was not quiet and soft. Staff 2 stated Resident 267's care plan was updated. When asked about Resident 267's call light being taken away, Staff 2 stated Resident 267 informed her the CNA removed the call light form her/his hands and she/he had to call her/his brother to get assistance. Staff 2 stated the CNA was not coming back to the facility due to the allegation of taking away Resident 267's call light. Staff 2 stated the incident could have been abuse depending upon why the CNA took away the call light and for how long. Staff 2 denied interviewing the CNA and stated the compliant should have been investigated to rule out abuse. On 9/12/24 at 11:47 AM Staff 16 (RNCM) stated if abuse is suspected, a Facility Incident Report should have been completed and sent to the State Survey Agency.

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 4 sampled residents (#267) reviewed for dignity. This placed residents at risk for abuse and neglect. Findings include: Resident 267 was admitted to the facility in 9/2024 with diagnoses including malignant brain cancer. A 9/9/24 Grievance communication Form stated Resident 267 had concerns related to her/his night shift CNA not being responsive to the call light and not friendly during care. The DNS and LPN Resident Care Manager spoke with Resident 267 and her/his family about the concerns and determined Resident 267 can be overstimulated by noise, her/his care plan was updated. The conclusion of the grievance stated the CNA would not be working with Resident 267 anymore. On 9/10/24 at 10:00 AM Resident 267 stated on her/his first night in the facility there was a night shift CNA who did not take care of her/him and took her/his call light away. Resident 267 stated she/he called her/his brother to get assistance. Resident 267 was tearful when she/he described the night. A 9/10/24 Admission MDS indicated Resident 267 had mild cognitive impairment. On 9/12/24 at 10:17 AM Staff 12 (LPN Resident Care Manager) stated she became aware of Resident 267's concerns through his/her brother. Staff 12 stated she spoke with Resident 267 with Staff 2 (DNS). Resident 267 stated the CNA was slow to respond to her/his call light and was not friendly. Staff 12 stated Resident 267's care plan was updated after talking with the family and the CNA was not coming back to the facility. When asked about the CNA taking Resident 267's call light, Staff 12 replied she thought the call light was taken away to provide care and then given back to Resident 267. On 9/12/24 at 11:03 AM Staff 2 (DNS) stated Resident 267 made a compliant about the night shift CNA on 9/6/24. Staff 2 stated she and Staff 12 spoke with Resident 267 and her/his family and she/he stated the CNA made her/him feel uncomfortable. Staff 2 stated Resident 267 like interactions to be quiet and soft and this CNA was not quiet and soft. Staff 2 stated Resident 267's care plan was updated. When asked about Resident 267's call light being taken away, Staff 2 stated Resident 267 informed her the CNA removed the call light form her/his hands and she/he had to call her/his brother to get assistance. Staff 2 stated the CNA was not coming back to the facility due to the allegation of taking away Resident 267's call light. Staff 2 stated the incident could have been abuse depending upon why the CNA took away the call light and for how long. Staff 2 denied interviewing the CNA and stated the compliant should have been investigated to rule out abuse.

Based on observation, interview and record review it was determined the facility failed to ensure accurate assessments for 2 of 12 sampled residents (#s 11 and 20) reviewed for communication, dental, and activities. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 11 was admitted to the facility in 6/2023 with diagnoses including chronic diastolic (congestive) heart failure (a condition where the left heart ventricle becomes stiff and does not pump blood efficiently) and chronic respiratory failure with hypoxia (a condition where there is not enough oxygen or there is too much carbon dioxide in the blood). A review of resident 11's 6/25/24 annual MDS revealed she/he was cognitively intact and had no oral or dental issues. On 9/9/24 at 11:03 AM Resident 11 was observed to have teeth that were gray and jagged. Resident 11 stated she/he needed dental care and she/he had tooth decay, missing and broken teeth. Resident 11 stated she/he used a medicated mouthwash prescribed by her/his doctor to treat the infections in her/his teeth. She/he also said no facility staff ever looked in her/his mouth. A review of Resident 11's active orders revealed the following prescription: Chlorhexidine Gluconate Mouth/Throat Solution 0.12%; Give 15 ml by mouth every 12 hours as needed for prevention of oral infections. Resident 11's 6/24/24 Quarterly Dental Assessment indicated she/he refused to let the licensed nurse who completed the assessment to visually inspect her/his oral cavity. On 9/13/24 at 11:04 AM Staff 11 (MDS Coordinator) stated she completed Resident 11's annual MDS based on her/his 6/24/24 Dental Assessment. She stated she did not look in Resident 11's mouth and should have coded the entry as unable to assess. Staff 11 confirmed Resident 11 had the order for Chlorhexidine Gluconate since 2023 and added she would have reapproached her/him if she knew she/he had orders for the mouthwash. Staff 11 stated she did not accurately capture Resident 11's dental needs which, in turn, did not trigger dental care on the MDS. On 9/13/24 at 2:06 PM Staff 1 stated she expected Staff 11 to reapproach Resident 11 to accurately assess her/his dental status and needs. 50928 2. Resident 20 was admitted to the facility in 7/2016 with diagnosis of dementia. Resident 20's Annual MDS 6/19/24 indicated the primary language for Resident 20 was English and she/he needed or preferred an interpreter to communicate with a doctor and health care staff. Resident 20's Social Determinant of Health Assessment on 6/19/2024 indicated the primary language for Resident 20 had been Laotian or Thai and the resident preferred to have an interpreter when communicating with physicians and health care staff. On 9/9/2024 at 2:17 PM Staff 14 (CNA) entered Resident 20's room and asked if she/he needed assistance. Staff 14 asked yes-or-no questions in English to identify the resident's needs. The resident did not respond to the questions being asked. On 9/12/24 between 10:40 AM and 12:23 PM Staff 9 (Activities Director), Staff 5 (Social Services) and Staff 13 (LPN Care Manager) confirmed the assessments found in Resident 20's MDS had not been completed using an interpreter. On 9/13/2024 at 2:06 PM Staff 1 (Administrator) acknowledged interpretative services were not used to complete assessments for Resident 20.

1. Based on observation, interview and record review it was determined the facility failed to ensure standard and contact precautions for infection control were performed by staff. This failure, determined to be an immediate jeopardy situation, resulted in 30 residents identified and treatment prescribed for potential scabies (a contagious skin disease marked by itching and small raised red spots caused by mites). This placed all residents at risk for contracting scabies and the psychosocial impact related to symptoms, isolation, pain, and discomfort and serious harm and/or death. Findings include: According to the Centers for Disease Control and Prevention website, dated 11/2010, section: Parasites - Scabies indicated the following: -On a person, scabies mites can live for as long as 1-2 months. Off a person, scabies mites usually do not survive more than 48-72 hours. Scabies mites will die if exposed to a temperature of 50 C (122 F) for 10 minutes. -Possible complications include bacterial skin infections that can lead to inflammation of the kidneys. On 6/7/23 at 10:25 AM Staff 42 (CNA) and Staff 11 (CNA) provided close contact direct care to Resident 14. Signage adjacent to Resident 14's door indicated Enhanced Barrier Precautions (EBP: PPE used during high contact care such as bathing or changing) were in place. Staff 42 and Staff 11 wore masks and gloves and did not have gowns donned while providing care. On 6/7/23 at 11:01 AM Staff 42 stated she did not see the EBP signage prior to providing direct care to Resident 14 and she was unsure why Resident 14 required EBP. Staff 42 stated she and Staff 11 should have worn gowns during care. On 6/9/23 at 8:11 AM Staff 4 (Housekeeping/Laundry Manager) stated the facility had an ongoing issue with residents' with rashes since about 1/2023. Staff 4 stated they were to start a new system in laundry to separate the infected residents laundry due to the 30 residents who were identified yesterday with rashes from scabies. Staff 4 confirmed the laundry was washed at at least 122 degrees F for at least 10 minutes. On 6/9/23 at 8:17 AM Staff 40 (CNA) and Staff 41 (Agency CNA) were observed to reposition Resident 31 in bed. Resident 31 was on contact precautions and neither CNA donned a gown at the time physical assistance to Resident 31 was provided. On 6/9/23 at 8:21 AM Staff 40 stated she was not sure why Resident 31 was on contact precautions and was not sure when she was supposed to wear a gown when assisting this resident. Staff 40 further stated she did not receive any training related to the contact precautions sign. On at 1:32 PM Staff 41 stated she did not know she was supposed to wear a gown at the time she provided assistance to Resident 31. Staff 41 further stated she did not think she needed to wear a gown when entering a resident's room who was on contact precautions. On 6/9/23 at 8:21 AM Resident 49 was observed in her/his wheelchair in the common area hallway near nursing station three. Staff 38 (CNA) assisted the resident back to her/his room which had contact precautions signage posted. The signage indicated hand hygiene was required before and after gloving, gown and gloves donned at door prior to entering, use resident-dedicated or disposable equipment, clean and disinfect shared equipment between residents and before removing equipment from the room. Staff 38 stated he thought some of the residents were on contact precautions because of a potential scabies outbreak and was unsure if residents who were on contact precautions should stay in their rooms. On 6/9/23 at 8:29 AM Staff 39 (Agency CNA) entered room [ROOM NUMBER] which had contact precautions signage posted and attempted to obtain Resident 43's blood pressure while the resident was lying in bed. Staff 39 leaned across the resident's body, which caused Staff 39's clothing to come into direct contact with the resident and her/his linens and placed the blood pressure cuff around Resident 43's left arm. Staff 39 was unable to obtain a blood pressure reading, leaned over the resident's body again, which caused her clothing to come into direct contact with the resident and her/his linens, retrieved the cuff and placed it on Resident 43's right arm. Staff 39 failed to obtain a blood pressure again, removed the blood pressure cuff from the resident's arm and held the cuff under her chin and against her chest while she reset the vital signs machine. During this interaction, Staff 39 did not wear gloves or a gown and her bare hands were in direct contact with Resident 43's skin, clothing and linens. At 8:36 AM Staff 39 gathered her papers off of Resident 43's bedding, placed the papers in her pocket, gathered the vitals equipment and exited the room. Staff 39 did not perform hand hygiene and did not disinfect the vital signs equipment. Staff 39 walked across the hall to room [ROOM NUMBER] which had contact precautions signage posted, retrieved a gown from the PPE bin and donned gloves and a gown. At 8:38 AM, Staff 39 entered Resident 55's room with the vitals equipment, obtained the resident's vital signs, and during the interaction touched the resident, her/his belongings and linens. At 8:43 AM Staff 39 doffed the PPE and exited room [ROOM NUMBER]. Staff 39 did not perform hand hygiene, did not disinfect the vitals equipment and walked across the hall to room [ROOM NUMBER] which had contact precautions signage posted. Staff 39 retrieved a gown and stated, Oh my gosh, it's every room. I wish they would have told me there was a scabies outbreak. I don't know how contagious it is but I have to work in three different facilities over the next three days. The surveyor intervened when Staff 39 attempted to don a gown and enter room [ROOM NUMBER]. When asked about contact precautions, PPE usage and hand hygiene, Staff 39 stated she did not see the contact precautions signs for room [ROOM NUMBER], acknowledged she did not wear gloves and a gown and did not perform hand hygiene after direct contact with the resident. Staff 39 stated she was unsure if the vitals equipment was disinfected between every resident and it probably should be. Staff 39 stated she wore gloves a couple of times but should have probably performed hand hygiene between each resident. On 6/9/23 at 9:20 AM Staff 3 (LPN/Infection Preventionist) stated Resident 116 went to the hospital and the facility was notified on 6/6/23 the resident was diagnosed with scabies and crusted (Norwegian, highly contagious) scabies while at the hospital. Resident 116 was treated for a rash in the facility prior to the hospital admission for an unrelated health concern. Staff 3 stated the facility conducted skin audits on 6/7/23 for all residents in the facility and identified 30 residents with skin rashes. She stated the facility put all of those residents on contact precautions and planned to put the roommates of some of those residents on contact precautions as well. Staff 3 stated the facility was to start treating those 30 residents orally and with a cream but needed a plan due to staffing and the need to shower each resident prior to the cream treatment. Signs for contact precautions were posted and she expected staff to follow standard and contact precautions. On 6/9/23 at 10:30 AM Staff 3 provided a list of residents on contact precautions. Staff 3 stated all of the 30 residents on contact precautions were related to identified rashes for potential scabies. Staff 3 stated this had occurred since 1/2023 with the first diagnosis of scabies. She stated we always have a rash or 2 or 10 and the rashes would get better and come back again. The facility was to offer to staff treatment for scabies and she had already contacted her provider to start medications to treat possible scabies. Staff 3 contacted the county health department and since the facility only had the one confirmed case, diagnosed at the hospital and no other residents were tested for scabies, the facility was not in an official scabies outbreak. On 6/9/23 at 11:12 AM a community visitor was followed from the facility front door to room [ROOM NUMBER]. room [ROOM NUMBER] had contact precautions signage posted. The visitor did not perform hand hygiene, did not don gloves and a gown, entered the room and touched the resident. Staff did not educate the visitor regarding infection control practices related to contact precautions. On 6/9/23 at 1:53 PM Staff 1 (Administrator) was informed of the immediate jeopardy (IJ) situation related to the facility's failure to follow appropriate infection control, standard and transmission based precautions. The IJ template was provided and an IJ removal plan was requested. On 6/9/23 at 4:34 PM the facility submitted a removal plan which was accepted by the survey team. The IJ Removal Plan indicated the facility would implement the following actions: - Staff from all departments would be in-serviced on infection control precautions, use of PPE, enhanced hand hygiene, disinfection of shared equipment. In-services were to take place in person prior to start of next working shift and by phone. - Residents were to be educated verbally about the importance to stay in their rooms for the duration of precautions unless escorted by staff or appropriate personnel. - Audits were to begin weekly to ensure infection control practices were followed. Between 3:00 PM on 6/9/23 and 4:00 PM on 6/10/23 Staff 2 (DNS) provided in-services / education to staff related to appropriate infection control practices, proper use of PPE, hand hygiene between residents, disinfection of shared equipment and expectations for residents on precautions. On 6/12/23 from 5:12 AM to 5:35 AM interviews were conducted with Staff 10 (CNA), Staff 22 (LPN), Staff 44 (CMA) and Staff 45 (Agency CNA). Staff verified they received training and education related appropriate infection control and PPE practices. On 6/12/23 at 8:40 AM Staff 1 provided documentation to verify all staff received the required training and education related to appropriate infection control practices and PPE use. Staff 1 and Staff 2 verified all elements of the IJ removal plan were completed on 6/10/23 at 4:00 PM. 2. Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 6/12/23 at 4:51 AM wet laundry, which included resident clothing, was observed in two washing machines in the laundry room. Condensation was visible on the inside of door windows and the wash cycle was complete. On 6/12/23 at 5:46 AM Staff 8 (Laundry Services Manager) confirmed wet laundry was left in the two washing machines overnight as the laundry staff did not start their shift until 7:00 AM. Staff 8 stated the wet laundry should never be left for an extended period due to potential of bacterial growth. 3. Based on observation, interview and record review it was determined the facility failed to ensure provision of appropriate hand hygiene for residents observed during the breakfast meal. This placed residents at risk for spread of infection and lack of hygiene. Findings include: On 6/12/23 at 7:18 AM observations of the breakfast meal revealed staff did not offer or provide residents with assistance to complete hand hygiene prior to the breakfast meal. On 6/12/23 at 8:12 AM Staff 10 (CNA) and Staff 34 (CNA) stated they did not recall being told to provide hand hygiene for residents before meals. Staff 10 and Staff 34 confirmed no hand hygiene was provided to residents before the breakfast meal. On 6/15/23 at 11:24 AM Staff 2 (DNS) stated it was an expectation for caregivers to assist residents with hand hygiene before all meals.

