Every finding on record at Avamere Health Services of Rogue Valley

Based on observation, interview, and record review it was determined the facility failed to ensure staff followed transmission-based precautions and provided wound care in a sanitary manner for 2 of 3 halls reviewed for infection control and 1 of 1 sampled resident (#47) reviewed for pressure ulcers. This placed residents at risk for spread of infections. Findings include: 1. On 8/18/25 at 12:35 PM, signage was posted outside room [ROOM NUMBER] and instructed all staff who assisted the resident in Bed A to wear gowns and gloves during high-contact (frequent physical interaction) activities, including resident transfers. On 8/18/25 at 12:36 PM, Staff 29 (PT) was observed transferring the resident in Bed A from the bed to a wheelchair without wearing a gown or gloves. Staff 29 stated she did not wear personal protective equipment (PPE) because she did not handle the resident's catheter. On 8/20/25 at 8:40 AM, Staff 19 (IP) stated therapy staff were provided with a list of residents on transmission-based precautions. Staff 19 reported therapy staff were expected to reference the list and follow signage posted outside resident rooms to ensure appropriate PPE use. 2. On 8/18/25 at 11:56 AM, Staff 32 (CNA) was observed walking into room [ROOM NUMBER], a room on contact precautions, without a gown or gloves. Staff 32 acknowledged she did not wear a gown or gloves when delivering the tray to room [ROOM NUMBER], she stated she did not touch the resident. The contact precaution sign indicated staff were to where a gown and gloves upon entering room. Staff 32 acknowledged the sign said to wear a gown and gloves before entering the room, and stated, well ok and walked away. On 8/20/25 at 8:40 AM, Staff 19 (IP) stated staff were expected to follow the signage posted outside resident rooms. 3. Resident 47 was admitted to the facility in 8/2023 with diagnoses including depression. The 7/24/25 Annual MDS indicated Resident 47 had a stage 4 pressure wound (a wound caused by pressure that has gone through all layers of skin and fat to reach down to muscle, bone, or tendon) on her/his coccyx which was present upon admission. On 8/18/25 at 2:08 PM, Resident 47 stated she/he had a pressure wound. On 8/21/25 at 10:42 AM, Resident 47's pressure wound dressing change was observed with Staff 31 (LPN). The pressure wound was located on Resident 47's coccyx and the wound appeared to meet the criteria of a stage 4 pressure wound. Staff 31 gathered the wound care supplies, completed hand hygiene, donned a gown and gloves, and entered Resident 47's room. Staff 31 set up the dressing supplies on Resident 47's bed. While wearing the same gloves, Staff 31 cleaned Resident 47's wound, applied the clean dressing, reached into her pocket, retrieved a pen, dated and signed Resident 47's dressing, and put the pen back into her pocket. Staff 31 then removed her gloves, gown, and washed her hands. On 8/21/25 at 10:51 AM, Staff 31 stated she completed hand hygiene before starting Resident 47's wound care and after completing the wound care. Staff 31 stated she did not change her gloves during Resident 47's wound care. Staff 31 stated this was how she always completed wound care. On 8/21/25 at 10:55 AM, Staff 19 (IP) stated she expected hand hygiene to be completed, new gloves applied after and in between dirty and clean steps during wound care. Staff 19 stated Staff 31 should have completed hand hygiene, donned gown and gloves, entered Resident 47's room, set up wound care supplies, removed soiled gloves, completed hand hygiene, applied new gloves, cleaned the wound, removed soiled gloves, completed hand hygiene, applied new gloves, applied clean dressing, removed soiled gloves, completed hand hygiene, applied new gloves, retrieved pen out of her pocket, dated wound, returned pen to pocket, removed soiled gloves and gown, and completed hand hygiene.

Based on interview and observation it was determined the facility failed to store medications in a safe manner for 2 of 3 halls. This placed residents at risk for misuse of medications. Findings include:On 8/18/25 at 12:13 PM, an observation was made with Staff 18 (LPN) of a bottle of antifungal powder in an unlocked precaution cart outside room [ROOM NUMBER]. Staff 18 stated the antifungal powder should be locked in the treatment cart.On 8/19/25 at 11:05 AM, an observation was made with Staff 18 of a bottle of antifungal powder located in room [ROOM NUMBER] on a small table near the bed. Staff 18 stated the antifungal powder should be locked in the treatment cart.On 8/21/25 at 8:28 AM, an observation was made with Staff 16 (RN) of a bottle of antifungal powder located in room [ROOM NUMBER] on the overbed table. Staff 16 stated the antifungal powder should be locked in the treatment cart.On 8/21/25 at 8:45 AM, Staff 2 (DNS) stated antifungal powder should be locked in the treatment cart.

Based on observation and interview it was determined the facility failed to provide a safe and comfortable environment for 1 of 7 sampled residents (# 84) and 2 of 3 halls reviewed for environment. This placed residents at risk for discomfort and burns. Findings include:1. On 8/19/25 at 8:03 AM, Resident 84 stated her/his room was very cold and at night she/he wore two pairs of socks on her/his feet, sweatpants, a sweatshirt, and socks on her/his hands to stay warm. Resident 84 was observed in the wheelchair, had a blanket around her/his shoulders. At this time a staff entered the room and asked Resident 84 if she/he was still cold. On 8/19/25 at 3:29 PM, Staff 17 (Maintenance Director) stated he checked temperatures in the resident rooms weekly and would expect resident rooms to be between 72 and 78 degrees. Staff 17 was asked to check the room temperature in Resident 84's room. Temperatures obtained were 64 degrees, 65 degrees, and the area around the air conditioner vent in Resident 84's room was 54 degrees. On 5/19/25 at 3:44 PM, Staff 1 (Administrator) acknowledged the temperature in Resident 84's room. 2. On 8/18/25 at 2:48 PM, room [ROOM NUMBER]'s hot water in the restroom was turned on and became very hot within 10 seconds. The resident in room [ROOM NUMBER] confirmed she/he did not go into the restroom.On 8/19/25 at 3:29 PM, Staff 17 (Maintenance Director) stated the water temperature in the resident rooms were not to exceed 120 degrees. Staff 17 stated he checked five resident rooms per week. The temperature of the hot water in room [ROOM NUMBER] was checked and revealed to be 132 degrees. On 8/19/25 at 3:44 PM, Staff 1 (Administrator) stated the water temperature should not exceed 120 degrees. On 8/20/25 at 2:35 PM, Staff 17 was asked to check the water temperature for multiple rooms and the public restroom in the 300 hall. It was found to be 142 degrees.

Based on interview and record review the facility failed to treat resident's pain in accordance with resident preference for 1 of 2 sampled residents (#10) reviewed for pain. This placed residents at risk for unmanaged pain. Findings include: Resident 10 was admitted to the facility in 2017 with diagnoses including chronic pain. A 7/9/25 Progress Note revealed the resident requested she/he be prescribed lidocaine patches to manage her/his pain. The request was also documented in the Provider Communications Notebook by Staff 22 (former LPN-Resident Care Manager). A review of the 8/2025 Pain Level Summary revealed Resident 10 reported pain levels of 3 to 6 (moderate to severe) on 9 of 21 days reviewed. On 8/19/25 at 8:44 AM, Resident 10 stated she/he regularly experienced severe pain.On 8/21/25 at 12:22 PM, Staff 23 (Medical Director) stated she was not aware Resident 10 requested lidocaine patches. Staff 23 stated she and the nurse practitioner reviewed the Provider Communications Notebook during each visit to the facility. On 8/22/25 at 11:30 AM, Staff 2 (DNS) stated she was unable to locate any documentation from the Provider Communications Notebook of Resident 10's request for lidocaine patches. On 8/22/25 at 12:05 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed nursing staff should document residents' medication needs in the Provider Communications Notebook and follow up if they do not receive a response from the provider.

Based on observations, interviews, and record review it was determined the facility failed to provide meaningful activities for 2 of 3 sampled residents (#s 2 and 3) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include:1. Resident 2 was admitted to the facility in 8/2025 with diagnoses including Alzheimer's (major decline in cognitive abilities) disease and stroke. An 8/10/25 admission MDS indicated Resident 2 was assessed with a BIMS score of 2 (severe cognitive impairment), it was important to the resident to have things to read, to do her/his favorite activities, and get outside when the weather was good. Activities were encouraged for Resident 2 related to her/his cognitive impairment and staff were to anticipate her/his needs. An 8/18/25 care plan indicated Resident 2 required assistance to attend activities and in-room materials as indicated. Resident 2's interests included: engineering shows, technology reading materials, table games, gardening, and music. Review of the 8/5/25 through 8/18/25 CNA Tasks: Activities for Groups and One on One revealed no activities were provided for Resident 2. On 8/19/25 at 8:27 AM and 8/20/25 at 8:24 AM, Resident 2 was observed sitting in the hall in her/his wheelchair with no activity or staff interaction. On 8/19/25 at 9:18 AM, Staff 16 (RN) indicated Resident 2 had behaviors and confirmed no activities were offered to the resident. On 8/19/25 at 10:14 AM, Staff 30 (Activities Director) acknowledged she lacked understanding of appropriate activities for residents with dementia and lacked time to provide residents with one-on-one interactions without the assistance of CNAs. On 8/20/25 at 6:50 PM, Staff 26 (CNA) stated she assisted Resident 2 and was not aware of her/his care plan related to activities. On 8/21/25 at 1:03 PM, Staff 15 (LPN-Resident Care Manager) expected residents with dementia to be busy with meaningful activities which would include CNA involvement. 2. Resident 67 was admitted to the facility in 8/2025 with diagnoses including Parkinson's (degenerative nerve) disease and sepsis (life-threatening and overreactive immune response). An 8/10/25 admission MDS indicated Resident 67 was assessed with a BIMS score of 15 (cognitively intact) and activities which included books, music, news and getting outside when the weather was good were very important to the resident. An 8/18/25 care plan indicated Resident 67 was interested in joining group activities and her/his interests included: gardening, reading, exercise classes, music, and videos. An 8/6/25 Activity Profile revealed likes and dislikes for group activities, individual activities, and the resident's preference for exercise were all left blank. Review of the 8/6/25 through 8/18/25 CNA Tasks: Activities for Groups and One on One revealed no activities were provided for Resident 67. On 8/18/2025 at 12:26 PM Resident 67 was observed sitting in her/his room in her/his wheelchair with no television on and stated she/he was bored. Resident 67 was shown the daily activity calendar in her/his room with no locations listed. Resident 67 stated she/he was open to attend activities if she/he was invited. She/he did not know where activities were located. On 8/19/25 at 8:17 AM, Resident 67 was observed sitting in her/his room in her/his wheelchair just waiting to go home.On 8/19/25 at 9:47 AM, Resident 67 was sitting in her/his room with no television on. Staff 30 (Activities Director) entered Resident 67's room and provided the resident an activity calendar with no further discussion. On 8/19/25 at 10:14 AM, Staff 30 acknowledged she was behind on activity assessments which resulted in an incomplete assessment for Resident 67.On 8/21/25 at 1:03 PM Staff 15 (LPN-Resident Care Manager) acknowledged the lack of staff education related to activities and confirmed Resident 67 required additional staff engagement to meet her/his need for socialization and activities.On 8/22/25 at 10:37 AM, Staff 27 (CNA) stated, at times, Resident 67 declined reading materials and they were unsure where to chart activities for residents. On 8/21/25 at 4:49 PM, Staff 1 (Administrator) expected residents to have meaningful activities supported by all staff.

Based on interviews, observations, and record reviews it was determined the facility failed to maintain a healthy nutritional status for 1 of 2 sampled residents (#55) reviewed for nutrition. This placed residents at risk for malnutrition and weight loss. Findings include: Resident 55 was admitted to the facility on [DATE] with diagnoses including falls and Multiple Sclerosis (an autoimmune disease of the brain and spinal cord where the body's immune system attacks the protective area around nerve cells causing damage that disrupts communication between the brain and body).A 7/31/25 Physician Order revealed Resident 55 had orders for a regular diet.A review of Resident 55's weights revealed the following: 7/31/25 146.8 lbs. (weight was struck out for being inaccurate) 8/4/25 131.8 lbs. 8/5/25 128 lbs. 8/11/25 123.6 lbs. 8/12/25 124.2 lbs.An 8/13/25 Progress Note revealed Resident 55 had a 5.8% weight loss.On 8/18/25 at 12:39 PM, Resident 55 stated she/he did not eat much due to the food being, terrible. Resident 55 stated she/he was not sure if she/he lost weight.A review of Resident 55's medical record revealed no evidence of supplements or other interventions for weight loss.On 8/21/25 at 12:49 PM, Staff 25 (CNA) stated Resident 55 did not have much of an appetite, but at times requested a snack.Resident 55's weight was documented on 8/21/24 as 123.2 lbs.On 8/21/25 at 1:07 PM, Staff 31 (LPN) stated she was not sure if Resident 55 lost weight.On 8/21/25 at 1:27 PM, Staff 5 (RD) stated Resident 55's weight was on 8/12/25 showed significant weight loss. Staff 5 stated Resident 55 was to be seen in the Nutrition at Risk meeting on 8/21/25. Staff 5 acknowledged Resident 55 had no interventions or supplements in place for weight loss.On 8/21/25 at 4:54 PM, Staff 15 (LPN Resident Care Manager) stated between Resident 55's weight on 8/4/25 and 8/12/25, she/he showed significant weight loss. Staff 15 stated an assessment of Resident 55's significant weight loss was completed on 8/21/25 and Staff 5 ordered a nutritional supplement for Resident 55 to be started on 8/22/25. Staff 15 stated her expectation for residents with significant weight loss was for them to be assessed, reviewed by the IDT in the Nutritional at Risk meeting, and weight loss prevention interventions put in place within the same week the significant weight loss occurred.On 8/22/25 at 10:40 AM, Staff 2 (DNS) acknowledged there were 12 days between Resident 55's significant weight loss and assessment, and having interventions put in place. Staff 2 stated she expected interventions to prevent any further weight loss to be put in place quicker than 12 days.

Based on observations, interviews, and record review it was determined the facility failed to implement fall precautions for 2 of 4 sampled residents (#s 5 and 13) reviewed for accidents. This placed residents at risk for injuries related to falls. Findings include:1. Resident 5 was admitted to the facility in 7/2025 with diagnoses including stroke, hip fracture, and dementia.An 8/13/25 revised care plan indicated Resident 5 was at high risk for falls and instructed staff to place fall mats on each side of her/his bed. On 8/19/25 at 2:20 PM, Resident 5 was observed in bed with no fall mats at her/his bedside. On 8/20/25 at 2:05 PM, Witness 2 (Family) stated she visited Resident 5 routinely and no fall mats were used for Resident 5. On 8/20/25 at 6:48 PM, Staff 26 (CNA) stated she provided care for Resident 5 and was unaware fall mats were indicated in her/his care plan. On 8/21/25 at 11:45 AM, Staff 24 (LPN) stated she was not aware Resident 5 was to have fall mats in place because it was not on the TAR. On 8/21/25 at 1:03 PM, Staff 15 (LPN-Resident Care Manager) expected staff to utilize fall mats as indicated in the care plan.On 8/22/25 at 11:22 AM, no fall mats were in place while Resident 5 was in bed. On 8/22/25 at 11:36 AM, Staff 2 (DNS) confirmed staff were to use fall mats for Resident 5.2. Resident 13 was admitted to the facility in 7/2025 with diagnoses including sepsis (severe reaction to infection in the body) and respiratory failure.A 7/5/25 care plan for falls indicated to place Resident 13's bed in the lowest position, except during care. The 7/9/25 admission MDS indicated Resident 13 was admitted with generalized weakness, some disorganized thinking, was assessed to have a BIMS score of 14 (cognitively intact) and was dependent on staff for toileting. On 8/19/25 at 8:32 AM, Resident 13 was observed lying crosswise on her/his bed with the bed in an elevated position.On 8/22/25 at 10:07 AM, Resident 13's bed was in an elevated position, the resident was positioned lying across the bed with her/his feet within one foot of the floor. Resident 13 indicated she/he required staff assistance. On 8/22/25 at 10:24 AM, Staff 28 (CNA) stated Resident 13 always positioned herself/himself in the bed in unsafe positions and refused to keep her/his bed in the low position. Staff 28 stated nursing staff were not informed.On 8/22/25 at 10:37 AM, Staff 27 (CNA) stated he told nurses four to five times about his concern related to Resident 13's positioning in bed. Staff 27 confirmed Staff 15 (LPN-Resident Care Manager) was not informed.On 8/22/25 at 11:27 AM, Staff 2 (DNS) expected information about Resident 13's positioning and bed position to be communicated to Staff 15. Staff 2 acknowledged Resident 13's care plan was not updated to address her/his bed placement and she/he needed a care plan revision to address appropriate fall risk interventions.

Based on interview and record review it was determined the facility failed to ensure care plans were revised to reflect resident-centered care for 1 of 1 sampled resident (#6) reviewed for behavior. This placed residents at risk for unmet needs. Findings include: Resident 6 admitted to the facility in 3/2025 with diagnoses including dementia. A comprehensive care plan dated 5/21/25 revealed Resident 6 had a behavior monitor in place, with behaviors of agitation, fabricating stories, and anxiety. The behavior monitor identified the following triggers: history of growing up in an alcoholic environment, dealing with physical/mental changes, and roommate issues. There was no additional behavior care plan.A 5/28/25 progress note revealed Resident 6 had hallucinations. A 6/18/25 progress note revealed Resident 6 was very confused and argumentative with CNA staff. A 6/26/25 Quarterly MDS revealed Resident 6 had verbal behaviors towards others. A 7/16/25 progress note revealed Resident 6 often called out, had difficulty sleeping, displayed agitation with staff and other residents, and displayed agitation surrounding meals. The progress note also indicated television noise and commercials caused Resident 6's behaviors. The progress note also revealed Resident 6 made comments about hitting and raping staff. A 7/30/25 progress note revealed Resident 6 accused the staff of attempting to kill her/him. A 7/31/25 progress note revealed Resident 6 stated the facility staff tried to kill her/him with food and made death threats towards staff. An 8/15/25 progress note revealed Resident 6 yelled at a CNA and was triggered after seeing the color yellow. In an interview on 8/19/25 at 7:51 AM Resident 6 became fixated on food preferences and stated she/he should kill the facility cook but was afraid of God. Resident 6 made multiple statements of how she/he could kill others.On 8/20/25 at 8:40 AM, Staff 12 (CMA) stated Resident 6 threatened staff, yelled for care, and became upset if the staff were not in the room immediately. On 8/21/25 at 8:12 AM, Staff 9 (CNA) stated Resident 6 was very religious, made statements about going to hell, made derogatory statements towards women, and what Resident 6 watched on television affected how she/he acted. On 8/21/25 at 8:15 AM, Staff 13 (LPN) stated Resident 6 made sexual comments, stated she/he would rape the CNA staff, and her/his behaviors were affected by which television show she/he watched.On 8/21/25 at 10:41 AM, Staff 10 (CNA) stated Resident 6 became easily frustrated, could be verbally abusive, and made statements of killing others but would also say she/he was Godly. Staff 10 also stated she recently picked up on Resident 6's mood being affected by what was on the television, but that was not in the care plan.On 8/21/25 at 3:24 PM Staff 4 (Social Services Director) stated Resident 6 became agitated with certain things, including roommates. Staff 4 stated Resident 6 fabricated stories and what she/he watched on television affected how she/he acted, such as a military movie resulting in Resident 6 talking about killing. Staff 4 reviewed Resident 6's care plan and stated the care plan did not address all of her/his behaviors.On 8/21/25 at 4:09 PM Staff 2 (DNS) reviewed Resident 6's care plan and confirmed it would be appropriate for the care plan to address her/his current behaviors.

Based on interview and record review it was determined the facility failed to investigate allegations of verbal abuse for 1 of 1 sampled resident (#14) reviewed for dignity. This placed residents at risk for verbal abuse.Resident 14 was admitted to the facility in 6/2025 with diagnoses including alcohol abuse and seizures.On 8/18/25 at 2:41 PM, Resident 14 stated she/he received a NOMNC (Notice of Medicare Non-Coverage) from the Social Service Director and a nurse. Resident 14 stated the nurse told her/him the facility was not a homeless shelter. Resident 14 stated she/he felt belittled by the comment, and she/he notified the administrator via email but did not hear back from the administrator. Resident 14 provided a copy of a NOMNC signed on 8/6/25 by Staff 4 (Social Service Director) and Staff 19 (LPN Infection Preventionist).On 8/20/25 at 2:20 PM, Staff 1 provided an email between Resident 14 and himself sent from Resident 14 on 8/7/25 with a subject line Formal Complaint Regarding Improper Notice, Coercion, and Staff Conduct. Item 3 of the email stated while Resident 14 was receiving a NOMNC the nurse stated, 'This isn't a homeless shelter'. I asked, 'Do you think I'm homeless?' To which she smirked but did not respond. This type of comment is not only demeaning but reflects an unprofessional and prejudiced tone that should have no place in a care setting. Regardless of intent, the remark was belittling and left a lasting emotional impact. Staff 1 replied to Resident 14 on 8/12/25, Regarding items 3 and 4: I will address this concern with the staff member involved. We do not have a nurse by that name working here, could you clarify her name?On 8/20/25 at 2:45 PM, Staff 1 (Administrator) stated he received an email from Resident 14 regarding a staff complaint. Staff 1 stated Resident 14 never got back to him with the staff's name, so an investigation was not completed.On 8/22/25 at 10:01 AM, Staff 1 acknowledged he should have asked Resident 14 when he did not receive a reply to the email. Staff 1 also acknowledged Resident 14's email was an allegation of verbal abuse, and the allegation should have been investigated to rule out abuse.

Based on observation, interview, and record review it was determined the facility failed to obtain routine dental services for 1 of 2 sampled residents (#27) reviewed for dental care. This placed residents at risk for unmet dental needs. Findings include: Resident 27 was admitted to the facility in 1/2025 with diagnoses including dementia.A 2/6/25 progress note revealed Resident 27's diet was downgraded due to loose dentures.A 2/13/25 progress note revealed Resident 27 did not want to get up for meals as she/he was having trouble with her/his dentures.A 3/21/25 progress note revealed Resident 27 did not want other people to see her/his top dentures because they always fell down while eating.A Care Plan revised 4/21/25 revealed Resident 27 wore upper dentures.A 5/27/25 social service progress note revealed an attempt to make a dental appointment for Resident 27. A 6/20/25 Care Conference Information evaluation revealed Resident 27 was concerned about her/his dentures not fitting and had a dental appointment coming up. On 8/19/2025 at 7:49 AM, Resident 27 was observed eating in her/his room. Resident 27's dentures appeared to not fit well and moved while she/he talked and ate.On 8/21/25 at 8:09 AM, Staff 9 (CNA) stated Resident 27 liked to seclude her/himself due to of being self-conscious about her/his dentures. On 8/21/25 at 10:46 AM, Staff 10 (CNA) stated Resident 27's dentures have been loose since she/he admitted to the facility and the dentist appointment was still being worked on. On 8/21/25 at 3:35 PM, Staff 4 (Social Services Director) stated she was made aware of Resident 27's need for a dental appointment and first reached out to a dentist on 5/27/25. She also confirmed Resident 27's dentures still did not fit and she/he was self-conscious. On 8/21/25 at 4:11 PM, Staff 2 (DNS) reviewed Resident 27's records and confirmed there was delay in arranging the dental appointment.