1. Based on interview and record review it was determined the facility failed to safely transfer a resident according to the care plan for 1 of 4 sampled residents (#264) reviewed for accidents. This failure resulted in Resident 264 experiencing severe pain related to a right hip dislocation and requiring hospitalization and surgery. Findings include: Resident 264 was admitted to the facility in 8/2022 with diagnoses including fracture of the right femur. Resident 264's Admission MDS revealed the resident was severely cognitively impaired and required extensive assistance from two or more staff with transfers. Resident 264's 8/24/22 ADL Self Care Performance Deficit Care Plan indicated the following: - Weight bearing as tolerated to right lower extremity, posterior hip precautions; and - The resident required two staff participation with transfers. A 9/16/22 Incident Report prepared by Staff 26 (LPN) revealed the following: - Staff 27 (Agency CNA) was told in shift report that Resident 264 needed the assistance of one person with transfers and was unaware the resident had any hip precautions in place. - Staff 27 did not review Resident 264's care plan prior to transferring the resident to the toilet. - Staff 27 independently transferred Resident 264 to the toilet. - Staff 28 (CNA) responded to Resident 264's bathroom call light. Staff 28 observed the resident on the toilet hunched over, drooling and crying. Resident 264 informed Staff 28 her/his legs hurt. Staff 28 and Staff 29 (CNA) assisted Resident 264 off of the toilet with a stand pivot transfer during which the resident's crying increased. - Staff 28 and Staff 29 transferred the resident to her/his bed and the resident was noted to be in distress and yelled anytime her/his right leg was moved. It was noted the resident was unable to use her/his leg during the transfers. - The resident was sent to the hospital on 9/16/22 for a dislocation of her/his hip prosthesis. The hip prosthesis was separated into two parts during an attempted reduction in the emergency department on 9/16/22. The resident was admitted to the hospital, had surgical repair to her/his hip prothesis on 9/18/22 and returned to the facility on [DATE]. On 6/12/23 at 12:30 PM Staff 28 stated she remembered she found Resident 264 on 9/16/22 on the toilet crying from pain. Staff 28 stated she recalled Staff 27 independently transferred the resident onto the toilet. On 6/13/23 at 9:54 AM Staff 27 stated he assisted Resident 264 onto the toilet on 9/16/22 by himself. Staff 27 stated he was told Resident 264 had hip precautions and required two staff for transfers at the end of his shift, not at the beginning. Staff 27 stated he did not have time to review resident care plans because his resident assignment was changed multiple times during his shift. On 6/14/23 at 11:13 AM Staff 13 (RNCM) stated Resident 264 was care planned for posterior hip precautions, which included no acute angles in the hip, not turning her/his foot/hip out to the side, the assistance of two staff with transfers at the time of the incident. Staff 13 stated Staff 27 independently transferred Resident 264 onto the toilet. Staff 13 confirmed the resident's care plan was not followed in terms of the transfer. On 6/14/23 at 1:31 PM Staff 2 (DNS) acknowledged the findings and no additional information was provided. 39632 2. Based on observation, interview and record review it was determined the facility failed to ensure smoking materials were secured and not accessible to residents for 1 of 1 (#57) resident reviewed for smoking. This placed residents at risk for access to hazardous materials and accidents. Findings include: Resident 57 was admitted to the facility in 3/2023 with diagnoses including schizophrenia. Resident 57's 12/22/22 Smoking Safety Evaluation specified the resident smoked independently. Resident 57's 4/3/23 Smoking Care Plan indicated her/his lighter was stored in a lock box in the nursing treatment cart at station two. On 6/7/23 at 11:19 AM, Resident 57 walked independently to the outdoor smoking area. Once she/he sat down, Resident 57 lit her/his own cigarette and smoked. At 11:25 AM, the resident stated her/his lighter and cigarettes were stored at the nursing station. Resident 57 did not provide additional details related to the process for returning the lighter and continued to smoke her/his cigarette. On 6/7/23 at 11:31 AM Resident 57 returned from the outdoor smoking area and placed a green lighter on the station two nursing station counter, did not notify staff she/he placed the lighter on the counter and walked to her/his room. The lighter was accessible and within reach of residents and staff. On 6/7/23 at 1:11 PM a blue lighter was observed on top of a medication cart located on the hall between rooms [ROOM NUMBERS], adjacent to Resident 57's room. The lighter was accessible and within reach of residents in the area. At 3:00 PM, the lighter was no longer on top of the medication cart. On 6/13/23 at 10:35 AM a blue lighter was observed in a white rectangular tray on top of a medication cart. The rectangular tray also contained medication cups and an open tube of permethrin 5% medicated cream (used to treat scabies or lice). Staff 19 (Agency RN) stated she saw the lighter there earlier and she was unsure where the lighter came from, where it was stored or what the facility's policy was regarding storage of smoking materials. At 10:41 AM Staff 13 (RNCM) approached the medication cart and observed the lighter in the tray. Staff 19 asked Staff 13 how and where smoking materials and the lighter were stored. Staff 13 stated smoking materials were locked in the lock box located in the medication cart. Staff 13 was notified of the 6/7/23 observations when the lighter was accessible and within reach of residents and stated the lighter should have been secured in the lock box at all times when not in use. On 6/13/23 at 10:56 AM Staff 2 (DNS) was notified about the instances of the lighter left unattended and within reach of residents at the nursing station and on top of the med cart. Staff 2 stated the lighter should always be secured in the lock box when not in use. 38140 3. Based on interview and record review it was determined the facility failed to ensure the resident did not experience a fall for 1 of 4 sampled residents (#114) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 114 was admitted to the facility in 3/2023 with diagnoses including wrist fracture. Review of Resident 114's 3/2023 care plan revealed she/he required physical assistance from one person with the use of a four wheeled walker and a gait belt to ambulate. Resident 114 required assistance with her/his colostomy bag (small pouch used to collect waste from the body). In an interview on 6/12/23 at 11:45 AM Resident 114 confirmed on 4/2/23 she/he did not receive assistance when she called for help to empty her/his full colostomy bag and she/he walked to the bathroom without staff assistance, due to no responce from the call light to empty her/his colostomy bag. The colostomy bag exploded all over [her/himself], to the floor and [she/he] slipped and fell . A facility incident report initiated 4/2/23 revealed Resident 114 took her/himself to the bathroom because after her/his call light was not answered. Resident 114 experienced a full colostomy bag, which erupted, and spilled contents on the floor. Resident 114 slipped and fell in the waste on her/his bathroom floor. On 6/14/23 at 3:35 PM Staff 35 (LPN/Resident Care Manager) stated she expected staff to follow the resident's care plan to prevent accidents. On 6/14/23 at 4:05 PM Staff 1 (Administrator) confirmed Resident 114's fall on 4/2/23 was due to a lengthy call light time. She expected staff to follow the resident's care plan and answer call lights timely to prevent accidents.

Based on observation, interview and record review it was determined the facility failed to promptly intervene when a resident experienced unplanned significant weight loss for 1 of 5 sampled residents (#12) reviewed for medications. This resulted in an unplanned severe weight loss for Resident 12 and placed residents at increased risk of unplanned weight loss. Findings include: Resident 12 admitted to the facility in 2/2016 with diagnoses including dementia. Record review of Resident 12's past year of Nutritional Assessments revealed the RD completed an assessment on 6/21/22 and 2/14/23. The 2/14/23 assessment was completed after a re-admission. No formal assessments were found reguarding weight loss after 2/14/23. Resident 12's 2/2023 physician order directed staff to provide a general regular diet with pureed texture and mildly thick consistency liquids. The order directed staff to weigh her/him once a month. Resident 12's 2/2023 nutritional care plan indicated a potential problem related to the mechanically-altered diet. Interventions were to maintain adequate oral intake and to keep her/his weight stable. Resident 12 was to receive large protein portions with lunch and dinner and oatmeal with brown sugar on her/his breakfast tray. The RD would evaluate and make diet change recommendations PRN. Review of Resident 12's medical record revealed she/he was weighed on the following dates: -11/1/22 at 220.2 lbs. (pounds) -2/10/23 at 227.1 lbs. -4/1/23 at 191.6 lbs. -5/2/23 at 189.0 lbs. -6/12/23 at 186.4 lbs. Resident 12's 3/30/23 Quarterly MDS indicated she/he was cognitively intact with no behaviors, no signs or symptoms of a possible swallowing disorder and experienced no weight loss or gain. Review of the initial 5/11/23 NAR (Nutrition at Risk) meeting indicated Resident 12 was not reviewed by the IDT (interdisciplinary team) between 11/2022 and 5/11/23. The 5/11/23 NAR meeting it was identified Resident 12 had a 16.8% weight loss since 2/10/23. Resident 12's intake was not adequate, with 55% intake during the past two weeks. Resident 12 was noted to experience high levels of energy, with her/him up in her/his wheelchair, completing laps around the building. The next day sh/he slept all day. It was noted the IDT would contact the residents primary care physician for a speech evaluation related to diet texture. On 6/7/23 and 6/8/23 Resident 12 was observed in a deep sleep throughout each day. On 6/9/23 at 8:34 AM Resident 12 was observed to speak with Staff 20 (Dietary Services Manager) in her/his room. Resident 12 was overheard to speak about her/his food preferences, concerns and dislikes with the food. On 6/9/23 at 3:25 PM Resident 12 was observed to self-propel her/his wheelchair around the facility hallway. On 6/12/23 at 8:10 AM Staff 24 (RA) asked Resident 12 if she/he wanted anything to eat or just water. Resident 12 asked for just water. Staff 24 left Resident 12 with four glasses of thickened water. No other alternatives were offered to Resident 12 to eat. On 6/12/23 at 10:27 AM Resident 12 was observed to speak pleasantly on the phone in her/his room. On 6/13/23 at 12:32 PM Resident 12 was observed to sleep though out the morning. On 6/13/23 at 1:16 PM Staff 43 (RD) stated she started following Resident 12 in the beginning of May for weight loss. She stated the resident did not like the consistency of the food and water. Staff 43 tried to get an SLP order to evaluate the resident for swallowing food and liquids, but it was difficult to get results between the spouse and the outside care provider. Staff 43 stated Resident 12 had not been evaluated for a change in her/his food texture by an SLP since the weight loss was identified. Staff 43 stated Resident 12 did not want food someday's and other days she/he ate the pureed food and thickened water. On 6/15/23 at 11:04 AM Staff 24 stated Resident 12 was difficult to redirect, often expressed her/his choices strongly and chose what to eat and when. On 6/15/23 at 11:10 AM Staff 2 (DNS) and Staff 35 (LPN/Resident Care Manager) confirmed Resident 12 had not been weighed between 2/10/23 and 4/1/23 and then not until 5/2/23. Staff 35 confirmed Resident 12 had a NAR meeting initiated for the review of significant weight loss on 5/11/23 with an identified 16.8% weight loss since 2/10/23. Staff 2 and Staff 35 stated it was difficulty to get an SLP order to change the diet texture and fluid consistency due to the outside provider and the spouse. Staff 35 confirmed Resident 12 had not been evaluated by an SLP since the 2/2023 for her/his identified weight loss or a diet texture evaluation. Staff 2 and Staff 35 acknowledged they would expect the severe weight loss to be addressed [NAME] timely. No additional information was provided.

Based on interview and record review it was determined the facility failed to administer medications as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#2) reviewed for medications. As a result Resident 2 became non-responsive to verbal stimuli and was sent out to the hospital after being administered another resident's medications. The facility identified the noncompliance, immediately initiated a plan of correction, including in service training for staff providing services and care to residents with similar orders and completed audits to ensure administration of resident medication. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 2 admitted to the facility in 2/2022 with diagnoses including Metabolic Encephalopathy (a condition caused by a chemical imbalance in the brain). The facility submitted a FRI on 2/14/23 which revealed Resident 2 recived her/his roommates medication in error. As a result, Resident 2 became non-responsive and required hospitalization . The 2/14/23 Facility Medication Error report indicated at Resident 2 was provided with morning medication at approximately 1058 by Staff 4 (CMA). At approximately 1230, resident 2 was in the community dining room and became non-responsive to verbal stimuli. Resident 2 was transported to the hospital via ambulance a short time later. At approximatively 1350, Staff 4 indicated to Staff 1(Administrator) and Staff 2 (DNS) that she incorrectly administered Resident 2's medication. Staff 4 stated Resident 2 recevied her/his roommates medication which included Sertraline (Antidepressant), Clozapine (Antipsychotic), Haldol (Antipsychotic), and Benztropine (Anticholinergic). A 2/14/23 Hospital Note indicated Resident 2 received a diagnosis of Acute Toxic Encephalopathy (a condition caused by altered consiousness in the brains central nervous system) due to administration of Clozapine, Haloperidol, Sertraline and Benztropine while at the facility. On 3/1/23 at 9:35 AM Staff 4 (CMA) confirmed she made a medication administration error while passing medications for Resident 2. Staff 4 stated she did not follow administration protocol prior to medication administration for Resident 2. Staff 4 stated once she discovered her error, she reported her findings to Staff 1 and Staff 2. On 3/1/23 at 11:20 AM Staff 2 (DNS) stated Resident 2 was called for a full code when she/he was found unresponsive in the dining room. Staff 2 stated Resident 2 was transferred to hospital by ambulance after several attempts to arouse the resident. Staff 2 stated Staff 4 (CMA) reported to Staff 2 and Staff 1 (Administrator) that she made a medication error by administering Resident 3's medication to Resident 2. Staff 2 contacted the hospital to report these findings and notified family of the occurrence. Staff 2 stated Staff 4 was suspended and a full investigation was launched. On 3/2/23 at 1:53 PM Staff 1 (Administrator) and Staff 2 (DNS) confirmed findings and provided no additional information. The incident met the criteria for non compliance as follows: 1. The incident indicated non compliance for F760 2. There was sufficient evidence the facility corrected the non compliance and was in substantial compliance with F760 as evidenced by: -No deficient practice was found at F760 with additional sampled residents. -The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for the medication error, provided in service training to all medication aides and nursing staff for proper medication administration of orders from 2/15/23 to 2/20/23. -Weekly audits of medication carts were immediately implemented to ensure proper storage of resident medicaitons.

Based on interview and record review it was determined the facility failed to implement care plan interventions to prevent falls for 1 of 3 sampled residents (#100) reviewed for accidents. As a result, Resident 100 fell out of bed, was hospitalized and sustained multiple fractures. Findings include: Resident 100 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), congestive heart failure and fracture of the sacrum. Resident 100's 10/2/22 MDS revealed a BIMS score of 14, indicating no cognitive impairment. Resident 100's care plan dated 9/29/22 revealed she/he had orders for adaptive devices (bedside rails) on her/his bed to assist with bed mobility. On 10/3/22 the facility submitted a FRI to the state agency which revealed Resident 100 fell out of bed on 10/2/22 at 10:15 PM. The resident reported hitting her/his head and later complained of pain all over her/his body. The physician was notified and directed staff to send Resident 100 to the hospital. The facility's risk management report dated 10/2/22 revealed upon admission, Resident 100 was assessed to be appropriate for a bariatric bed with side rails to assist her/him with bed mobility. A new bed was placed outside of her/his room on 9/30/22. The bed rails were installed by maintenance but the bed was not moved into the resident's room prior to her/his fall. Hospital notes reviewed by the facility revealed Resident 100 was diagnosed with a left acetabulum (hip socket) fracture and 4-6 rib fractures as a result of the fall. On 12/29/22 at 1:28 PM, Staff 4 (Admissions Coordinator) stated she obtained the bariatric bed for Resident 100 on 9/30/22 and left a work order with maintenance to install the bed rails before the resident was placed in the bed. On 12/29/22 at 1:39 PM, Staff 3 (RN) stated she provided care to the resident on 9/30/22, saw the bed outside the resident's room but did not know the bed was for Resident 100. She confirmed she did not initiate a bed transfer for Resident 100. On 1/9/23 at 11:23 AM, Staff 2 (DNS) confirmed the baritric bed with side rails was not moved into Resident 100's room before she/he fell out of bed.

Based on interview and record review it was determined the facility failed to ensure care planned interventions were followed for 1 of 8 sampled residents (#6) reviewed for quality of care. As a result of facility staff not following the care planned interventions to transfer Resident 6 from her/his bed to wheelchair, this resulted in pain, hospitalization and a hairline fracture was identified. Findings include: Resident 6 admitted to the facility in 5/2022 with diagnoses including hip fracture and [CONDITION(S)]. The 5/14/22 Admission MDS assessed Resident 6 with a BIMS of 13 (cognitively intact) and as a two-person physical assist for transfers. Resident 6's 5/26/22 Kardex care plan directed staff to use a mechanical aid lift sling for transfers. A 5/27/22 progress note revealed Resident 6 reported an injury while attending the care conference. Resident 6 reported she/he was in bed, the wheelchair was on the side of the bed at the foot of bed, the staff lifted her/his feet to put her/him in a seated position on the bed. The staff put a transfer belt on her/him, assisted her/him to stand and pivot to the wheelchair. During the transfer her/his leg was caught on the bed and her/his leg was twisted. Resident 6 reported she/he screamed to stop but the staff continued. Resident 6 was assessed to have a pain level of seven out of ten (ten as the highest level) pain and with 1+ [CONDITION(S)] (swelling). A 5/27/22 progress note revealed Resident 6 was sent to the hospital on 5/27/22 due to pain and swelling caused from the improper transfer. A facility Alleged Neglect incident form initiated on 5/27/22 identified Staff 8 (Former CNA) as the staff who transferred Resident 6 from her/his bed to the wheelchair on the morning of 5/27/22. Staff 8 was suspended. A 5/30/22 progress note by Staff 2 (DNS) revealed the resident was diagnosed with a hair-line fracture at the hospital during the 5/27/22 admission. During an interview on 9/8/22 at 12:06 PM Staff 8 confirmed she was aware Resident 6 was care planned to transfer from the bed to the wheelchair by a mechanical aid lift sling, but she used a transfer belt on 5/27/22 and did not follow the care plan. On 9/8/22 at 12:27 PM Staff 2 state staff were to follow the care plan as directed. Staff 2 confirmed Resident 6 was care planned to be transferred by mechanical aid lift sling when Staff 8 transferred her/him by use of a transfer belt on 5/27/22.