Based on observations, interviews, and record review it was determined the facility failed to provide dental care to 1 of 2 sampled residents (#1) reviewed for ADLs. This placed residents at risk for unmet care needs. Findings include:Resident 1 was admitted to the facility in 7/2025 with diagnoses including COPD (chronic obstructive pulmonary disease) and dementia. A 7/25/25 Dental/Oral Evaluation revealed Resident 1 had oral thrush (fungal infection of the mouth) and wore full upper and partial lower dentures. A 7/27/25 admission MDS indicated Resident 1 was assessed with a BIMS score of 2 (severe cognitive impairment) and required set-up assistance for oral hygiene. An 8/5/25 care plan revealed oral care was to include cleaning her/his full upper and partial lower dentures. On 8/18/25 at 9:23 PM, Witness 3 (Family) stated she was in the facility for 72 hours with Resident 1 and family cleaned and inserted the resident's dentures because staff did not assist the resident. On 8/20/25 at 8:58 AM, Resident 1 was observed with mouth odor and the resident stated she/he wore her/his dentures overnight. On 8/20/25 at 4:44 PM, Staff 25 (CNA) stated a note was in Resident 1's room to ensure denture care was provided. Staff 25 stated dentures were to be removed and cleaned nightly and confirmed Resident 1's dentures were found in her/his mouth in the mornings on the last two days. Staff 25 stated nurses were not informed in order to address Resident 1's lack of oral care. On 8/20/25 at 6:51 PM, Staff 26 (CNA) stated she was not aware Resident 1 wore dentures and confirmed she assisted Resident 1 in the evenings with oral care. On 8/21/25 at 1:03 PM, Staff 15 (LPN-Resident Care Manager) confirmed Resident 1's dentures were to be cleaned in the morning and evenings and removed at night. Staff 15 expected staff to communicate resident care concerns to ensure adjustments were made for Resident 1's oral care hygiene.

Based on interview and record review it was determined that the facility failed to report to the State Survey Agency allegations of verbal abuse for 1 of 1 sampled resident (#14) reviewed for dignity. This placed residents at risk for verbal abuse. Findings include:Resident 14 was admitted to the facility in 6/2025 with diagnoses including alcohol abuse and seizures.On 8/18/25 at 2:41 PM, Resident 14 stated she/he received a NOMNC (Notice of Medicare Non-Coverage) from the Social Service Director and a nurse. Resident 14 stated the nurse told her/him the facility was not a homeless shelter. Resident 14 stated she/he felt belittled by the comment, and she/he notified the administrator via email but did not hear back from the administrator. Resident 14 provided a copy of a NOMNC signed on 8/6/25 by Staff 4 (Social Service Director) and Staff 19 (LPN Infection Preventionist).On 8/20/25 at 2:20 PM, Staff 1 provided an email between Resident 14 and himself sent from Resident 14 on 8/7/25 with a subject line Formal Complaint Regarding Improper Notice, Coercion, and Staff Conduct. Item 3 of the email stated while Resident 14 was receiving a NOMNC the nurse, stated, 'This isn't a homeless shelter'. I asked, 'Do you think I'm homeless?' To which she smirked but did not respond. This type of comment is not only demeaning but reflects an unprofessional and prejudiced tone that should have no place in a care setting. Regardless of intent, the remark was belittling and left a lasting emotional impact. Staff 1 replied to Resident 14 on 8/12/25, Regarding items 3 and 4: I will address this concern with the staff member involved. We do not have a nurse by that name working here, could you clarify her name?On 8/20/25 at 2:45 PM, Staff 1 (Administrator) stated he received an email from Resident 14 regarding a staff complaint. Staff 1 stated Resident 14 never got back to him with the staff's name, so an investigation was not completed.On 8/22/25 at 10:01 AM, Staff 1 acknowledged he should have asked Resident 14 when he did not receive a reply to the email. Staff 1 also acknowledged Resident 14's email was an allegation of verbal abuse, and it should have been reported to the State Agency.

Based on interview and record review it was determined the facility failed to address with resident council grievances for 1 of 1 resident council reviewed for grievances. This placed residents at risk for unmet needs. Findings include: An 4/17/24 review of resident council notes revealed a Bi-Monthly Resident Counsel Questions form was completed on 4/10/24 which revealed the following concerns: -Residents did not feel they were treated respectfully by staff. -Residents did not feel staff listened to their needs or responded timely. -Residents did not feel staff followed up with them when they had a concern or issue. -Residents felt staff retaliated when they expressed concerns. -Residents stated staff did not answer their call lights within 10 minutes. -Residents felt the noise level in the facility was unacceptable. -Residents stated the facility did not offer snacks at bedtime and when requested. -Residents stated the food did not taste good and it was cold. -Residents stated lost items were not replaced by the facility. -Residents did not feel there were enough activities to interest them. -Residents stated they did not receive showers timely. During a resident council meeting on 4/17/24 at 11:00 AM residents stated the facility staff did not respond to concerns indicated on the 4/10/24 Bi-Monthly Resident Counsel Questions. On 4/19/24 at 8:34 AM Staff 21 (Activity Director) stated the Bi-Monthly Resident Counsel Questions form process was initiated on 4/10/24. Staff 21 stated she did not forward a completed copy of the Bi-Monthly Resident Counsel Questions to anyone. On 4/19/24 at 8:51 AM Staff 1 (Administrator) stated he did not receive a copy of the 4/10/24 Bi-Monthly Resident Counsel Questions. Staff 1 stated he should receive a copy of the form as soon as it is completed and grievances should be addressed within five days. Staff 1 acknowledged the grievances on the 4/10/24 Bi-Monthly Resident Counsel Questions form were not addressed.

Based on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food-borne illness. Findings include: On 4/17/24 at 8:24 AM the beverage carts for Wing 1 and Wing 2 were observed with dirty coffee pots which were used for the residents. Staff 28 (Dietary Services Manager) acknowledged the coffee pots needed deep cleaning. On 4/17/24 at 11:45 AM the following was observed during preparing and plating food from the kitchen's steam table for lunch: -Staff 31 (Dietary Aide) performed a temperature check on all food. The food was within normal limits except for the potato salad which was 51 degrees and needed to be 41 degrees. No further checking was performed for the potato salad. -Staff 31 was observed touching the food with utensils and his gloved hands, he then stepped away from the steam table to retrieve tongs and did not perform hand hygiene or don new gloves. Staff 31 left the steam table twice to retrieve food from the refrigerator and was observed to open the refrigerator with his gloved hand, retrieve a tote with ice, uncover bowls of potato salad and close the refrigerator door with his gloved hand. Staff 31 did not change his gloves or complete hand hygiene during the above observations. He then returned to the steam table, removed hamburger buns from a bag, placed them on a tray for delivery to a resident and then continued to handle food using utensils and his gloved hands. Staff 31 left the steam table to retrieve cheese slices from the refrigerator, touched his nose and watch, removed his gloves, and tossed one glove on top of the tote of ice with uncovered potato salad. -Staff 31 had a beard and mustache but only wore a surgical facemask which did not restrain all his beard or mustache. On 4/17/24 at 12:56 PM Staff 31 acknowledged There was a break in infection control and he should have changed his gloves, performed hand hygiene, worn a beard restraint and checked the temperature again for the potato salad before it was served to residents.

Based on interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the Direct Care Staff Daily Reports (DCSDR) from 11/23/23 through 12/15/23 revealed no staff hours were documented on eight days, census was documented only one day, and the number of staff was not documented two days out of 23 days reviewed. On 4/19/24 at 7:39 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they were not aware of the issues with the DCSDR reports. Staff 2 stated the Staffing Coordinator was newer to the facility during the above reviewed time period.