Based on observation, interview and record review, it was determined the facility failed to investigate a facility acquired pressure ulcer and failed to provide routine monitoring and wound assessment for facility acquired pressure ulcers for 2 of 3 sampled residents (#s 64 and 30) reviewed for pressure ulcers. As a result, Resident 64's pressure ulcer worsened from a Stage 2 (partial-thickness loss of skin; shallow open ulcer) to a Stage 3 (full-thickness loss of skin; subcutaneous fat may be visible in the ulcer). Findings include: According to the facility's Wound Management Guidelines revised on 8/25/20, .If a resident is identified to have a new skin alteration the Licensed Nurse will: a. Notify the Nurse Manager and/or designees and they will: 1) Initiate Risk Management and investigate the potential cause, develop and implement interventions. b. Documentation of the new skin alteration will be completed in the resident's clinical records. Documentation will include: 1) Location 2) Size 3) Wound description 4) Drainage type 5) Surrounding tissue Skin documentation of wounds or pressure injury identification is completed in the EHR (electronic health record) Skin and Wound module. An assessment will be completed for each area . 1. Resident 64 was admitted to the facility in 4/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 64's current care plan indicated she/he had a pressure injury to her/his sacrum, with interventions including assess, record, monitor wound healing at least weekly. Measure length, width and depth status of wound perimeter, wound bed and healing progress, turn and reposition frequently and complete a skin assessment form as required and update at least weekly. Resident 64's 2/1/22 Pressure Ulcer CAA assessed the resident as being at risk for pressure ulcers and she/he needed one person assistance for bed mobility and transfers. Staff were to monitor skin daily for redness and other signs and symptoms for breakdown and licensed nurse to audit skin every week. Resident 64's 2/2022 Skin and Wound Evaluations documented the following: -On 2/21/22: Stage 2 facility acquired pressure ulcer located on sacrum, 1.8 cm x 2.1 cm x 1.1 cm. Wound bed is 90% filled granulation, 10% slough (devitalized tissue), increased pain, no odor, periwound edges attached. -On 2/28/22: Stage 2 facility acquired pressure ulcer located on sacrum, 0.1 cm x 1.4 cm x 0.3 cm. Wound bed is 100% covered, surface intact. There was no documented evidence Resident 64's Stage 2 facility acquired pressure ulcer identified on 2/21/22 was not investigated to identify possible causative factors and to ensure care plan interventions were effective and implemented. Resident 64's 3/2022 Skin and Wound Evaluation, Progress Notes and TAR documented the following: -A 3/8/22 Skin and Wound Evaluation noted: Stage 2 facility acquired pressure ulcer located on sacrum, 1.8 cm x 2.1 cm x 1.3 cm. Wound was resolved. -A 3/22/22 Progress Note indicated: Resident noted with small 1 cm skin tear on bottom/coccyx. Cleansed area with wound cleanser, patted dry and applied dressing. Notified PA . -The 3/2022 TAR indicated: Wound care to coccyx, clean with wound cleanser, pat dry and apply dry dressing (order date 3/22/22). There were two dates with no documentation to show treatment was administered on 3/30/22 and 3/31/22. There was no documented evidence a skin assessment was conducted after Resident 64 was noted to have a 1 cm skin tear to her/his coccyx (a pressure point area). Resident 64's 4/30/22 Quarterly MDS, Section C: Cognitive Patterns and Section M: Skin Conditions identified the resident as moderately impaired and had an unhealed, facility acquired Stage 3 pressure injury. Resident 64's 4/2022 Progress Notes and TAR documented the following: -On 4/12/22 Physician's Progress Note identified: Staff reports concern regarding [the resident's] coccyx wound with increased pain and a foul smell .has been refusing to let staff change [the resident's ] bandage on [the resident's] coccyx .[The resident] reports increased pain in the coccyx area in the past week. Foul smell noted upon walking into room and worse when examining wound .Coccyx area with large open area without purulent drainage .collect wound culture . -A 4/15/22 Physician's Progress Note identified: Staff reported concern regarding [the resident's] coccyx wound with increased pain and a foul smell .[the resident] reports increased pain in the coccyx area . -A 4/29/22 Progress Note identified: Resident presents with Stage 3 pressure ulcer measuring 4.0 cm x 1.5 cm x 0.02 cm. Noted pink tissue surrounding the edges. Resident compliant with offloading. -The 4/2022 TAR noted: Wound care to coccyx, clean with Dakin's, pat dry, apply .dressing then apply 4 x 4 [MEDICATION(S)] dressing (order date 4/23/22). There was no documented evidence wound assessments were conducted after 4/12/22, when Resident 64 was identified to have a large open area to her/his coccyx. On 4/29/22 a progress note revealed Resident 64 had a Stage 3 pressure ulcer, 17 days after documentation noted the resident had an open area and 38 days after documentation noted the resident had a skin tear to her/his coccyx. The 5/2022 contracted wound specialist notes identified the following: -On 5/2/22: Unstageable facility acquired pressure ulcer located on sacrum, 2.6 cm x 2.3 cm x 1.5 cm. Wound bed with 100% slough, moderate exudates, periwound with attached edges. Subcutaneous level surgical debridement of nonviable and viable tissue was performed. -On 5/9/22: Unstageable facility acquired pressure ulcer located on sacrum, 4.0 cm x 2.2 cm x 0.6 cm. Wound bed with 100% slough, moderate exudates, periwound intact. Surgical debridement of nonviable and viable tissue was performed. On 5/16/22 at 8:36 AM and at 10:12 AM, Resident 64 was observed either resting in her/his bed on her/his side or sitting at the edge of her/his bed. Resident 64 had a low bed with a pressure relieving mattress. The resident presented alert, oriented, and had a pained affect as exhibited by a furrowed brow. Resident 64 declined to have the RN surveyor observe her/his wound. In an interview on 5/16/22 at 11:18 AM, when asked about the resident's pressure ulcer, Resident 64 stated, yes she/he had one and it hurts. The resident stated her/his sore had gotten out of hand and she/he questioned her/his care at times. In an interview on 5/17/22 at 10:45 AM, Staff 22 (Agency LPN), stated she was aware the resident had a wound and a wound doctor came weekly to assess the wound. Staff 22 stated she felt the resident's wound was getting better. In an interview on 5/17/22 at 11:02 AM, Staff 37 (CNA), stated she was aware the resident had an open area and would reposition the resident when she/he allowed. Staff 37 stated the resident could reposition herself/himself. In an interview on 5/18/22 at 11:29 AM, Staff 5 (RNCM) when asked about the resident's pressure ulcer, stated nurses were responsible for conducting initial wound assessments and then a recommendation was made to a wound specialist. Staff stated she last observed the resident's wound on 4/29/22. After reviewing the resident's progress notes from 3/22/22 to 4/12/22, Staff 5 stated she expected staff to assess and monitor the resident's wound. In an interview on 5/19/22 at 10:08 AM, Staff 2 (DNS), was informed of the findings related to Resident 64's pressure ulcer and lack of monitoring and assessment. Staff 2 stated when a resident had a facility acquired pressure ulcer, the expectation was to do an incident report. Staff 2 stated the resident should have had an assessment on 3/22/22 and a potential wound specialist referral and the resident's skin should have been addressed by the RCM at that time. 2. Resident 30 was admitted to the facility in 3/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . End of life care was identified on admission. Weekly skin audits and a care plan addressing the potential for skin breakdown were put in place on 3/10/22. Interventions included use of a pressure relieving mattress, minimizing moisture to body parts, and minimize potential causative factors when possible. A 3/22/22 progress note indicated two open areas on the left buttock and one open area on the right buttock were discovered, each measuring 0.3 cm x 0.3 cm. Areas of non-blanchable redness were noted. Resident 30 was placed on alert charting, a geo (an enhanced pressure reducing) mattress was provided and the hospice nurse was notified. The 3/22/22 Facility Incident Investigation identified the hospice nurse was notified and provided orders to turn the resident every two hours and apply a barrier cream TID. Although the investigation reviewed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no investigation around the report a nurse was informed of the open areas on 3/21/22, but failed to evaluate the resident at that time. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly skin checks revealed the following: - On 3/31/22, three open areas to the buttocks were noted; - On 4/8/22, wound to coccyx with zinc barrier cream order in place; - On 4/14/22, MASD (moisture-associated skin damage) to buttocks; - On 4/22/22, an Excoriated bottom was noted. There was no other evidence found in the clinical record the resident's pressure ulcers were monitored for worsening or improvement (i.e. measurements, description, staging) or treatments were evaluated for their effectiveness. During observations from 5/17/22 at 12:10 PM through 5/19/22 at 11:28 AM, Resident 30 was sitting up in bed. No signs of pain or discomfort were noted. In a 5/19/22 interview at 3:37 PM, Staff 2 (DNS) and Staff 43 (Consulting DNS) acknowledged there was a breakdown in the system to document pressure ulcers, but believed care was provided. When questioned regarding the incident investigation, both acknowledged it was a statement of fact and did not review the contributing factors that lead to the skin breakdown. In a 5/20/22 interview at 9:55 AM, Staff 5 (RNCM) stated she had observed the resident's three Stage 2 pressure ulcers in the past, but had not seen them recently. Staff 5 believed they were not healed as there was still a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] In a 5/20/22 interview at 12:49 PM, Staff 36 (CNA) stated she had observed the resident's coccyx on 5/20/22 and the skin was darkened, but there were no open areas found.

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 3 sampled residents (#2) was free from sexual abuse from Resident 1. This failure did not honor the resident's right to be free from abuse and psychosocial harm. Findings include: Resident 1 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. The 4/6/18 Cognitive Loss/Dementia CAA noted Resident 1's BIMs (Brief Interview For Mental Status) score of six out of 15, indicating severe cognitive impairment. The 4/2018 Care Plan noted Resident 1 was independent with bed mobility, transfers, and ambulation. Resident 1 had a potential for mood/behavior/psychosocial issues. Interventions included behavior monitoring as needed and staff were to notify social services of any decline in mood or behavior. The 1/7/19 Quarterly MDS noted Resident 1 had a BIMs score of five out of 15. Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 4/29/18 Cognitive Loss/Dementia and Communication CAAs noted Resident 2 was alert and oriented to herself/himself. Resident 2's cognitive impairment impacted her/his ability to communicate, the resident was able to speak but did not always produce words that were understood by staff, and staff relied on the resident's body language to meet her/his care needs. The 8/2018 ADL Care Plan noted Resident 2 required two person assistance with bed mobility, dressing, and transfers. Resident 1's 2/8/19 at 7:05 AM and Resident 2's 2/8/19 at 4:52 AM Progress Notes revealed Resident 1 was found in Resident 2's bed. Resident 1 stated Resident 2 was her/his spouse. Resident 1 was escorted out of the room and the facility notified the police. The facility's 2/8/19 Alleged Sexual investigation noted during a routine room check at around 4:30 AM Staff 16 (CNA) found Resident 1 in bed with Resident 2. Resident 1 was naked and was lying on top of Resident 2. Resident 2's brief was open and her/his nightgown was pulled up, exposing her/his breasts. There appeared to be contact between the genitalia. When asked to leave the room Resident 1 stated Resident 2 was her/his spouse and she/he wanted privacy. Staff 16 turned on all the call and assist lights in the room until Staff 12 (LPN) arrived. Staff 12 and 16 calmly convinced Resident 1 to return to her/his room, explaining to her/him Resident 2 could not consent. Resident 1 was immediately placed on one to one supervision. The investigation noted Resident 2 had a BIMs score of 0, was totally dependent for all care and could not be interviewed. Resident 2's 2/8/19 at 7:31 AM and 2/9/19 at 8:10 AM Progress Notes disclosed Resident 2 was sent to the hospital for evaluation. The resident returned to the facility with [DIAGNOSES REDACTED].appears scared through facial expression and both arm (sic) were tightly crossed and tense . The 2/8/19 ED (Emergency Department) Notes described Resident 2 as nonverbal, does not follow commands, severe dementia at baseline . The ED Provider Notes [DIAGNOSES REDACTED]. On 2/13/19 at 2:19 PM and 4:33 PM Resident 1 was observed lying in bed, awake. Staff were observed providing one to one supervision of the resident. When interviewed Resident 1 did not appropriately answer questions. On 2/20/19 at 7:54 AM Resident 1 stated regarding the 2/8/19 incident nothing happened really. Resident 1 initially stated she/he sat on the side of Resident 2's bed then stated she/he laid in the bed. Resident 1 stated she/he and Resident 2 were friends, she/he stopped by to say hello, she/he was clothed, both residents were awake, and there was no physical contact between the residents. On 2/13/19 at 2:22 PM Resident 2 was observed lying in bed with her/his eyes open. Resident 2 did not respond to this surveyor's presence or questions verbally, with facial expressions, or eye contact. On 2/13/19 at 3:58 PM Witness 1 (Complainant) stated she received a call from the facility, informing Resident 2 was in the ED being evaluated for rape. The ED physician told Witness 1 the sexual assault was verified. On 2/15/19 at 4:41 AM and 5:35 AM Staff 16 stated prior to 2/8/19 Resident 1 wandered in the halls at night staying to herself/himself or briefly talking to staff. Staff 16 stated Resident 2 was one of the most vulnerable residents in the facility. On 2/8/19 at approximately 2:00 AM Resident 2 was observed in bed, sleeping. At around 3:00 AM to 3:30 AM Resident 1 was observed in bed, possibly asleep. At 4:00 AM Resident 1 was not in her/his room per her/his norm. During rounds at around 4:30 AM Staff 16 checked on Resident 2 and found Resident 1 in bed with Resident 2. Per Staff 16 Resident 2 exhibited her/his typical facial expression and was vacant, confused, looking straight at the ceiling. Resident 2 mumbled something unintelligible, per her/his norm. Resident 2's brief was open and sexual contact occurred. Staff 16 told Resident 1 to get out of the bed which the resident refused. Staff 16 alerted other staff by turning on all the call and assist lights in the room and Staff 12 responded right away. Staff 12 told Resident 1 that Resident 2 could not consent due to her/his cognitive status. Resident 1 returned to her/his room, she/he was placed on one to one supervision, and the police responded. On 2/15/19 at 5:01 AM Staff 12 stated on 2/8/19 all the lights in Resident 2's room were on which indicated Staff 16 needed help. Staff 12 entered Resident 2's room and observed Resident 1 lying on top of Resident 2 and there was contact between both residents' genitalia. Staff 12 told Resident 1 she/he could not be in the room and that Resident 2 could not consent. Resident 1 stated Resident 2 was her/his spouse and staff were making it sound like she/he was raping Resident 2. Resident 1 left the room and was placed on one to one supervision. Staff 12 contacted Staff 2 (DNS) who directed her to call the police, which occurred.

Based on interview and record review it was determined the facility failed to meet professional standards of care for 2 of 5 residents (#1 and #5) for whom medication administration was reviewed. Resident 1 received medications in error for another resident which resulted in Resident 1 being admitted to the hospital for treatment. OSBN Nurse Practice Act, [PHONE NUMBER] Scope of Practice Standards for all Nurses (1)(a) Advocates for the client's right to receive appropriate care. 1. Resident 1 was admitted to facility in October 2013 with [DIAGNOSES REDACTED]. Review of nursing note dated 10/25/13 at 10:00 am noted a medication error occurred when Resident 1 was in the therapy gym. The licensed nurse (Witness 1) thought Resident 1 was another resident. Witness 1 indicated Resident 1 answered to a different resident's name. The Witness 1 did not check Resident 1's wrist band before administering amliodipine (hypertensive), [MEDICATION NAME] (hypertensive), glipazide (antidiabetic), [MEDICATION NAME] (antidiabetic), [MEDICATION NAME] (anticonvulsant) and ducosate (stool softener) to Resident 1. Witness 1 notified the RNCM, DNS, physician and family. The physician's recommendation was to check blood pressure and CBGs every hour for 24 hours. CBG was noted to be 131 (normal range is 70 to 110). Review of nursing note dated 10/25/13 at 4:40 pm indicated a low CBG of 72. The physician went to facility to evaluate Resident 1 and gave an order to send Resident 1 to the emergency room (ER) for low CBGs. When emergency personnel arrived, fluids were given intravenously (IV) and the resident's CBG rose to 288. Resident 1 was transported to the hospital. Review of the physician visit summary dated 10/25/13 indicated there was a medication error reported by nursing in the morning of 10/25/13 stating Resident 1 was given another resident's medications. CBG noted to be 131. Review of the Hospital History and Physical dated 10/25/13 indicated Resident 1 was inadvertently given another resident's medications at approximately 10:00 am on 10/25/13. Physician noted the medications given in error were [MEDICATION NAME] and potassium chloride. Resident 1 had no history of diabetes. As a result of receiving [MEDICATION NAME] and [MEDICATION NAME], the resident became recurrently hypoglycemic. The resident was given multiple doses of IV fluids. After a five-hour ER stay, resident's glucose levels did not stabilize and her/his mental status remained somnolent and unarousable. Due to concern for her/his blood pressure, Resident 1 was given a unit of packed red blood cells in the ER. Review of physician visit summary dated 10/29/13, physician noted Resident 1 was hospitalized from [DATE] to 10/28/13 for complications related to inadvertent administration of hypoglycemics and hypotensives prescribed for another resident. The summary indicated hospital course noted lowest CBG was 47. In an interview on 12/31/13 at 11:30 am Staff 1 (Administrator) acknowledged the medication error did occur which resulted in the transfer of Resident 1 to a local hospital for evaluation and treatment. In a phone interview on 1/10/14 Witness 1 confirmed she had given Resident 1 another resident's medication on 12/18/13. She further stated she failed to check the wrist band as she should have. She realized her error about fifteen minutes after giving the medications and reported the error immediately. Resident 1 was placed on alert monitoring and was sent to the hospital because of low blood sugar. Refer to F-333

Based on interview and record review it was determined the facility failed to meet professional standards of care for 2 of 5 residents (#1 and #5) for whom medication administration was reviewed. Resident 1 received medications in error for another resident which resulted in Resident 1 being admitted to the hospital for treatment. OSBN Nurse Practice Act, [PHONE NUMBER] Scope of Practice Standards for all Nurses (1)(a) Advocates for the client's right to receive appropriate care. 1. Resident 1 was admitted to facility in October 2013 with [DIAGNOSES REDACTED]. Review of nursing note dated 10/25/13 at 10:00 am noted a medication error occurred when Resident 1 was in the therapy gym. The licensed nurse (Witness 1) thought Resident 1 was another resident. Witness 1 indicated Resident 1 answered to a different resident's name. The Witness 1 did not check Resident 1's wrist band before administering amliodipine (hypertensive), [MEDICATION NAME] (hypertensive), glipazide (antidiabetic), [MEDICATION NAME] (antidiabetic), [MEDICATION NAME] (anticonvulsant) and ducosate (stool softener) to Resident 1. Witness 1 notified the RNCM, DNS, physician and family. The physician's recommendation was to check blood pressure and CBGs every hour for 24 hours. CBG was noted to be 131 (normal range is 70 to 110). Review of nursing note dated 10/25/13 at 4:40 pm indicated a low CBG of 72. The physician went to facility to evaluate Resident 1 and gave an order to send Resident 1 to the emergency room (ER) for low CBGs. When emergency personnel arrived, fluids were given intravenously (IV) and the resident's CBG rose to 288. Resident 1 was transported to the hospital. Review of the physician visit summary dated 10/25/13 indicated there was a medication error reported by nursing in the morning of 10/25/13 stating Resident 1 was given another resident's medications. CBG noted to be 131. Review of the Hospital History and Physical dated 10/25/13 indicated Resident 1 was inadvertently given another resident's medications at approximately 10:00 am on 10/25/13. Physician noted the medications given in error were [MEDICATION NAME] and potassium chloride. Resident 1 had no history of diabetes. As a result of receiving [MEDICATION NAME] and [MEDICATION NAME], the resident became recurrently hypoglycemic. The resident was given multiple doses of IV fluids. After a five-hour ER stay, resident's glucose levels did not stabilize and her/his mental status remained somnolent and unarousable. Due to concern for her/his blood pressure, Resident 1 was given a unit of packed red blood cells in the ER. Review of physician visit summary dated 10/29/13, physician noted Resident 1 was hospitalized from [DATE] to 10/28/13 for complications related to inadvertent administration of hypoglycemics and hypotensives prescribed for another resident. The summary indicated hospital course noted lowest CBG was 47. In an interview on 12/31/13 at 11:30 am Staff 1 (Administrator) acknowledged the medication error did occur which resulted in the transfer of Resident 1 to a local hospital for evaluation and treatment. In a phone interview on 1/10/14 Witness 1 confirmed she had given Resident 1 another resident's medication on 12/18/13. She further stated she failed to check the wrist band as she should have. She realized her error about fifteen minutes after giving the medications and reported the error immediately. Resident 1 was placed on alert monitoring and was sent to the hospital because of low blood sugar. Refer to F-333 2. Resident 5 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. A facility medication investigation report dated 12/18/13 documented Resident 5 was given medications ordered for another resident (choleceaciferol, Rantidine, [MEDICATION NAME] (Tyelenol), [MEDICATION NAME] (antidepressant), metropolol (blood pressure medication). Resident 5 was placed on alert monitoring and no negative outcome was identified. In a phone interview on 12/31/13 at 2:11 pm Staff 6 (DNS) confirmed that Staff 7 (LPN) gave Resident 5 the wrong medications. In an interview on 1/9/13 at 8:59 am Staff 7 (LPN) confirmed that she gave Resident 5 the wrong medication. She stated she was distracted and thinking about Resident 5 when she had prepared the medications for another resident. She further stated she reported it immediately when she realized the error and was staying focused with no further errors. Refer to F-309

Based on interview and record review it was determined the facility failed to ensure care planned fall interventions were available for CNA staff for 1 of 4 sampled residents (#6) reviewed for falls. Resident 6 had a fall, was sent to the hospital and received staples to her/his head. Findings include: Resident 6 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The 1/8/13 ADL Care Plan indicated the resident was totally dependent on staff for repositioning and turning in bed. The care planned fall interventions included "2 person assist for cares in bed to prevent rolling out." The 3/1/13 Status Tool (CNA pocket care plan) did not include the fall interventions. A 3/11/13 Progress Note disclosed Resident 6 fell from bed during care. The resident was found lying on the floor and blood was evident under the resident's head. The resident was transported to the Emergency Department. The 3/11/13 facility investigation identified the resident as disoriented. Staff 18, CNA, reported she had pulled the resident's hips toward the center of the bed and turned the resident to change her/him and the resident fell off the bed. Staff 18 did not see Resident 6's actual impact to the floor due to the height of the bed. When Staff 18 went to the side of the bed, she observed bleeding from the resident's head and the resident was on her/his back. The nurse was informed immediately. The investigation did not address the care planned fall intervention of two person assist with cares when the resident was in bed. The facility ruled out abuse/neglect and noted the Status Tool was updated for two person assistance with care. The 3/11/13 Hospital Discharge Instructions noted the resident received staples for a scalp laceration. A 3/12/13 Progress Note revealed cleaning and dressing the resident's head was painful for the resident. On 3/14/13 at 3:24 pm, Witness 3, Complainant, reported the resident sustained [REDACTED]. Witness 3 stated Resident 6 had dementia and did not speak. In interview on 3/15/13 at 9:14 am, Staff 3, Asst. DNS, reviewed Resident 6's care plan and questioned why there were not two staff providing the care for Resident 6. Staff 3 stated the fall "needs to be re-investigated." In interviews on 3/15/13 at 9:47 am and 10:35 am, Staff 1, Administrator, stated when completing the investigation, they were not aware the resident was care planned for two person assist with cares. Staff 1 stated CNAs looked at the Kardex on the computer for direction. Staff 1 stated the Kardex only included the directives regarding ADL care, which noted the resident was totally dependent for bed mobility. The Kardex did not note if the resident was one or two person assist with and the fall care planned interventions did not show up in the Kardex. In interview on 3/15/13 at 2:02 pm, Staff 18, CNA, stated she was not aware the resident required two person assist with cares as it was not on the Status Tool. In interview on 3/18/13 at 8:00 am, Staff 5, RNCM, stated she was new to the facility and did not know the resident was a two person assist with cares. Staff 5 stated she had not known how to add the fall interventions to the Kardex on the computer "until just now." .