Based on observation, interview, and record review it was determined the facility failed to have adequate staff available to timely meet the needs of residents for 3 of 18 sampled residents (#s 32, 60 and 160) and for 2 of 3 wings (Wings 1 and 2). This placed residents at risk for unmet needs. Findings include: 1. A 2/7/24 Quality Assurance Resident Council note indicated call light wait times were too long. The 2/12/24 Response Form indicated the facility followed the state minimum CNA staffing requirements. A 3/6/24 Resident Council Department Response Form indicated the residents felt they needed more nurses and there were not enough which affected their care. The facility's response was they staffed to meet the state minimum staffing requirements. An 4/10/24 Bi-Monthly Resident Counsel Questions form revealed the questions if residents felt staff answered call lights within a 10-minute time frame, and if the resident counsel felt the facility was staffed well enough to meet the needs of the residents, to which the answer to both was documented as no. An 4/10/24 Resident Council Department Response Form indicated the facility needed more CNAs on the evening shift because staff was working with residents who were sundowning (a neurological phenomenon associated with increased confusion and restlessness in people with delirium or dementia). The facility response was the facility staffed to meet or exceed the state minimum staffing requirements on all three shifts. On 4/15/24 interviews were conducted revealing the following: -11:28 AM Resident 1 stated she/he had to activate the call light long before she/he had to urinate as after 2:00 PM call light wait times were 10 minutes to an hour. Resident 1 stated she/he fell because she/he took herself/himself self to the bathroom. One night no CNAs ever came after activating the call light. -11:51 AM Resident 44 stated she/he was a dissatisfied consumer as she/he had chronic bowel issues, and she/he would be on the bedpan after activating the call light for up to 30 to 45 minutes. At times staff gathered and just gossiped and did not answer call lights. -1:21 PM Resident 31 stated she/he had to wait up to 30 minutes for her/his call light to be answered and stated the facility needed more staff. -1:26 PM Resident 52 stated the call light wait time was approximately one to one and a half hours for a response on all shifts. -1:35 PM Resident 37 stated it took an hour and a half to get assistance and on 4/15/24 she/he had to wait 40 minutes. At times staff came in to the room, turned off the call light, and then did not come back. Resident 37 stated at times she/he was in pain, and she/he had to wait an hour. Resident 37 stated it depended on who was working and not the time of day. -1:36 PM Resident 36 stated the facility was always short of staff. In the middle of the night she/he heard hear her/his roommate in pain and activated her/his call light, but waited an hour for a response. -1:42 PM Resident 6 stated it took forever for staff to respond to call lights. Resident 6 stated she/he would go down the hall to try and find someone to help but could not find anyone. Resident 6 stated it happened a lot on the evening shift around 7:00 PM and ,at times, she/he saw staff talking at the nurses' station and not answering call lights. -1:51 PM Resident 50 stated during the night she/he had to wait for care, she/he was a two-person assist and there were not always two staff members available to help. Resident 50 stated she/he, at times, had incontinent episodes because she/he could not wait any longer for assistance. -2:13 PM Resident 29 stated at night and on the weekends when she/he activated her/his call light it took a long time for staff to respond. Resident 29 stated at times she/he had incontinent episodes because she/he had to wait too long. -2:24 PM Resident 34 stated there was not enough staff on day and evening shifts, and residents had to wait a long time for their call lights to be answered. -2:25 PM Resident 308 stated she/he had to call out for help one night because her/his call light was not answered. Resident 308 stated she/he did not feel the facility had enough nurses. -5:24 PM Resident 26 stated call light wait times were over 15 minutes. Resident 26 stated the facility needed more CNAs and nurses during the day. On 4/16/24 at 7:35 AM Resident 8 stated her/his call light wait times were mostly over half an hour. On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 10/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes. On 4/18/24 at 9:30 AM Staff 8 (CNA) stated that call light wait times went over 20 minutes. On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she took lunch break, and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents activated their call light when on a bedpan and did not have timely follow up. Residents who were continent had incontinent episodes and their dignity was affected because of a long call light wait times. On 4/18/24 at 1:00 PM Staff 11 (CNA) stated residents complained of long call light wait times very much and she observed residents who were left on a bedside commode for long periods of time, and a couple of residents had incontinent episodes when they were continent because staff did not attend to timely. On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours. 2. Resident 32 was admitted to the facility in 2023 with diagnoses including stroke and dementia. A 9/29/23 care plan indicated Resident 32 was incontinent of bowel and bladder with interventions including an incontinent program to toilet upon rising, before meals, after meals, at bedtime, and PRN. An 10/23/23 MDS indicated Resident 32 had moderate cognitive impairment and was occasionally incontinent of bowel and bladder. Resident 32 was normally aware of her/his need to go to the bathroom and staff assisted her/him with toileting and incontinent care needs. A review of the Direct Care Staff Daily Reports from 10/22/23 through 11/22/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA staffing requirements on the following days: 10/28/23 day shift, 10/29/23 day shift,11/12/23 day shift, and 11/24/23 night shift. On 11/22/23 a public complaint was received which indicated Resident 32 was left in a soiled brief for an extended period. A family member visited daily and observed Resident 32 sitting in wet brief because not enough staff were available to assist, and stated call light wait times were longer than 20 minutes. On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 10/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes. On 4/18/24 at 9:16 AM Witness 1 (Family Member) confirmed Resident 32 was left in a soiled brief for an extended period of time. On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she went on lunch break and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents activated their call light when on a bedpan and there was no timely response. Staff 4 stated she found Resident 32 in a soaked brief, and she/he complained to her about having to wait a long time for assistance. On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours. 3. Resident 60 was admitted to the facility in 2023 with diagnoses including anxiety, a pressure ulcer to the right buttock, and muscle weakness. A review of the Direct Care Staff Daily Reports from 11/15/23 through 11/14/23 revealed the facility did not have sufficient CNA staff to meet the state minimum CNA staffing requirements on the following days: 11/24/23 night shift, 11/26/23 evening shift, 12/1/23 night shift, 12/3/23 evening shift, and 12/7/23 night shift. A 11/15/23 care plan indicated Resident 60 was incontinent of bowel and bladder and was at risk for skin impairment. Interventions included an incontinent program to toilet upon rising, before meals, after meals, at bedtime, and PRN. Resident 60 used briefs for dignity. A 11/18/23 Nursing Care Note indicated Resident 60 called the police for help. The note indicated Resident 60 wanted staff to always stay in her room. The note indicated Resident 60 used her/his call light multiple times and each time it was answered timely. The note indicated the facility would do frequent checks on the night of 11/18/23. A 11/19/23 MDS indicated Resident 60 had moderate cognitive impairment and was frequently incontinent of bladder and always incontinent of bowel. Resident 60 was at risk for skin impairment and was dependent on staff for assistance with toileting. A Documentation Survey Report for 11/2023 indicated no documentation of assistance with toileting hygiene for the day shift on 11/22/23 and the night shift on 11/23/23. A public complaint was received on 12/14/23 which indicated Resident 60 was lying in urine and she/he attempted to reach staff by phone, but no one answered. Resident 60 called Witness 2 (Family Member) and Witness 2 stayed on the phone with Resident 60 until staff came and assisted Resident 60. This occurred two nights in a row and Resident 60 ended up calling 911. Police came to the facility for a welfare check. On 4/16/24 at 12:03 PM Witness 2 confirmed call light wait times of up to an hour and staff standing around and talking with multiple lights on at the nurses' station. On 4/17/24 at 5:45 AM Staff 3 (CNA) stated from 11/2023 through 12/2023 the facility was short-staffed approximately six out of seven days a week and she worked a lot of double shifts. Residents complained of long call light wait times up to 20 to 30 minutes. On 4/17/24 at 10:28 AM Staff 6 stated in 11/2023 the facility was short-staffed and she had to work very fast. Staff 6 stated it was overwhelming and stressful and residents thought staff were ignoring them. On 4/18/24 at 10:56 AM Staff 4 (CNA) stated at times she would go on lunch and when she came back her assigned residents' call lights were on for over 20 minutes. Staff 4 stated residents would activate their call light when on a bedpan and not have it answered timely. Staff 4 stated she had found Resident 60 in a soaked brief and if she/he would push her/his call light a lot it was because her/his needs were not met. On 4/19/24 at 7:46 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the expectation for call light response was five to 10 minutes and to check on the residents every couple of hours. 34703 4. Resident 160 was admitted to the facility in 2023 with diagnosis including shoulder replacement. A 8/12/23 Admission MDS indicated Resident 160 was cognitively intact and required supervision or touching assistance from staff for toileting. A 9/7/23 FRI indicated on 8/27/23 Resident 160 had her/his call light on for 45 minutes and needed to use the restroom. Resident 160 indicated she/he heard Staff 36 (Former CNA) talking in the hallway. Resident 160 stated Staff 36 came into her/his room, turned around and left without attending to the resident's needs. Resident 160 stated Staff 36 did not return to assist her/him. On 4/18/24 at 8:09 AM Staff 27 (CNA) stated she remembered Staff 39; she did not answer her resident's call lights or other resident's call lights. On 4/18/24 at 9:14 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Staff 39 (Former CNA) worked in the facility for years and had multiple warnings and write ups related to resident care and not answering call lights. Staff 36 was terminated.

Based on observation, interview, and record review it was determined the facility failed to maintain water temperatures below 120 F for 3 of 4 resident bathrooms (room [ROOM NUMBER], 108, 111) reviewed for hot water and follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 4 sampled residents (#6) reviewed for falls. This placed residents at risk for injury. Findings include: 1. On 4/17/24 from 10:55 AM through 12:02 PM with Staff 44 (Maintenance Lead) the following bathroom water temperatures were obtained: -room [ROOM NUMBER] 123 F -room [ROOM NUMBER] 125 F -room [ROOM NUMBER] 121 F Resident 26 and Resident 29 resided in room [ROOM NUMBER] and both required staff assistance for toileting transfers. Resident 20 and Resident 52 resided in room [ROOM NUMBER], both were cognitively intact. Resident 52 was independent for toileting and Resident 20 required one staff assistance for toileting transfers. room [ROOM NUMBER] was currently empty. On 4/17/24 at 12:30 PM Staff 1 (Administrator) indicated the water heater was new, acknowledged the water temperature was greater than 120 F in rooms [ROOM NUMBER], and Staff 44 would adjust and monitor the water temperatures. 41458 2. Resident 6 admitted to the facility in 8/2023 with diagnoses including infection and pressure ulcer of the lower spine. Resident 6's 8/28/23 Admission MDS revealed the resident had no cognitive impairments and required extensive assistance of two or more persons for transferring and toileting. Resident 6 had no falls within the last two to six months (prior to admission) and no falls since her/his admission. Resident 6's Fall CAA indicated Resident 6 was at risk for falls due to prescribed psychotropic medications (medications affecting a person's mental state), the need for staff assistance with balance and mobility and the need for staff to monitor Resident 6 for safety. Resident 6's 11/28/23 Quarterly MDS revealed the resident had no cognitive impairments and required supervision or touch assistance for transferring and toileting. Resident 6 had two or more falls since admission. Resident 6's 2/28/24 Quarterly MDS revealed the resident had moderate cognitive impairments and required substantial/maximal assistance for transferring and toileting. The resident was frequently incontinent of urine and occasionally incontinent of bowel and was not on a toileting program. Resident 6 had two or more falls since the last assessment. From 8/24/23 through 4/15/24 31 fall risk evaluations were completed. Resident 6 was identified to be at a moderate to high fall risk. Resident 6's current Care Plan indicated the resident was at risk for falls related to impaired mobility, muscle weakness, wasting, atrophy and pain. The following fall prevention measures were in place: -Call light within reach at all times; initiated 8/25/23. -Notify family/responsible party of any fall; initiated 8/25/23. -Notify Resident 6's physician of any fall; initiated 8/25/23. -Keep bed in lowest position except during care; initiated 8/29/23. -Physical Therapy/Occupational Therapy evaluation and/or treatment as needed; initiated 8/29/23. -Mobility bed canes to bilateral sides of the bed; initiated 8/30/23, revised 3/19/24. -Monitor for decline or improvement; initiated 8/30/23. -Frequently remind Resident 6 to use the call light for any assistance; initiated 9/1/23, revised 1/1/24. -Education given to therapy staff to come to the nursing station to report any falls; initiated 9/21/23. -Keep the wheelchair in a locked position, centered on Resident 6's left side; initiated 9/21/23. -Resident 6 was to wear non-skid foot wear at all times; initiated 10/2/23. -Frequent rounding; initiated 10/13/23. -Nightstand moved closer to Resident 6's bed with all personal items within reach; initiated 10/28/23. -Continue to remind and encourage the resident to ask for assistance multiple times during the shift; initiated 10/14/23, revised 1/31/24. -Staff to remind Resident 6 frequently to ask for assistance and use her/his call light to transfer out of bed; initiated 11/10/23. -Keep Resident 6's door open at all times except during care; initiated 11/13/23. -Ensure Resident 6 had her/his soda pop and snacks within wheelchair accessibility so she/he could reach them; initiated 11/15/23. -Therapy to evaluate cushion in electric wheelchair; initiated 12/30/23. -Fall mats on both sides of the bed for safety; initiated 2/5/24. -Staff to anticipate Resident 6's needs; initiated 2/5/24. From 10/12/23 through 4/19/24 Resident 6 experienced 30 falls in the facility. Fall investigations revealed the following: -10/12/23 at 8:30 PM: Resident 6 had an unwitnessed fall in her/his bathroom due to self-transferring without assistance. New fall care plan intervention: staff to educate Resident 6 on self-transferring and need to ask for assistance. -10/26/23 at 2:42 PM: Resident 6 had an unwitnessed fall in her/his room due to self-transferring without assistance. Interventions: continue to educate and encourage Resident 6 to use the call light for assistance with transferring and to keep her/his non-skid socks on at all times. No new fall care plan interventions were put into place. -10/28/23 at 9:30 PM: Resident 6 had an unwitnessed fall in her/his room due to reaching for something on her/his nightstand and falling. The resident did not ask for help when self-transferring. New fall care plan intervention: Resident 6's nightstand was moved closer to her/his bed so all personal items were within reach. -11/10/23 at 3:55 AM: Resident 6 had an unwitnessed fall in her/his room while getting up to reach for a can of soda pop. New fall care plan intervention: ensure Resident 6 had her/his soda pop and snacks within wheelchair accessibility so she/he could reach them. -11/12/23 at 4:35 PM: Resident 6 fell when being transferred by two CNA staff due the resident's legs being weak and giving out. New fall care plan intervention: Resident 6 was changed to a two person mechanical lift until Physical Therapy evaluated the resident. -11/19/23 at 1:15 PM: Resident 6 had an unwitnessed fall in her/his room and was found at the end of her/his bed. No interventions were documented. No new fall care plan interventions were put into place. -12/25/23 at 10:17 PM: Resident 6 had an unwitnessed fall while self-transferring to her/his power wheelchair. Interventions: Continue to remind Resident 6 to use the call light. New fall care plan intervention: therapy to look at Resident 6's wheelchair cushion. -1/1/24 at 3:00 AM: Resident 6 had an unwitnessed fall while self-transferring into her/his power wheelchair. Interventions: continue to encourage Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -1/25/24 at 9:33 PM: Resident 6 had a fall while her/his family member assisted the resident with a transfer from the toilet. Interventions: education given to family to let staff transfer resident. No new fall care plan interventions were put into place. -1/26/24 at 5:23 PM: Resident 6 had an unwitnessed fall while attempting to self-transfer to the bathroom. Interventions: continue to encourage Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -1/28/24 at 7:01 PM: Resident 6 had an unwitnessed fall in her/his bathroom. Interventions: continue to remind and encourage Resident 6 to ask for assistance, multiple times during the shift. No new fall care plan interventions were put into place. -2/4/24 at 3:20 AM: Resident 6 had an unwitnessed fall in her/his room while standing up and self-ambulating to reach her/his soda pop. Interventions: education provided to Resident 6 to use her/his call light for assistance, ensure call light remained within reach and bed was in lowest position. Resident 6's care plan was not followed as the resident's soda pop was not within reach. No new fall care plan interventions were put into place. -2/5/24 2:30 AM: Resident 6 had an unwitnessed fall and was found on her/his back on the floor at the foot of her/his bed. Interventions: encourage Resident 6 to use the call light for assistance and place the bed in the lowest position. New fall care plan intervention: Fall mats to be placed on both sides of the bed for safety. -2/10/24 at 3:00 PM: Resident 6 had an witnessed fall while self-transferring from her/his wheelchair to the bed. Interventions: continue to remind and encourage Resident 6 to ask for assistance, multiple times during the shift. No new fall care plan interventions were put into place. -2/13/24 at 5:51 PM: Resident 6 had an unwitnessed fall while she/he attempted to walk to her/his bathroom. Interventions: encourage Resident 6 to ask for assistance for transfers and other care needs. Continue to regularly round on Resident 6. No new fall care plan interventions were put into place. -2/16/24 at 5:00 PM: Resident 6 had an unwitnessed fall while she/he attempted to self-transfer from her/his bed to her/his wheelchair. Interventions: education provided to Resident 6 to use her/his call light to ask for assistance, ensure call light remained within reach, the bed was in the lowest position and continue frequent rounding on Resident 6. No new fall care plan interventions were put into place. -2/25/24 2:00 PM: Resident 6 had an unwitnessed fall in her/his room and was found on the floor leaning on her/his wheelchair. Interventions: continue encouragement and reminders for Resident 6 to use the call light for assistance and the resident to be rounded on when up in a chair. No new fall care plan interventions were put into place. -3/9/24 6:00 AM: Resident 6 had an unwitnessed fall and was found on her/his right side on the floor by her/his bed. At the time of the incident there was no fall mat in place. Interventions: ensure fall mats were in place, education was provided to the nurse regarding facility protocols when a fall occurred, continue to educate and encourage Resident 6 to use the call light. Resident 6's care plan was not followed as no fall mats were in place. No new fall care plan interventions were put into place. -3/16/24 12:42 PM: Resident 6 had an unwitnessed fall in her/his room and was found on the floor leaning on her/his wheelchair after self-transferring. Interventions: encouragement provided to Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -3/18/24 9:35 AM: Resident 6 had an unwitnessed fall in her/his bathroom while she/he attempted to look in the bathroom mirror to trim her/his beard. Interventions: encouragement provided to Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -3/18/24 10:45 AM: Resident 6 had an unwitnessed fall due to self-transferring. The resident was found on the ground between the foot of the bed and a table and appeared to be sleeping. Interventions: encouragement provided to Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -3/18/24 9:53 PM: Resident 6 had an unwitnessed fall in front of her/his bathroom. Interventions: encourage Resident 6 to use the call light for assistance. No new fall care plan interventions were put into place. -3/30/24 11:45 PM: Resident 6 had an unwitnessed fall and was found in her/his room on the floor next to her/his bed due to self-transferring. Interventions: encouragement provided to Resident 6 to use the call light for assistance and ensure fall mats were in place. No new fall care plan interventions were put into place. -4/2/24 3:51 AM: Resident 6 had an unwitnessed fall and was found on the floor next to her/his bed due to self-transferring. Interventions: encourage Resident 6 to call for assistance and continue to place fall mats to the sides of the bed. No new fall care plan interventions were put into place. -4/5/24 1:44 PM:Resident 6 had an unwitnessed fall and was found in the bathroom in the hallway near Staff 19's (LPN Unit Manager) office due to self-transferring. Interventions: encourage Resident 6 to use the call light for assistance and round on Resident 6 frequently. No new fall care plan interventions were put into place. -4/10/24 6:38 AM: Resident 6 had an unwitnessed fall and was found laying on the floor mat next to her/his bed due to self-transferring. Interventions: fall mats placed to both sides of Resident 6's bed and call light placed within reach. No new fall care plan interventions were put into place. Resident 6's Progress Notes from 4/10/24 through 4/19/24 revealed the resident experienced additional falls on 4/12/24, twice on 4/14/24 and once on 4/19/24. None of Resident 6's 30 falls resulted in injuries. Observations from 4/15/24 through 4/19/24 between the hours of 8:07 AM and 4:06 PM revealed the following concerns: -Resident 6's room was the last room at the end of the unit with minimal staff activity or traffic. -Resident 6 did not use her/his call light to call for assistance. -Resident 6 was often up in her/his wheelchair and alone in her/his room. -Resident 6 attempted to stand up while in her/his wheelchair, at times, while no staff were around. -Resident 6 was not checked on by staff for up to one hour at times. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 6 was adequately supervised. On 4/15/24 at 1:39 PM Witness 6 (Family) stated Resident 6 fell all of the time, every day and sometimes several times a day. Witness 6 stated Resident 6 was usually found on her/his floor or in her/his bathroom. Witness 6 reported staff talked about moving Resident 6 by the nurses' station over a month ago but nothing happened. On 4/16/24 at 2:38 PM Staff 17 (LPN) stated Resident 6 was a high fall risk. Staff 17 reported Resident 6 would benefit from being closer to the nurses' station but there were no appropriate beds to accommodate Resident 6 at the current time. Staff 17 stated the resident fell frequently due to self-transferring and he checked on Resident 6 when he did his rounds. Staff 17 stated on 3/28/24, Resident 6 left the facility without being seen by staff and was located at a restaurant near the facility. On 4/16/24 at 2:54 PM Staff 38 (CNA) stated Resident 6 was confused, unpredictable and unable to use her/his call light. Staff 38 stated Resident 6 had many falls due to self-transferring and he checked on her/him a minimum of every two hours. Staff 38 stated staff tried to remind Resident 6 not to get up but she/he did not remember. Staff 38 stated Resident 6 continued to fall despite fall preventions being in place. On 4/17/24 at 2:32 PM Staff 4 (CNA) stated Resident 6 was unsuccessful using the call light so she/he required checks at least every two hours. Staff 4 stated Resident 6 was a high fall risk and fell a lot and she worried about her/him. Staff 4 stated Resident 6 would benefit from being closer to the nurses' station where there was more staff activity. On 4/18/24 at 10:52 AM Staff 19 (LPN Unit Manager) reported Resident 6 had many falls because she/he self-transferred. Staff 19 stated Resident 6 needed to have round-the-clock rounding, all of the time, as frequently as possible. Staff 19 stated Resident 6 did not use her/his call light and had many falls, often on evening or night shift, because she/he was not being rounded on frequently enough and her/his room was at the end of the unit where she/he could not be seen. Staff 19 reviewed Resident 6's current fall care plan interventions and confirmed there were no new fall interventions attempted for several months and the team needed to reassess Resident 6 and determine other fall interventions to try because she did not want to see the resident continue to fall and get injured.

Based on interview and record review it was determined the facility failed to ensure residents received medications as prescribed, were monitored for medication side effects and provide wound care as ordered for 4 of 14 sampled residents (#s 8, 52, 58 and 59) reviewed for dignity, medications, and pressure ulcers. This placed residents at risk for an ineffective medication regimen and worsening wounds. Findings include: 1. Resident 8 admitted to the facility in 2018 with diagnoses including depression and irregular heartbeat. A 2/22/24 revised care plan indicated the following: -Resident 8 was on anticoagulant therapy and was at risk for bleeding. Interventions included monitoring, documenting, and reporting to the physician any anticoagulant complications. -Resident 8 was on antidepressant medications to reduce sexual behaviors toward staff. Interventions included monitoring the side effects of antidepressant medication and its effectiveness. An 4/2024 MAR instructed staff to administer Zoloft (for treating depression) every morning for depressive disorder and apixaban (an anticoagulant) for an irregular heartbeat. No documentation was found in clinical records Resident 8's anticoagulant and antidepressant medication side effects were monitored and documented daily. On 4/19/24 at 8:01 AM Staff 1 (Administrator) and Staff 2 (DNS) stated Resident 8's monitoring for anticoagulant and antidepressant medication should be in the physician's orders and monitored daily. 26991 2. Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system). An 4/2024 MAR revealed Resident 52 was to be administered Folic Acid 400 micrograms QD for vitamin B12 deficiency. The MAR indicated the Folic Acid was not administered from 4/13/24 through 4/16/24. Progress Notes revealed the following: -4/13/24 Folic Acid-dose on order -4/14/24 Folic Acid-waiting on pharmacy to deliver -4/15/24 Folic Acid-waiting on pharmacy to dispense -4/16/24 Folic Acid-waiting on pharmacy to dispense On 4/17/24 at 3:50 PM Staff 10 (LPN Unit Manager) stated Folic Acid 400 micrograms was an over-the-counter medication which was available in the central supply closet and should have been administered. 47001 3. Resident 58 admitted to the facility in 4/2023 with diagnoses including an infection in a right foot wound. On 9/11/23 a public complaint was received alleging Staff 15 (LPN) failed to complete wound care and falsified records by signing the wound care as complete. A review of Resident 58's 8/2023 TAR indicated her/his dressing change to the right great toe was not completed on 8/24/23 and 8/25/23. A review of Resident 58's 8/2023 Progress Notes revealed the dressing change to the right great toes was passed to the next shift on 8/24/23 and 8/25/23. No evidence was located which indicated Resident 58's dressing was changed on 8/24/23 and 8/25/23. A review of Resident 58's 8/2023 Progress notes revealed on 8/26/23 it was discovered Resident 58's right great toe dressing was not changed for two days, 8/24/23 and 8/25/23, and it was noted there were maggots found in the wound and the wound had increased redness around it. A review of Resident 58's 8/28/23 Wound Evaluation indicated there was increased redness around the wound. A review of Resident 58's 8/2023 MAR revealed on 8/30/23 Resident 58 began Keflex (an antibiotic) for her/his wound. An 8/30/24 Order Note stated new orders for an antibiotic were received due to redness around the wound. On 4/15/24 at 6:34 PM Witness 4 (Complainant) stated she was unable to complete Resident 58's wound care on 8/24/23 and 8/25/23 and she notified the next shift. Witness 4 stated Staff 15 did not complete Resident 58's wound care the days before 8/24/23 but signed it as completed. On 4/16/24 at 6:15 PM Witness 3 (Complainant) stated they were informed Resident 58's wound care was not completed for two days which resulted in maggots being in the wound and a wound infection. On 4/17/24 at 9:04 AM Staff 15 stated she changed Resident 58's dressing to her/his right great toe on 8/23/24 and there were no maggots present. Staff 15 denied signing wound care was completed when it was not. On 4/19/24 at 8:41 AM Staff 2 (DNS) stated she was aware maggots were found in Resident 58's right great toe wound on 8/26/24. Staff 2 acknowledged Resident 58's wound care was not completed on 8/24/23 and 8/25/23 and Resident 58 was started on antibiotics on 8/30/24 related to her/his right great toe wound. Staff 2 denied any increased redness around the wound and stated the wound did not worsen. 4. Resident 59 admitted to the facility in 7/2018 with diagnoses including a pressure injury (wound caused by pressure) to the sacrum region (the large, triangle-shaped bone in the lower spine that forms part of the pelvis). On 9/11/23 a public complaint was received alleging Staff 15 (LPN) failed to complete wound care and falsified records by signing the wound care was completed in 5/2023. A review of Resident 59's 5/2023 TAR revealed blank entries related to Resident 59's sacral wound care on 5/19/23 and 5/20/23. A review of Resident 59's 5/2023 Progress Notes revealed no evidence her/his sacral wound dressing was changed on 5/19/23 and 5/20/23. On 4/15/24 at 6:34 PM Witness 4 (Complainant) stated Staff 15 did not complete Resident 59's wound care in 5/2023, but Staff 15 signed on the TAR the wound care was completed. On 4/17/24 at 9:04 AM Staff 15 stated if she was unable to complete wound care she passed the wound care task to the next shift and informed management. Staff 15 denied signing wound care as completed when it was not. On 4/19/24 at 8:41 AM Staff 2 (DNS) stated she expected wound care to completed as ordered. Staff 2 acknowledged missed documentation on 5/19/23 and 5/20/23 for Resident 59's sacral wound care. Staff 2 and Staff 35 (Regional Nurse Consultant) acknowledged there was no indication wound care was completed for Resident 59's sacrum wound on 5/19/23 and 5/20/23.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility 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 4/15/24 through 4/19/24 identified the following issues: -room [ROOM NUMBER] had a missing floorboard in the center of the room. -room [ROOM NUMBER] had a large chunk of the bathroom door missing which exposed the inside material of the door and there was missing paint. -room [ROOM NUMBER]-B had wall damage with missing paint behind the bed and along the wall where the bathroom was located. -room [ROOM NUMBER]-A had wall damage with missing paint along the wall to the left of the residents bed. -Lights were not working on the 200 hall outside rooms [ROOM NUMBERS]. -A small round table in the smoking area had sharp and jagged edges that were approximately 18 inches long. -The double doors at the end of the 100 hall had multiple cobwebs, residual tape and splatter marks covering them. -A ceiling tile outside room [ROOM NUMBER] was damaged with a thick layer of what appeared to be different shades of brown mold. -The transition strip in the large dining room had corners that did not line up and sections of the strip were torn and peeling. -On Hall 100 where mechanical lifts were stored the carpet along the entryway was torn and tattered and there were gaps along the transition strip. -On Hall 100 there was approximately three to four feet of tattered carpet at the nurse's station. -On Hall 200 there were two areas near the fire doors with approximately 12 inches of black tape holding the carpet together. -On Hall 200 near the nurses' station there were two areas with approximately 12 inches of black tape holding the carpet together. -The main entryway had a large section of carpet that was loose with waves/wrinkles in it. On 4/18/24 at 8:21 AM Staff 1 (Administrator) and Staff 44 (Maintenance Director) acknowledged the identified above concerns needed to be addressed.