Based on interviews and record review, it was determined the facility failed to appropriately implement treatment with a [MEDICAL CONDITION] machine (bimanual positive airway pressure) and obtain medications ordered by the physician for 1 of 2 sampled residents (#1). The resident required hospitalization for respiratory distress. Findings include: Oregon State Board of Nursing Nurse Practice Act-Scope of Practice Standards for Registered Nurses [PHONE NUMBER]-(2) (d)Implement the plan of care by (A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling(3) Standards related to the Registered Nurse's responsibility for collaboration with interdisciplinary team. The Registered Nurse:(c) Communicates with other relevant personnel regarding integrated client-centered plans of care; and (d) Make referrals as necessary and ensures follow-up on those referrals. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The 4/1/11 local hospital's Discharge Summary with Issues to Address at Skilled Nursing Facility and For the Future indicated ongoing monitoring of his/her tenuous and chronically terrible [MEDICAL CONDITION] status. The 4/1/11 physician's orders [REDACTED]. The resident had severe [MEDICAL CONDITION] and was to have 8 liters of O2 via nasal cannula and 6-8 liters of O2 at rest with an increase of up to 10 liters as needed for exertion and increased shortness of breath. The 4/3/11 night shift Interdisciplinary Notes written by Staff 3 (RN) indicated the resident's call light was on at 4:30 am and the resident's [MEDICAL CONDITION] machine was off and the nasal cannula (for oxygen) was on. The resident indicated the [MEDICAL CONDITION] was choking him/her and refused to put on the [MEDICAL CONDITION]. The resident stated he/she took off the [MEDICAL CONDITION] at 2:30 am. The CNA stated he/she refused the [MEDICAL CONDITION] at 3:30 am. The resident's O2 sats were checked and were between 60 and 70 percent. Staff 3 told the resident the O2 sats level needed to be increased. The resident agreed to put the [MEDICAL CONDITION] machine back on and his/her O2 sats level increased to 90 percent on 6 liters of O2 at 4:55 am. Staff 3 indicated the resident's [MEDICAL CONDITION] was in place when Staff 3 left the room at 4:55 am. The Interdisciplinary Note written on 4/3/11 at 7:00 am by Staff 2 (LPN) indicated Staff 7 (CNA) reported Resident 1 was having trouble using the [MEDICAL CONDITION] and Staff 7 did not know how to "hook it up." Staff 2 found the resident gray in color and the [MEDICAL CONDITION] tube was disconnected from the machine and the tube was in the resident's mouth. The resident's respirations increased and his/her eyes were watering. The resident's [MEDICAL CONDITION] was reassembled and attempts to place the [MEDICAL CONDITION] on the resident were unsuccessful. The resident was described as being too restless and pulled the [MEDICAL CONDITION] machine off. Staff 2 was unable to obtain an O2 sats reading at the time. Staff 2 administered 6 liters of O2 through a nasal cannula and the resident's O2 sats were 15 percent. The resident's O2 was increased to 10 liters and the O2 sats were 90 percent. Staff 2 replaced the nasal cannula with an O2 mask. The resident's physician was called and the resident was admitted to the local hospital emergency department. The local hospital's 4/3/11 history and physical indicated Resident 1 had the wrong mask and exhalation valve on the [MEDICAL CONDITION] machine at the facility. An investigation conducted by Staff 1 (DNS) regarding the [MEDICAL CONDITION] machine was provided on 4/19/11 at 1:45 pm. The investigation indicated the resident's [MEDICAL CONDITION] machine was delivered on 4/1/11 when the resident was to be admitted . The [MEDICAL CONDITION] machine was delivered to the facility on [DATE] unassembled with no mask provided. Staff 1 indicated the resident was admitted to the facility on [DATE]. Staff 1 determined Staff 4 (RN) worked the evening of 4/2/11 and Staff 4 did not assemble the [MEDICAL CONDITION] machine. Staff 4 indicated she saw the [MEDICAL CONDITION] machine in the room with all of the components of the [MEDICAL CONDITION], except for the mask. Staff 4 stated the resident's spouse brought the mask to the facility and put it in the closet. Staff 4 did not place the [MEDICAL CONDITION] on the resident. An interview on 4/19/11 at 2:37 pm with Staff 4 (RN) revealed she saw the [MEDICAL CONDITION] in the room unassembled and the resident's spouse stated the mask was in the closet. Staff 4 stated she did not "touch" the resident's [MEDICAL CONDITION] machine. There was no documentation the facility contacted the Durable Medical Equipment company to inform them the resident was admitted to the facility and the [MEDICAL CONDITION] was unassembled and the mask was not attached to the machine. An interview on 4/21/11 at 2:30 pm with Witness 1 (Durable Medical Equipment Company Corporate Compliance Officer), Witness 4 (local Durable Medical Equipment Respiratory Therapy Manager) and Witness 5 (Corporate Respiratory Therapy Manager) revealed the company received a physician's orders [REDACTED]. On 4/1/11 at 3:30 pm, an urgent physician's orders [REDACTED]. Witness 4 indicated the company delivered a [MEDICAL CONDITION] machine to the facility on [DATE] at 6:35 pm. Witness 4 stated when a delivery was made the company representative informed the facility of the need to contact the company in order to set up the machine accurately. The [MEDICAL CONDITION] machine was set at the ordered setting and the company did not deliver a mask as the physician's orders [REDACTED]. Witness 4 stated the resident was not at the facility when the [MEDICAL CONDITION] machine was delivered. Witness 4 indicated that it was a standard of practice the facility contact the durable medical equipment company regarding the installation of the device once the resident was at the facility. The durable medical equipment company's contact information was on the [MEDICAL CONDITION] machine. Witness 1 indicated the company had a system to verify when the facility staff contacted the company about a specific resident. There was no documentation of contact from the facility until 4/4/11 (after the resident was discharged from the facility and was residing in the hospital). An interview on 4/25/11 at 3:02 pm with Staff 1 (DNS) revealed Staff 3 (RN on the night shift) was not aware the resident's [MEDICAL CONDITION] had not been set up appropriately when she placed the [MEDICAL CONDITION] machine on the resident. Staff 1 stated usually the [MEDICAL CONDITION] machines are set up for the residents prior to admission. There had never been an occasion when the durable medical equipment agency needed to be contacted about the set up of a [MEDICAL CONDITION] machine. Staff 1 stated the facility was not aware the resident's [MEDICAL CONDITION] mask was not the right one for the [MEDICAL CONDITION] machine. Refer to F-309 b. The 4/1/11 local hospital's Discharge Summary with Issues to Address at Skilled Nursing Facility and For the Future: Ongoing monitoring of his/her pain management for the rib fractures/contusion. The 4/2/11 physician's orders [REDACTED]. There was an order for [REDACTED]. The physician's orders [REDACTED]. The facility's Admission Nursing Database indicated the resident's respiratory pattern was irregular related to rib pain and labored respiration effort. The back of the April 2011 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED] There was no evidence the resident's physician was informed the resident's medications had not been provided as ordered. The resident was transported to the local hospital emergency department on the morning of 4/3/11. The local hospital's 4/3/11 history and physical indicated the resident's family reported the resident had no [MEDICATION NAME] after his/her discharge from the hospital to the facility. The hospital physician confirmed with the facility nursing staff his/her [MEDICATION NAME] prescription was not delivered. The physician indicated that it was unclear what happened and why the medication was not delivered. The resident was assessed in the emergency department to have a recurrence of fairly significant pain. The physician's assessment and plan indicated the resident was restarted on [MEDICATION NAME] and the facility was to investigate why the pain medication was not delivered. The physician indicated the insurance care coordinator and pharmacy would be contacted about the process to ensure "excellent care for this patient in the future and other patients in the future ...." On 4/19/11 at 1:45 pm Staff 1 (DNS) provided an investigation regarding Resident 1's medications. Staff 1 indicated the facility faxed the physician orders [REDACTED]. The medications did not arrive from the pharmacy at 5:00 pm and Staff 4 (RN) called the pharmacy when the pharmacy was closed. The resident's medications were not included in the pharmacy's medication delivery at 7:30 pm. Staff 4 (RN) called the on-call consultant pharmacist/RPH (Witness 2) at 8:00-8:30 pm and left a message for him to call the facility. Staff 4 did not inform Staff 3 (RN on the night shift) that Resident 1's medications had not been delivered. An interview on 4/19/11 at 2:37 pm and 4/21/11 at 5:00 pm with Staff 4 (RN) revealed she was aware the resident's medications had not arrived from the pharmacy. Staff 4 stated Witness 2 (RPH) was called at 8:00-8:30 pm and Witness 2 did not return the phone call. Staff 4 stated she did not inform the resident's physician the medications had not arrived and were not provided. An interview on 4/21/11 at 2:00 pm with Witness 2 (on-call pharmacist) revealed the facility had the ability to contact the Geriatric Long Term Care Team (Care Team). The Care Team included physicians who were available 24 hours a day to provide care for the resident. The Care Team was a resource for the facility to obtain the resident's medications. An interview on 4/26/11 at 11:13 am with Witness 3 (RPH Manager) revealed the facility needed to contact the physician to indicate the resident's prescription for the [MEDICATION NAME] and [MEDICATION NAME] had not been obtained. Witness 3 indicated it would have been possible for the facility to obtain the medication through the emergency box/kit from the facility's vendor pharmacy. An interview on 4/26/11 at 2:00 pm with Staff 1 (DNS) revealed there was no documentation the resident's physician had been informed the resident did not receive the prescribed medications. Refer to F-309.