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 4 sampled residents (#52) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include: Resident 52 was admitted to the facility in 2024 with a diagnosis of pernicious anemia (inability of the body to absorb vitamin B12; left untreated it can cause irreversible damage to the nervous system). A 3/23/24 admission MDS revealed Resident 52 was cognitively intact. On 4/15/24 at 1:17 PM and 4/17/24 at 11:47 AM Resident 52 stated she/he took medication which was required to prevent her/his health from significantly declining. The side affects of the medication made her/him feel ill for up to four hours after it was administered and she/he preferred to take the medication in the morning. One Thursday morning Resident 52 asked the nurse when her/his medication could be administered. The nurse's response was that she had the medication in her pocket and would administer the medication when the nurse wanted to administer it. Resident 52 stated the nurse's response hurt her/his feelings. On 4/16/24 at 6:42 PM Staff 26 (LPN) stated she worked with Resident 52 but denied any verbal interactions with the resident about administering the medication on her time and not the resident's preferred time. On 4/16/24 at 7:04 PM Staff 42 (LPN) stated Resident 52 reported Staff 26 spoke to her/him in a manner which was not very nice. The resident reported she/he felt like she/he was an inconvenience to Staff 26. Staff 42 stated she did not report the resident's concern to management because she did not feel it was verbal abuse. On 4/17/24 at 8:04 AM and 10:26 AM Staff 2 (DNS) stated if a resident reported to staff they were not spoken to in a dignified manner it should be reported to management. Management should investigate the incident and educate staff as needed. Staff 2 stated she spoke to Staff 26 and Staff 26 acknowledged when Resident 52 requested her/his medication Staff 26 responded I'll get to it when I get to it.

Based on the lack of effective systems for ensuring adequate staffing levels and an adequate call light system, the facility administration failed to utilize its resources effectively and efficiently to ensure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. These failures placed residents at risk for delayed care. Findings include: 1. Deficient practice was identified regarding the facility's failure to ensure adequate RN and CNA staffing. In an interview on 11/22/22 at 11:03 AM Staff 1 (Assistant Administrator), Staff 2 (DNS), Staff 10 (Administrator) and Staff 81 (Regional Nurse Consultant) stated the facility followed the State minimum required staffing ratios for CNAs and the facility staffed to the acuity of the residents. Staff 1 stated on days when the facility needed more CNAs to work they did not accept new admissions to the facility. Staff 1 stated there was a concern regarding long call light wait times and the facility had been working on a solution since approximately 10/22/22 to reduce the call light wait times during meal times. Refer to F725 2. Deficient practice was identified regarding ensuring there was a functioning call light system. In an interview on 11/22/22 at 11:03 AM Staff 1 (Assistant Administrator), Staff 2 (DNS), Staff 10 (Administrator) and Staff 81 (Regional Nurse Consultant) stated she was at the facility on 11/14/22 and the company who was going to fix the call lights had to reschedule and the call lights still did not work. Refer to F919

Based on interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 3 sampled residents (#4) reviewed for falls. Resident 4 sustained a fracture to the left arm. Findings include: Resident 4 was admitted to the facility in 11/2021 with diagnoses including [CONDITION(S)] ([CONDITION(S)]), dementia and fatigue. A 11/24/21 care plan indicated Resident 4 was at risk for falls and was on a toileting schedule to assist her/him with self-transferring to the toilet and to place a bedside commode next to the bed at night for safety related to self-transferring. A 11/28/21 Admission MDS indicated Resident 4 required limited one-person assistance with transfers and supervision with toilet use. The resident was not steady with walking or when transitioning from seated to standing positions, but was able to stabilize her/himself without staff assistance and she/he did not have a fall history. A 12/2021 TAR instructed staff to provide oxygen via nasal cannula PRN with a start date of 12/13/21. A 12/24/21 5:15 AM Fall investigation report revealed Resident 4 was found on the floor on her/his right side near the bathroom door with decreased ROM to the left arm and complained of pain to right shoulder and arm. Resident 4 stated she/he tripped over her/his feet and fell . Resident 4 stated she/he was on her/his way to the bathroom. Staff 36 (CNA) indicated Resident 4 was sleeping at 4:06 AM and while Staff 36 was in another resident's room she heard someone calling for help. Resident 4 was visible from the doorway to her/his room. The resident had oxygen tubing on the floor which could have caused her/him to fall while she/he was trying to get to the bathroom. A 12/24/21 Emergency Department report revealed Resident 4 sustained a fracture to the left arm. On 11/16/22 at 11:58 AM Staff 36 stated Resident 4 was a standby assistance for toileting and if residents can use the bathroom, their oxygen tubing will be long enough to reach into the bathroom while the CNA held onto the tubing. When done the oxygen tubing should be wrapped up and secured. Staff 36 stated Resident 4's oxygen tubing was not wrapped up and secured before her/his fall. Staff 36 stated Resident 4 told her that something had pulled on her/him and then she/he fell and concluded the tubing was what caused her/him to fall. In an interview on 11/22/22 at 11:03 AM Staff 1 (Assistant Administrator), Staff 2 (DNS), Staff 10 (Administrator) and Staff 81 (Regional Nurse Consultant) stated Resident 4 moved abruptly, utilized oxygen, they could not determine what caused her/his fall and could not confirm it was the oxygen tubing.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards related to COVID-19 for 1 of 2 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy (IJ) situation. The facility was in the midst of a COVID-19 outbreak and staff were observed to mishandle and wear inappropriate PPE when entering an isolation room for a COVID-19 exposure placing residents at risk to contract COVID-19, a life-threatening illness. Findings include: On 1/3/22 after entering the facility, the survey team was notified of a new COVID-19 outbreak. Based on infection control standards and current guidance related to a COVID-19 outbreak, facility staff were to wear N95 masks and eye protection. An isolation gown and gloves were additionally needed when entering an isolation room. 1. Resident 9 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 9 resided in room [ROOM NUMBER]. On 1/4/22 Resident 9 was placed on isolation precautions related to exposure to her/his roommate who tested positive for COVID-19 while residing in room [ROOM NUMBER]. On 1/6/22 at 5:03 PM Staff 7 (CNA), after donning a gown and gloves, was observed to remove her soiled N95 mask and place it on an open box of clean gloves outside an isolation room. Staff 7 then donned a standard medical mask instead of the required N95 mask and entered isolation room [ROOM NUMBER]. On 1/6/22 at 5:15 PM Staff 8 (CNA), after donning a gown and gloves, was observed to remove her soiled N95 mask and place it on a clean roll of paper towels outside an isolation room. Staff 8 then donned a standard medical mask instead of the required N95 mask. Staff 3 (LPN) walked up to the disinfection table outside room [ROOM NUMBER] and notified Staff 8 she contaminated the whole roll of paper towels by placing her used N95 mask on the roll. Staff 3 then placed the roll of paper towels in a large plastic bag for disposal. On 1/6/22 at 5:20 PM Staff 8 exited room [ROOM NUMBER] wearing the standard medical mask and face shield. Staff 8 proceeded to remove the trash from a small bin below the disinfection table and placed it on the disinfection table. Staff 8 then pulled off a section of paper towel from the contaminated roll inside the plastic bag and placed it on the disinfection table. Staff 8 then disinfected her face shield and placed it on the contaminated paper towel. After waiting the required time, Staff 8 pulled off another section of paper towel from the contaminated roll and dried her face shield. On 1/6/22 at 5:25 PM Staff 8 was asked about using the contaminated paper towels for her face shield. Staff 8 acknowledged she used the contaminated paper towels to dry her face shield, stating she would throw the paper towels away. On 1/6/22 at 11:27 PM Staff 1 (Administrator) was informed of the immediate jeopardy situation and was provided a copy of the IJ template related to infection control. An immediate plan of correction was requested. On 1/7/22 at 1:31 AM the facility submitted a final plan of correction. The IJ removal plan included: -All staff would be in-serviced on infection control standards related to COVID-19, including PPE management and disinfection practices, proper mask usage, donning and doffing of all PPE and properly entering and exiting isolation rooms. -Staff would be required to demonstrate knowledge of infection control policies and procedures. -Audits would be conducted to verify staff were following infection control practices. On 1/7/22 at 1:45 AM Staff 1 (Administrator) was notified the immediate risk was removed based on observations and interviews. 2. A sign posted at the faceshield cleaning station indicated staff were to place their disinfected faceshields in a clear storage box and place the box in their assigned storage cubby. On 1/11/22 at 2:29 PM Staff 22 (CNA) explained the disinfection process for leaving the facility correctly. However, during observation Staff 2 placed her disinfected faceshield directly into her assigned storage cubby but failed to place it in the storage box first. On 1/11/22 at 4:22 PM Staff 2 (DNS) was asked to observe staff storage cubbies in the lobby. One cubby contained a plastic storage box with two N95 masks, a medical mask, a thermometer, a pulse oximeter (used to measure oxygen in the blood) and miscellaneous paper. Staff 2 removed the contaminated plastic storage box and set it on a ledge near the disinfection station. When asked about the procedure Staff 2 stated staff were to place their disinfected face shield in the plastic storage box and nothing else should be stored in the plastic box. On 1/12/22 at 1:45 PM the cubby area was observed and noted to have several storage cubbies which contained face shields on top of the plastic storage boxes. The contaminated plastic storage box removed from a cubby the day before was still located on the ledge near the disinfection station. On 1/12/22 at 2:00 PM Staff 1 (Administrator) was asked to observe the storage cubbies. The contaminated plastic box on the ledge was pointed out and several other cubbies with inappropriate face shield storage. Staff 1 stated she was made aware of the storage concerns the evening before.

Based on observation, interview and record review it was determined the facility failed to prevent residents from being served food to which they were allergic for 1 of 2 sampled residents (#41) reviewed for food. This deficient practice was determined to be an immediate jeopardy situation. Resident 41 was served two consecutive meals which contained foods to which the resident was allergic. The response to consuming these foods could cause anaphylactic shock (life threatening allergic reaction) which could lead to death. Findings include: Resident 41 was admitted to the facility in 11/2021 with diagnoses including diabetes and food allergies. Resident 41's 6/1/21 Nutrition CAA indicated the resident was at high risk for nutritional problems due to multiple food allergies. The 1/4/22 care plan indicated Resident 41 had multiple food allergies including eggs and fish which could cause an anaphylactic reaction. An observation on 1/6/22 at 10:46 AM revealed Resident 41's breakfast tray contained waffles. The meal ticket was highlighted to indicate an allergy to eggs. Staff 24 (Dietary Manager) verified eggs were an ingredient in the waffles. An observation on 1/6/22 at 2:23 PM revealed Resident 41's lunch tray contained fish and pie. The meal ticket was highlighted to indicate an allergy to eggs and fish. Staff 24 verified eggs were an ingredient in the pie and Resident 41 was allergic to fish. On 1/6/22 at 2:46 PM Resident 41 stated she/he would have an anaphylactic reaction if she/he ate the foods containing eggs or the fish. On 1/6/22 at 4:45 PM Staff 7 (CNA) stated she reviewed meal tickets and observed the meal provided to ensure there were no foods to which the resident was allergic. Staff stated the resident had a previous incident during which she/he was served mushrooms (which are included on resident's allergy list) which required staff to administer an [MEDICATION(S)] (medication used to treat serious allergies) to prevent anaphylactic shock. On 1/6/22 at 5:02 PM Staff 10 (CNA) and Staff 12 (CNA) acknowledged Resident 41's food allergies. On 1/6/22 at 11:27 PM Staff 1 (Administrator) was informed of the immediate jeopardy situation and was provided a copy of the IJ template related to food allergies. An immediate plan of correction was requested. On 1/6/22 at 12:00 AM Staff 2 was notified of the immediate concern of food allergies for residents and stated she agreed and would start education with staff immediately. On 1/7/22 at 1:31 AM the facility submitted a final plan of correction. The IJ removal plan included: -Dinner trays of residents with food allergies were checked on 1/6/22. -Breakfast and lunch tray line would be monitored by the dietary manager starting on 1/7/22 with breakfast. Fluorescent tray tickets would be in place on 1/7/22 and would continue for all residents with food allergies. -All staff would be in-serviced beginning 1/6/22. Additional staff would be in-serviced on 1/8/22 and 1/17/22. -Audits would be conducted for each meal for 10 days, then weekly for 4 weeks until they were in substantial compliance. Results of the monitoring and audits would be reported to the QAA committee until substantial compliance was reached. -Current staff were in-serviced on 1/6/22. In-services included education on topics such as food allergies, serving food, diet textures, checking for food allergies when passing trays, and giving snacks and drinks. On 1/7/22 at 1:45 AM Staff 1 (Administrator) was notified the immediate risk was removed based on interviews and record reviews.

1. Based on interview and record review it was determined the facility failed to promptly identify and intervene for an acute change of condition for 1 of 3 sampled residents (#5) reviewed for accidents. As a result of this deficient practice Resident 5 experienced a delay in being assessed and treated for [REDACTED]. An immediate jeopardy situation was called. Findings include: Resident 5 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED]. Transfer to the hospital and or intensive care unit if indicated. All treatments including breathing machine. An Investigation dated [DATE] revealed the following: -At approximately 8:00 AM Staff 38 (RN) entered Resident 5's room, prior to breakfast, to check her/his blood sugars and administer insulin. The resident was discovered breathing heavily, unable to clear her/his throat. -Resident 5 was on two liters of continuous oxygen, her/his heart rate was 84 beats per minute and the resident was unresponsive, unable to sit forward to clear her/his throat. -Staff were alerted and came to assist, worked to clear Resident 5's airway while the charge nurse called 911 and prepared paperwork. -The ambulance arrived by approximately 8:05 AM and the investigation revealed The resident stopped breathing as paramedics entered. -CPR was performed for approximately 15 to 20 minutes by the paramedics and by 8:30 AM paramedics ceased lifesaving efforts. -Relatives were notified of the resident's passing and physician was notified. -The police conducted an investigation as the death was unexpected and the resident was not resuscitate (DNR). An Accident/Incident Interview Form dated [DATE] revealed Staff 37 (CNA) checked on Resident 5 at 6:30 AM and the resident was in the bed. The incident report indicated Staff 37 reported to Staff 39 (CMA) at 7:00 AM that Resident 5 was breathing heavy and Staff 39 indicated she would talk to Staff 38 (RN). The incident report further indicated Staff 37 was in the assisted dining when Staff 38 checked on the resident and called 911. An Accident/Incident Interview Form dated [DATE] revealed Staff 39 was alerted, by Staff 38 while she was in the residents room to check her/his blood sugars. Staff 39 entered the room with Staff 38 and the resident was making a gurgling sound. Staff 39 was asked to get the crash cart (a wheeled container carrying medicine and equipment for use in resuscitation) and by that time Staff 36 (Interim DNS) joined her in the room. Staff 36 and Staff 39 removed the resident's many pillows, laid the resident's head down enough to roll the resident onto her/his side. Staff 39 cupped the resident's back and performed finger sweeps per Staff 36's instruction and removed the resident's dentures and mucus. Two other CNAs were holding the resident and nurses were getting the suction machine together. Resident 5 stopped making noise as medics entered the room. An undated form typed out and signed by Staff 38 indicated on [DATE] she was working on the 200 hall and around 7:00 AM the nurse from the 300 hall needed assistance with treatments and Staff 37 reported to Staff 39 the resident was breathing heavily. Staff 39 was very busy and did not pass the message on to me (Staff 38). Staff 38 stated she entered Resident 5's room at approximately 8:00 AM as the breakfast trays were coming down the hallway. Staff 38 indicated she discovered the resident needing immediate attention, as the resident was unable to clear the fluid in her/his throat. An Investigation Note dated [DATE] conducted by Staff 36 (Interim DNS) revealed the following: -At approximately 8:00 AM on [DATE] Resident 5 had a change of condition with wet respiration's at a rate of 24 to 26 respirations per minute. The residents heart rate was 80 to 84 beats per minute. -Staff 37 last saw the resident at 7:00 AM and reported to Staff 39 Resident 5 was breathing hard. Interview of Staff 39 stated she/he was snoring, this was normal. -Staff 36 believed it was approximately 8:20 AM and Staff 38 alerted him Resident 5 needed suctioning. Staff 36 went to the resident's room and Staff 39 assisted to turn the resident on her/his right side while Staff 36 went to get the suction machine and AED (automated external defibrillator). -Staff 39 removed the resident's false teeth and cleared the resident's mouth. Prior to Staff 36 leaving the room to retrieve the suction machine and AED the resident's heart rate was 80 to 84 beats per minute with wet respirations at 24 to 26 respirations per minute. The resident was not responding even when repositioned. -Staff 36 was headed down the hall to get the suction machine and AED, the paramedics arrived and were given a report. Staff 39 indicated Resident 5 took her/his last breath just as the paramedics entered her/his room. -The paramedics performed life saving procedures which were unsuccessful and Resident 5 passed away. In an interview on [DATE] at 8:00 AM Staff 17 (CNA) stated she worked the night shift on [DATE] and stated she recalled the resident having a difficult time breathing and her/his breaths were closer together. In an interview on [DATE] at 1:32 PM Staff 37 stated the morning of [DATE] she remembered checking on the Resident 5 around 6:30 AM to see if the resident was awake and the resident's breathing sounded like a chain smoker, the resident would stop breathing for a moment and then start up again. The resident was making a moaning sound and this breathing pattern repeated. She stated the night shift reported to her Resident 5 was having a hard time breathing and restless sleep. Staff 37 tried to ask the resident if she/he was ok, however the resident would not respond. It was like the resident was in a deep sleep, like an unconsciousness state. She stated she reported this to Staff 39 and Staff 39 was going to report to the nurse right away. In an interview on [DATE] at 11:01 AM Staff 38 (RN) stated the morning of [DATE] Staff 37 did not report anything to her regarding Resident 5 having difficulty with breathing. Staff 38 entered Resident 5's room around 8:00 AM to administer her/his insulin and the resident was unresponsive, breathing but very heavy and wet breathing. Staff 38 attempted to arouse Resident 5 but she/he was unresponsive. She immediately went and got help. She first spoke with Staff 39 and stated the resident did not sound good and then retrieved Staff 36. Staff 36 stayed in the room to assist with the resident while she called 911. Paramedics arrived and took over. The paramedics stopped life saving procedures at approximately 8:20 AM. In an interview on [DATE] at 2:44 PM Staff 36 stated Staff 38 came to his office at approximately 7:55 AM and indicated Resident 5 was not acting right. He arrived and entered the resident's room and the resident's breathing was 18 to 20 breaths per minute, very wet and her/his heart rate was 80 to 84 beats per minutes. Multiple staff were in the room and the resident was not responding to anything verbal. He directed an RN to check the resident's blood sugar and he went to retrieve the AED and suction machine. On his way back to the room the paramedics arrived, took over and began cardiopulmonary resuscitation (CPR). Staff 36 further stated in his investigation he recalled Staff 37 reported to Staff 39 Resident 5 was breathing funny. When he spoke with Staff 39 she indicated Resident 5 always snored and breathed heavy in the morning and that was normal. He further indicated after his investigation he felt Resident 5 had no change of condition and felt the incident happened suddenly and staff responded appropriately. On [DATE] at 12:54 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the failure to promptly identify and intervene for an acute change of condition for Resident 5. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately protect residents from having a delay in assessment when an acute change of condition occurred which could result in a resident's death. On [DATE] at 8:37 PM a final immediate plan of correction was received from the facility. The facility's abatement plan of correction included: -Inservices to be completed with all CNA and CMA staff regarding alerts in the electronic system and that all identified changes are put into an alert for Licensed Nurse (LN) follow-up and for significant changes of condition (resident short of breath, stopped breathing, loss of consciousness, had a critical vital sign) to walk the nurse to the room. -Inservices to be completed with all LN staff regarding change of condition, including notification to the responsible party and provider, to check the dashboard (the electronic medical record) frequently, at a minimum every shift and to monitor for alerts triggered by CNA/CMA staff. -Inservice to be completed with Resident Care Manager (RCM) regarding monitoring of 24 hour report daily to ensure all noted changes have a change of condition completed and follow up is addressed and all education to be provided by DNS or RN designee via face to face or phone/verbal prior to clocking in or being present in resident areas. -Date of compliance [DATE]. -DNS responsible for assuring compliance. On [DATE] at 2:30 PM the facility's implementation of the abatement plan was verified with staff interviews to ensure the staff were educated on a change of condition. On [DATE] at 10:19 AM the Staff 1 and Staff 2 were notified the immediate jeopardy was implemented removing the immediate risk to resident's health and welfare. 2. Based on interview and record review it was determined the facility failed to implement and follow physician orders [REDACTED].#s 1, 14 and 20) reviewed for pressure ulcers and medications. This placed residents at risk for delayed treatments and unmet needs. Findings include: a. Resident 1 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A review of the ,[DATE] TARS revealed the following: -A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the right ischial tuberosity (the sit bones) and cover with a non-adhesive foam dressing every day shift, evening shift and as needed. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the coccyx (the tailbone) every shift. -Records revealed on evening shift no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (antifungal) cream two percent to the face topically two times a day for seborrheic (crust or scale on the skin) [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (corticosteroid) .025 percent topically to the face two times daily for seborrheic [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE],,[DATE],,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to check oxygen saturation every shift. -Records revealed no checks were completed on evening shift or night shift for ,[DATE] or ,[DATE]. A ,[DATE] TAR instructed staff to administer oxygen at two liters per nasal cannula continuous every shift. -Records revealed no oxygen saturations were checked or completed on evening shift ,[DATE], ,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected to follow physician orders. A review of the ,[DATE] TARs revealed the following: A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] cream to the scrotum, inner thighs topically every shift for irritation, fungal infection and itching until resolved. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] to the coccyx (the tailbone) every shift for preventative care and a history of skin break down. -Records revealed no treatments were provided on ,[DATE], ,[DATE] and ,[DATE]/. A ,[DATE] and ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (a mild antiseptic) [MEDICATION NAME] to the Left Hallux (big toe) topically every day and evening shift for skin care. -Records revealed no treatments were provided on: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to document sleep every shift while the resident was on a stimulant. -Records revealed not documentation was completed on ,[DATE],,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments noted above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected staff to follow physician orders. b. Resident 20 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the facility's Bowel Care Protocol, revealed residents who did not have a bowel movement (BM) would be identified and placed on a BM report. -Evening shift would run the look back report for residents who did not had a bowel movement for two consecutive days. -Evening shift staff would administer Milk of Magnesia (a laxative) if no results, then; -Day shift would administer a suppository if no results, then; -Fleet enema would be given. If no results, complete a focused assessment of the abdomen and complete a digital exam and notify the doctor if needed. -Suppositories and enemas are not to be given on night shift unless it is a resident's request. Review of Resident 20's bowel records revealed from [DATE] through [DATE] (four days) and [DATE] through [DATE] (four days) Resident 20 did not have BMs documented. Review of the ,[DATE] MARs revealed Resident 20 did not receive Milk of Magnesia (MOM) per Bowel Care Protocol. On [DATE] at 1:02 PM Staff 11 (RNCM) acknowledged the bowel protocol was not followed. c. Resident 14 was admitted to the facility in with [DIAGNOSES REDACTED]. [DATE] and [DATE] physician orders [REDACTED]. A ,[DATE] MAR indicated [REDACTED]. On the following days Resident 14's blood pressure or heart rate was not checked before administering the medication: -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. No other documentation was found in the clinical record Resident 14's blood pressure or heart rate was checked as ordered on the above dates. On [DATE] at 10:27 AM Staff 11 (RNCM) stated she would review for additional information. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure resident care equipment was in safe operating condition for 1 of 3 sampled resident (#5) reviewed for falls. This resulted in Resident 5 being sent out to the hospital for uncontrolled pain resulting in a right [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. -The investigation indicated Staff 36 spoke with the Witness 5 (Complainant) and she reported Resident 5 was placed in the sit to stand (used to assist with mobility for patients that are unable to transition from a sitting position to a standing on their own) to be toileted and only one CNA, Staff 43 (CNA) was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called the witness and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed indicated Staff 43 (CNA) and Staff 40 (CNA) were both transferring the resident to the bed side commode when the battery on the sit-to-stand died . Staff 40 had to go down and exchange the batteries. Upon Staff 40's return the resident stated My legs are giving out and instead of using the sit-to-stand machine Staff 43 and Staff 40 both controlled lowered the resident to her knees and then laid the resident with pillows under her head . A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 (LPN) revealed Resident 5 continues to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for hoyer transfer to bed. Resident hoyered to bed with 3 staff assist . Hospital records dated [DATE] revealed Resident 5 had a mildly displaced right [MEDICAL CONDITION]. On [DATE] at 9:51 AM Staff 43 (CNA) stated she worked night shift, which started 10:00 PM at night and she recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 (CNA) got the resident up in the sit to stand and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either, so Staff 40 had to go a little farther down the hall to get a second battery and that one was not good either. Staff 43 stated two sets of batteries and both were dead. She indicated the batteries were often dead in the sit-to stands you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower her back down into the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about 2 minutes before she and Staff 40 lowered the resident to the ground manually, we took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a hoyer (mechanical lift) sling (a device used to suspend a resident in the hoyer and move them appropriately) that was not underneath the resident when they lowered her manually to the floor, so we had to log roll the resident on the floor to get the hoyer sling underneath the resident. We then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand station prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time that she was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 (LPN) came into the room and sent the resident out to the hospital. On [DATE] at 8:00 AM Staff 17 (CNA) stated she worked night shift and worked on the evening of [DATE] when Resident 5 had her/his incident, however she was assigned another hallway. She indicated she had worked with the resident on multiple occasion and the resident was alert and oriented and on occasion would have some confusion. Staff 17 stated the resident did not scream and holler to her knowledge during the night shift. The resident was a two person sit to stand transfer and she indicated the batteries for the sit to stand were located at the beginning of the hallway next to the scale machine and the residents room was at the very end of the hall . She indicated when the batteries start to run low the machine will stop and go. She always carried and extra battery with her for a back up. On [DATE] at 9:29 AM Staff 5 (CNA) stated she worked with Resident 5 on multiple occasions, was not present on [DATE]. She stated the resident was a two person sit to stand transfer. She stated they utilized an under arm sling for the resident when in the sit to stand, the resident bared weight with her legs, although could not for very long. If the batteries in the sit to stand ran low the machine would get more sluggish and a few of them would make a chirping noise. She stated if the batteries die the sit to stand had an emergency lever to utilize and you could get the resident back to safe area and lower the resident back down safely. She indicated the batteries were to be changed at beginning of every shift, however this did not always happen An observation on [DATE] at 8:34 AM revealed the sit to stands, hoyers, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. On [DATE] at 5:17 PM Staff 44 (LPN) worked night shift was familiar with Resident 5 and indicated she was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a hoyer sling(). They preceded to get the resident back up using the hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 (CNA) and Staff 43 (CNA) reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the battery died in the sit to stand machine and they had to manually lower the resident to the floor as they lowered the resident to the floor, the resident's hip could have spontaneously fractured her/his hip. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. On [DATE] at 11:33 AM Staff 1 (Administrator) acknowledged they did not have a system in place at the time of the incident related to assuring batteries were charged out appropriately after each shift. On [DATE] at 3:14 PM he stated maintenance does weekly checks to assure batteries are working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated that was implemented the week prior to [DATE]. Refer to F 689