Based on interviews and record reviews it was determined the facility failed to follow physician's orders regarding the provision of narcotic pain and antihypertensive medications and to appropriately implement treatment with a [MEDICAL CONDITION] machine (bimanual positive airway pressure) for 1 of 2 sampled residents (#1). Resident 1 was hospitalized for [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The 4/1/11 local hospital's Discharge Summary with Issues to Address at Skilled Nursing Facility and For the Future indicated ongoing monitoring of his/her tenuous and chronically terrible [MEDICAL CONDITION] status. The 4/1/11 physician's order was for the resident to use a [MEDICAL CONDITION] machine every night from 9:00 pm until 8:00 am and as needed. The resident had severe [MEDICAL CONDITION] and was to have 8 liters of O2 via nasal cannula and 6-8 liters of O2 at rest with an increase of up to 10 liters as needed for exertion and increased shortness of breath. The 4/3/11 night shift Interdisciplinary Notes written by Staff 3 (RN) indicated the resident's call light was on at 4:30 am and the resident's [MEDICAL CONDITION] machine was off and the nasal cannula (for oxygen) was on. Staff 3 stated the resident needed to keep the [MEDICAL CONDITION] machine on and had an order to wear the [MEDICAL CONDITION] until 8:00 am. The resident said "listen to what I am saying I'm not wearing it." The note indicated the resident said it was choking him/her and Staff 3 asked "How was it choking you?" The resident responded he/she was swallowing saliva and rolled his/her eyes. The resident was described as becoming very agitated, non-compliant and refused to put on the [MEDICAL CONDITION]. The resident stated he/she took off the [MEDICAL CONDITION] at 2:30 am. The CNA stated he/she refused the [MEDICAL CONDITION] at 3:30 am. The resident's O2 sats were checked and were between 60 and 70 percent. Staff 3 told the resident the O2 sats level needed to be increased. The resident agreed to put the [MEDICAL CONDITION] machine back on and his/her O2 sats level increased to 90 percent on 6 liters of O2 at 4:55 am. Staff 3 stated she instructed the resident to take deep breaths and breathe through his/her nose. The resident was given the call light in his/her right hand and Staff 3 stressed the importance of the resident keeping the [MEDICAL CONDITION] in place. Staff 3 wrote the resident stated the [MEDICAL CONDITION] was comfortable and not too tight. Staff 3 indicated the resident's [MEDICAL CONDITION] was in place when Staff 3 left the room at 4:55 am. The Interdisciplinary Note written on 4/3/11 at 7:00 am by Staff 2 (LPN) indicated Staff 7 (CNA) reported Resident 1 was having trouble using the [MEDICAL CONDITION] and Staff 7 did not know how to "hook it up." Staff 2 found the resident gray in color and the [MEDICAL CONDITION] tube was disconnected from the machine and the tube was in the resident's mouth. The resident's respirations increased and his/her eyes were watering. The resident's [MEDICAL CONDITION] was reassembled and attempts to place the [MEDICAL CONDITION] on the resident were unsuccessful. The resident was described as being too restless and pulled the [MEDICAL CONDITION] machine off. Staff 2 was unable to obtain an O2 sats reading at the time. Staff 2 administered 6 liters of O2 through a nasal cannula and the resident's O2 sats were 15 percent. The resident's O2 was increased to 10 liters and the O2 sats were 90 percent. Staff 2 replaced the nasal cannula with an O2 mask. The resident's physician was called and the resident was admitted to the local hospital emergency department. The local hospital's 4/3/11 history and physical indicated Resident 1 had the wrong mask and exhalation valve on the [MEDICAL CONDITION] machine at the facility. The resident's spouse reported the durable medical equipment company did not deliver the [MEDICAL CONDITION] machine to the facility. She/he brought the mask from the hospital and assembled the tubing herself/himself. The spouse indicated the facility nursing staff were asked to confirm the tubing and mask had been assembled correctly. The physician wrote the resident confirmed he/she felt like he/she was suffocating and he/she wanted to remove the [MEDICAL CONDITION]. The resident stated he/she was uncooperative with the nursing staff regarding the use of the [MEDICAL CONDITION]. The physician wrote that "it would appear that this was an appropriate response to problems with exhalation valves and incorrect mask." An investigation conducted by Staff 1 (DNS) regarding the [MEDICAL CONDITION] machine was provided on 4/19/11 at 1:45 pm. The investigation indicated the resident's [MEDICAL CONDITION] machine was delivered on 4/1/11 when the resident was to be admitted . The [MEDICAL CONDITION] machine was delivered to the facility on [DATE] unassembled with no mask provided. Staff 1 indicated the resident was admitted to the facility on [DATE]. Staff 1 determined Staff 4 (RN) worked the evening of 4/2/11 and Staff 4 did not assemble the [MEDICAL CONDITION] machine. Staff 4 indicated she saw the [MEDICAL CONDITION] machine in the room with all of the components of the [MEDICAL CONDITION], except for the mask. Staff 4 stated the resident's spouse brought the mask to the facility and put it in the closet. Staff 4 did not place the [MEDICAL CONDITION] on the resident. The investigation indicated Staff 3 (RN) found the [MEDICAL CONDITION] all connected including the mask and placed the [MEDICAL CONDITION] on the resident, attached the oxygen and turned on the unit at 10:30 pm. Staff 3 stated the resident's spouse was visiting between 10:00 and 11:00 pm and checked the resident's O2 sats level. Staff 3 stated the resident's spouse did not call or ask Staff 3 if the [MEDICAL CONDITION] was assembled correctly. On 4/3/11 at 4:30 am, Staff 3 observed the resident had taken the [MEDICAL CONDITION] off and refused to put the [MEDICAL CONDITION] back on. At 4:30 am, Resident 1 was toileted and was provided with 6 liters of O2. The resident's O2 sats decreased to 60-70 percent during the time of toileting. Resident 1 agreed to have the [MEDICAL CONDITION] replaced and the O2 sats increased to 90 percent. The investigation indicated on 4/3/11 at 5:55 am, Staff 2 (LPN) entered the room and found the resident was gray in color. The resident's [MEDICAL CONDITION] mask was lying next to the resident on the bed, the tube was connected to the [MEDICAL CONDITION] and the resident had the tube in his/her mouth. The resident had increased respirations and his/her O2 sats decreased. The resident was transferred to the local hospital emergency room . An interview on 4/19/11 at 2:37 pm with Staff 4 (RN) revealed she saw the [MEDICAL CONDITION] in the room unassembled and the resident's spouse stated the mask was in the closet. Staff 4 stated she did not "touch" the resident's [MEDICAL CONDITION] machine. An interview on 4/19/11 at 2:45 pm with Staff 3 (RN) revealed the resident's [MEDICAL CONDITION] machine was connected and placed the [MEDICAL CONDITION] machine on the resident at 10:00-10:15 pm. Staff 3 stated she answered the resident's call light at 4:30 am and the resident did not have the [MEDICAL CONDITION] machine in place. Staff 3 stated she encouraged the resident to wear the [MEDICAL CONDITION] machine and the last time she saw the resident was at 4:55 am and the resident had the [MEDICAL CONDITION] in place. An interview on 4/19/11 at 3:19 pm with Staff 5 (CNA) revealed it was the first night she worked with Resident 1. Staff 5 stated the resident refused the [MEDICAL CONDITION] and the resident requested the nasal cannula with oxygen. Staff 5 stated the last time she saw the resident was when she assisted Staff 3 in toileting the resident between 4:30 am to 5:00 am. An interview on 4/21/11 at 2:30 pm with Witness 1 (Durable Medical Equipment Company Corporate Compliance Officer), Witness 4 (local Durable Medical Equipment Respiratory Therapy Manager) and Witness 5 (Corporate Respiratory Therapy Manager) revealed the company received a physician's order for a [MEDICAL CONDITION] machine to be delivered to the facility on [DATE] at 2:00 pm. On 4/1/11 at 3:30 pm, an urgent physician's order was made for the [MEDICAL CONDITION] machine to be delivered to the facility. Witness 4 indicated the company delivered a [MEDICAL CONDITION] machine to the facility on [DATE] at 6:35 pm. Witness 4 stated when a delivery was made the company representative informed the facility of the need to contact the company in order to set up the machine accurately. The [MEDICAL CONDITION] machine was set at the ordered setting and the company did not deliver a mask as the physician's order indicated the resident was to use the mask provided at the hospital. Witness 4 stated the resident was not at the facility when the [MEDICAL CONDITION] machine was delivered. Witness 4 indicated that it was a standard of practice the facility contact the durable medical equipment company regarding the installation of the device once the resident was at the facility. The durable medical equipment company's contact information was on the [MEDICAL CONDITION] machine. Witness 1 indicated the company had a system to verify when the facility staff contacted the company about a specific resident. There was no documentation of contact from the facility until 4/4/11 (after the resident was discharged from the facility and was residing in the hospital). Witness 1 indicated it was very important the Respiratory Therapist (RT) assess the resident when he/she was in the facility to determine if the [MEDICAL CONDITION] machine was set up correctly and to determine if the mask was appropriate for the resident. Witness 4 indicated if the mask was not fitted correctly for the resident, the resident could be distressed and feeling as if he/she was choking. Witness 1 indicated through their investigation of the incident, the resident's [MEDICAL CONDITION] mask obtained from the hospital was not the right mask for the resident's [MEDICAL CONDITION] machine used at the facility. Witness 1 stated the problem with the [MEDICAL CONDITION] mask would have been identified by the RT during an assessment of the resident at the facility. Witness 1 indicated the RT assessment of the mask was very important. If the RT had determined there was a problem with the resident's [MEDICAL CONDITION] mask, the RT would have obtained a physician's order and would have provided the required mask. Witness 1 stated the mask the resident was using at the facility would have caused the resident to rebreathe carbon [MEDICATION NAME]. Witness 1 indicated if the [MEDICAL CONDITION] machine was assembled by someone who did not what they were doing, the [MEDICAL CONDITION] machine would not have worked properly. On 4/25/11 at 10:00 am, Staff 1 (DNS) was asked to provide the facility's policy and procedure regarding [MEDICAL CONDITION] machines. At 1:37 pm, Staff 1 provided a statement it was "the expectation that the [MEDICAL CONDITION] will be placed according to physician orders...." An interview on 4/25/11 at 3:02 pm with Staff 1 (DNS) revealed Staff 3 (RN on the night shift) was not aware the resident's [MEDICAL CONDITION] had not been set up appropriately when she placed the [MEDICAL CONDITION] machine on the resident. Staff 1 stated usually the [MEDICAL CONDITION] machines are set up for the residents prior to admission. There had never been an occasion when the durable medical equipment agency needed to be contacted about the set up of a [MEDICAL CONDITION] machine. Staff 1 stated the facility was not aware the resident's [MEDICAL CONDITION] mask was not the right one for the [MEDICAL CONDITION] machine. b. The 4/1/11 local hospital's Discharge Summary with Issues to Address at Skilled Nursing Facility and For the Future indicated ongoing monitoring of his/her pain management for the rib fractures/contusion. The 4/2/11 physician's orders indicated the resident was to receive 2.5-5 mg of [MEDICATION NAME] (narcotic pain medication) every eight hours at 8:00 am, 4:00 pm and 12:00 am. There was an order for [REDACTED].'s [MEDICATION NAME] usage in compliance with DEA (Drug Enforcement Agency) regulations. The physician's order indicated the resident was to receive 30 mg of [MEDICATION NAME] for hypertension at 8:00 pm. The facility's Admission Nursing Database indicated the resident's respiratory pattern was irregular related to rib pain and labored respiration effort. The April 2011 Pain Management Flowsheet indicated a pain assessment was to be completed every shift. The Flowsheet was blank for all shifts the resident resided at the facility on 4/2/11 and 4/3/11. On 4/25/11 at 1:37 pm, Staff 1 (DNS) provided the facility's Pain Management Guidelines. The Guidelines indicated the resident's pain was to monitored every shift using the pain scale and pain monitoring was documented on the medication record. The 4/2/11 Interdisciplinary Notes written at 12:10 pm indicated the resident reported pain on left side rib area. There was no evidence the resident's pain was assessed and PRN pain medication was offered or provided. The April 2011 MAR indicated [REDACTED]. There was no assessment of the effectiveness of the Tylenol until a 4/3/11 Interdisciplinary Note indicated the resident had no complaints of pain on 4/2/11 at 10:30 pm. The back of the April 2011 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The documentation on the MAR indicated [REDACTED] There was no evidence the resident's physician was informed the resident's medications had not been provided as ordered. The resident was transported to the local hospital emergency department on the morning of 4/3/11. The local hospital's 4/3/11 history and physical indicated the resident's family reported the resident had no [MEDICATION NAME] after his/her discharge from the hospital to the facility. The hospital physician confirmed with the facility nursing staff his/her [MEDICATION NAME] prescription was not delivered. The physician indicated that it was unclear what happened and why the medication was not delivered. The resident was assessed in the emergency department to have a recurrence of fairly significant pain. The physician's assessment and plan indicated the resident was restarted on [MEDICATION NAME] and the facility was to investigate why the pain medication was not delivered. The physician indicated the insurance care coordinator and pharmacy would be contacted about the process to ensure "excellent care for this patient in the future and other patients in the future ...." On 4/19/11 at 1:45 pm Staff 1 (DNS) provided an investigation regarding Resident 1's medications. Staff 1 indicated the facility faxed the physician orders to the consulting pharmacy on 4/2/11 at 12:00 (noon). The medications did not arrive from the pharmacy at 5:00 pm and Staff 4 (RN) called the pharmacy when the pharmacy was closed. The resident's medications were not included in the pharmacy's medication delivery at 7:30 pm. Staff 4 (RN) called the on-call consultant pharmacist/RPH (Witness 2) at 8:00-8:30 pm and left a message for him to call the facility. According to the investigation, Staff 4 administered one routine and one PRN dose of Tylenol and the resident indicated his/her pain was relieved. Staff 4 indicated the family was visiting and did not express concerns regarding the resident's pain. Staff 4 did not inform Staff 3 (RN on the night shift) that Resident 1's medications had not been delivered. Staff 1 (DNS) indicated Witness 2 (RPH) was aware the pharmacy received orders on Friday (4/1/11) and the resident's admission was postponed until 4/2/11. Staff 1 stated to Witness 2 the physician's orders were sent again on 4/2/11 and Witness 2 did not return the facility's phone call on 4/2/11. Witness 2 stated he called the facility at 11:00 pm and there was no answer. Witness 2 stated he did not attempt to call the facility again. Witness 3 (Manager of RPH) told Staff 1 the pharmacy called the facility on 4/2/11 to inquire if the resident was in the building. The pharmacy was informed the resident was not in the building and the pharmacy asked that the facility's admissions coordinator call the pharmacy when the resident arrived. According to the investigation, the admission's coordinator did not receive the message from the pharmacy. Staff 1 and Witness 3 changed the procedures regarding medication delivery. In the future, when a resident was to be admitted the physician's orders for medications would be filled and delivered as scheduled. If the resident's admission was delayed the facility would store the medications until the resident was admitted . The pharmacy would be notified if there were any changes in the physician's orders. If the resident was not admitted to the facility the medications would be returned to the pharmacy and the narcotics destroyed. An interview on 4/19/11 at 2:37 pm and 4/21/11 at 5:00 pm Staff 4 (RN) revealed she was aware the resident's medications had not arrived from the pharmacy. Staff 4 stated Witness 2 (RPH) was called at 8:00-8:30 pm and Witness 2 did not return the phone call. Staff 4 stated she did not inform the resident's physician the medications had not arrived and were not provided. Staff 4 stated the resident did not complain of pain and the resident's pain appeared to be controlled with Tylenol. An interview on 4/19/11 at 2:45 pm with Staff 3 (RN) revealed the resident did not complain of pain during the night shift of 4/3/11. An interview on 4/19/11 at 3:19 pm with Staff 5 (CNA) revealed the resident never indicated he/she was in pain during the night shift of 4/3/11. An interview on 4/21/11 at 1:00 pm with Witness 3 (Pharmacy Manager) revealed the consulting pharmacy received hospital discharge orders for the resident's admission to the facility on [DATE]. Witness 3 indicated the facility staff told the pharmacy not to send the resident's medications because the resident was not admitted on [DATE] and there was no hard copy for [MEDICATION NAME]. Witness 3 stated the pharmacy called the facility regarding the resident's admission on 4/2/11 at 9:45 am. The pharmacy was informed by the receptionist that she didn't know if the resident was going to be admitted . The receptionist indicated the nurse would contact the pharmacy when the resident was admitted . Witness 3 indicated the resident's medications were available and the pharmacy was waiting to be notified by the facility when to deliver them. Witness 3 stated the facility did not call the pharmacy when the resident was admitted to the facility on [DATE]. Witness 3 indicated the pharmacy received faxed physician orders for Resident 1 from the facility at 10:00 am on 4/2/11. The fax contained no indication the resident was admitted to the facility. Witness 3 verified the facility contacted Witness 2 (on-call pharmacist) at 8:00-8:30 pm and Witness 2 made an unsuccessful attempt to call the facility at 11:00 pm. Witness 3 indicated if the facility had a hard copy of the physician's order for [MEDICATION NAME] the facility was to contact the emergency pharmacy to fill the prescription. Witness 3 indicated the facility's pharmacy could have filled the prescription within a few hours. Witness 2 indicated Staff 1 (DNS) was aware of the need to pursue medications on an emergency basis through the facility's pharmacy. An interview on 4/21/11 at 2:00 pm with Witness 2 (on-call pharmacist) revealed the facility had the ability to contact the Geriatric Long Term Care Team (Care Team). The Care Team included physicians who were available 24 hours a day to provide care for the resident. The Care Team was a resource for the facility to obtain the resident's medications. Witness 2 stated the Care Team had been in existence for over five years. Witness 2 indicated he was not aware the facility needed to talk with him until 11:00 pm on 4/2/11. Witness 2 indicated when he called the facility at 11:00 pm the phone rang for twelve times and no one responded. Witness 2 stated he did not try to call the facility after the unsuccessful attempt at 11:00 pm. On 4/25/11 at 10:00 am, Staff 1 (DNS) was asked to provide the facility's policy and procedure regarding obtaining medications on an emergency basis. On 4/25/11 at 1:37 pm, Staff 1 provided a copy of the facility's 3/28/10 Long Term Care (LTC) Pharmacy Procedures for Intermediate and Skilled Nursing Facilities indicated "Urgent or emergency prescriptions...After business hours: Check facility emergency box/kit list and use from facility supply. If not available then-call LTC Pharmacy and ask to speak with On-call Pharmacist. If medication is required before Pharmacy is open, On-call Pharmacist will direct nurse to contact facility vendor pharmacy for the medication...." An interview on 4/25/11 at 3:02 pm with Staff 1 (DNS) revealed the LTC Pharmacy did not have an emergency box/kit available for the facility's use. Staff 1 stated the facility's pharmacy was unable to fill the prescription of [MEDICATION NAME] because the prescription had been sent to the original pharmacy the facility contacted. The facility could not send another prescription to the facility's pharmacy because the DEA would consider that "double-dipping" of the narcotic pain medication. The facility tried to call the on-call pharmacist for direction. Staff 1 was not aware if the physicians with the Geriatric Long Term Care Team would have helped to obtain the resident's medications. Staff 1 was asked about the completion of the resident's Pain Management Flowsheet. Staff 1 stated it was her expectation the Flowsheet be completed each shift. Staff 1 stated there was documentation on the evening shift of the resident's admission though the documentation indicated this was for the evening of 4/1/11 and the resident was not admitted until 4/2/11. Staff 1 was asked to provide documentation Resident 1's pain had been assessed and PRN pain medication provided on 4/2/11 at 12:10 pm. Staff 1 verified the 4/2/11 Interdisciplinary Notes written at 12:10 pm indicated the resident expressed pain. Staff 1 was asked to provide documentation the resident's PRN Tylenol was assessed as being effective after the med was given at 8:00 pm on 4/2/11. Staff 1 verified there had been no documentation regarding the resident's pain until 10:30 pm on 4/2/11. Staff 1 was asked for documentation the resident's physician was informed the resident's pain medication had not been delivered and provided to the resident as ordered. An interview on 4/26/11 at 11:13 am with Witness 3 (RPH Manager) revealed the facility needed to contact the physician to indicate the resident's prescription for the [MEDICATION NAME] had not been obtained. Witness 3 indicated it would have been possible for the facility to obtain the medication through the emergency box/kit from the facility's vendor pharmacy. An interview on 4/26/11 at 2:00 pm with Staff 1 (DNS) revealed she talked with the nurse who wrote the Interdisciplinary Note on 4/2/11 at 12:10 pm. The nurse indicated the resident did not have any pain on 4/2/11 at 12:10 pm and the resident was describing where his/her pain usually was. Staff 1 stated a late entry was to be written by the nurse involved. Staff 1 indicated the Interdisciplinary Note could be interpreted to read the resident had pain at the time it was written. Staff 1 indicated the resident did not receive the [MEDICATION NAME] as ordered though the resident's blood pressure was within normal limits. Staff 1 indicated there was no documentation the resident's physician had been informed the resident did not receive the prescribed medications. Staff 1 stated she talked with the resident's physician and Staff 1 was to review the circumstances with Witness 3 (RPH manager) again. Staff 1 reviewed the resident's Pain Management Flowsheet and observed the nursing staff wrote the resident's pain assessment on the evening of 4/1/11 instead 4/2/11. Staff 1 stated it appeared to be an error by the nursing staff.

Based on observation, interviews and record review it was determined the facility failed to implement a care planned fall intervention for 1 of 2 (#1) sampled residents who had a fall. Findings include: Resident 1 was admitted to the facility in January 2007 with [DIAGNOSES REDACTED]. On 1/2/11 the resident's comprehensive care plan indicated the resident was at risk for injury due to falls/wandering and identified multiple fall preventative interventions including a non-skid rug in the bathroom and beside the bed. On 1/9/11 an annual assessment indicated the resident was independent with transfers between surfaces including to or from: bed, chair, wheelchair, and standing position. The assessment identified the resident was not steady, but able to stabilize without staff assistance when moving from surface to surface or moving from a seated to a standing position. The assessment indicated the resident had two non-injury falls since admission and identified the resident had occasional mild pain. On 2/17/11 a Resident Care Tool (a CNA pocket care plan) indicated the resident had fall precautions that included a non-skid rug in the bathroom and on the floor, door side, next to the bed. On 2/22/11 a night shift nursing note identified Resident 1 had a fall around 2:00 am involving injury. The note indicated the resident hit the dresser (across from the bed) and sustained a laceration in the right eye area, approximately 1 cm in length. The note identified the resident was unable to recall "what happened" surrounding the fall. The note indicated the resident was sent to the hospital for evaluation. On 2/22/11 a Resident Occurrence Report identified the resident had an "appropriate care plan," which had not been followed by the assigned CNA (Staff 3). The report indicated the resident's non-skid rug had not been at the bedside at the time of the fall and the facility concluded that it's absence was "a contributing factor to the fall." On 2/22/11 an emergency room Report indicated the resident's laceration required three sutures and the resident "tolerated the procedure without complication." On 2/23/11 a facility Addendum indicated the resident returned from the ER and was noted to be at "baseline with daily routine, attending meals in dining room, independently propelling w/c about facility, playing solitaire in the dining room. Resident observed throughout day to be engaging in conversation and gin rummy games with visitors and observed to be laughing with the visitors throughout the conversation." On 2/25/11 a facility investigation identified that during an interview with Staff 3, CNA, she did not remember a non-skid rug at the bedside and confirmed she had the CNA Care Tool in her pocket. Review of the resident's February 2011 MAR revealed the resident was administered Ibuprofen once after the fall, on 2/23/11, for pain. On 3/7/11 at 9:35 am Resident 1 was observed in her/his wheelchair on top of a non-skid rug between the bed and dresser. The resident had a small steri-strip above the right eye and no bruising or redness visible. The resident was unable to recall events surrounding the fall. In an interview on 3/7/11 at 10:00 am Staff 1, DNS, reported Resident 1 had a history of [REDACTED]. Staff 1 stated the rug that was care planned to be beside the bed had not been in place at the time of the resident's fall which could be seen as "possibly a significant factor" in the fall. In an interview on 3/7/11 at 10:35 am Staff 2, RNCM, reported the resident was back to baseline within 30 minutes after the incident. Staff 2 reported the resident did request Ibuprofen one time after the fall and identified the resident also requested Ibuprofen for arthritic pain on occasion. On 3/8/11 and on 3/9/11 several attempts were made to contact Staff 3, CNA, without success. In an interview on 3/8/11 at 2:50 pm Staff 4, CNA, reported she was assigned to Resident 1 on 2/21/11 during the evening shift. Staff 4 stated she last observed the resident's non-skid rug at the bedside at 8:45 pm shortly before the end of her shift. In an interview on 3/8/11 at 3:00 pm Staff 5, CNA, reported he observed Resident 1 after the fall (at approximately 2:00 am on 2/22/11) on the floor in the room attempting to stand up. Staff 5 stated the resident had blood on her/his top and blood was observed on the resident's dresser. Staff 5 reported the resident's non-skid rug was not on the floor between the dresser and the bed at that time. Staff 5 stated the resident reported to him that she/he had "slipped." .