Based on observation, interview and record review it was determined the facility failed to ensure resident care equipment was in safe operating condition for 1 of 3 sampled residents (#5) reviewed for falls. This resulted in Resident 5 being sent out to the hospital for uncontrolled pain and a right [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. A complaint was received on [DATE] indicating Resident 5 had a fall on [DATE] in the facility that resulted in a [MEDICAL CONDITION]. Witness 5 (Complainant) indicated in the letter she received a phone call around 4:00 AM from Resident 58 and the resident was in distress. She found out Staff 43 (CNA) was in the resident's room to assist the resident to the bathroom by herself. The resident was suppose to be a two person assist when utilizing the sit to stand machine (an assistive device to be transferred between a bed and a chair or other similar resting places). Witness 5 called the resident and while talking with the resident she/he stated All I know is that one leg went this way and one leg went that way. And then the resident started screaming like crazy for help and was in terrible pain. She/he then said, Here talk to the nurse and handed the phone to Staff 44 (LPN). Staff 44 indicated the resident was complaining of pain in her/his leg and thought it might have been a blood clot and was sending the resident to the emergency department for further evaluation. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. Witness 5 (Complainant) reported the resident had a fall. -The investigation indicated Resident 58 stated about 3:30 AM Staff 43 (CNA) was walking to take the resident to the bathroom. Staff 43 went into the room and the resident started yelling like in pain. Resident 58 heard the resident state she was falling and stated it was after this the resident started yelling. -The investigation indicated Staff 36 was informed Resident 5 was sent out to the hospital at 3:30 AM and the day shift nurse stated the emergency department informed the staff the resident would not return due to a right [MEDICAL CONDITION]. -Per chart review Witness 5 reported Resident 5 was placed in the sit to stand lift to be toileted and only one CNA, Staff 43 was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called Witness 5 and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed on [DATE] indicated Staff 43 and Staff 40 (CNA) were both transferring the resident to the bedside commode when the battery on the sit-to-stand machine died . Staff 40 left the room to exchange the batteries. Upon Staff 40s return the resident stated My legs are giving out and instead of using the sit-to-stand machine to lower the resident Staff 43 and Staff 40 both manually lowered the resident to her/his knees and then laid the resident down with pillows under her/his head. -Staff 44 came down the hall and saw Staff 40 getting new batteries for the sit to stand machine. When Staff 44 entered the room the resident was on the floor with a Hoyer (mechanical lift) sling (a device used to suspend the resident in the Hoyer) by the resident's bed. They had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave the resident a pain pill after they used the Hoyer to get the resident back into bed. -The resident was in bed for approximately 20 to 30 minutes and began calling out in pain and Staff 44 was advised to send the resident to the hospital. Staff 44 reported to Staff 36 that Staff 40 and 43 indicated to her the resident did not fall. Staff 44 indicated to Staff 36 she did not know how to use the sit to stand machine. -X-rays from the hospital revealed a mildly displaced right intertropchanteric (hip) fracture. Non-displaced (the broken bones remain aligned) right proximal (just below the knee) fibular (the smaller shin bone) fracture. The report indicated irregularity in the posterior aspect of the medial tibial (large shin bone) plateau may represent a non-specific fracture, given the amount of osteopenia, consider non-emergent MRI (magnetic resonance imaging) of the right knee for further characterization. -The root cause: Fracture during transfer. It is reasonable to believe related to statements that the fracture occurred either upon rising with sit to stand or lowering to floor related to [MEDICAL CONDITION] (degeneration of the joints) and osteopenia (reduced bone mass). The care plan and Kardex (a tool utilized for CNAs to provide care) were followed and abuse and neglect could not be substantiated or unsubstantiated related to the sit to stand machine and Staff 40 leaving the room to get the battery. An undated form had three separate statements from Staff 44, Staff 40 and Staff 43 and revealed the following: -Staff 43 stated she and Staff 40 were using the sit to stand machine to get the resident up and transferred to the bathroom. The battery on the machine died . Staff 40 went down the hall to exchange the battery. The resident stated to Staff 43 my legs are giving out and at that point Staff 40 returned and instead of using the machine they both manually lowered the resident to her/his knees and then laid the resident out with a pillow under her/his head. Staff 44 arrived and helped move the resident's bed away from the wall so they could used the Hoyer lift instead. -Staff 40 stated he went to the end of the hall to obtain a new battery for the sit to stand machine. When he returned he helped Staff 43 slowly lower the resident to her/his knees and then to the ground with pillows under the resident's head. Staff 40 stated they had difficulty rolling the resident due to her/his leg pain. Staff 44 assessed the resident and gave her/him a pain pill. The resident was still in pain after they moved the resident into bed. -Staff 44 stated she came around the corner and saw Staff 40 down the 200 hall and could hear the resident yelling at the end of the hall. Staff 40 was getting a new battery for the sit to stand machine. Staff 44 entered the room and the resident was on the floor with the Hoyer sling by her/his bed. The resident was complaining of leg pain. Staff 44 assisted the two CNAs with getting the resident back into bed. Resident 5 was watching TV comfortably for ,[DATE] minutes until the resident began calling out in pain. Staff 44 called the on call physician and was advised to send the resident to the hospital. Staff 44 stated the aides told her the resident did not fall, and Staff 44 did not know how to use the sit to stand machine. A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 revealed Resident 5 continued to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand machine to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist. No noted injury at this time. Resident continue to complain of pain, 'pain all over honey.' Observed bilateral lower extremity for injury, increased [MEDICAL CONDITION], redness and heat. No noted changes. Resident does not use her/his lower extremity so no range of motion was not observed. Reassured and redirected without success. Pain medication was given, yet resident continues to yell and states staff doesn't like her. Call made to on call physician and resident was sent out to the emergency department for evaluation and treatment. Resident was aware of the plan, Witness 5 was notified. Hospital records dated [DATE] through [DATE] revealed Resident 5 had a history of [REDACTED]. The resident resided at an assisted living facility and said that she/he had an incident when they were transferring her/him to the bathroom. According to Witness 5 the resident had been non-ambulatory since 2012. On [DATE] at 9:51 AM Staff 43 stated she worked night shift, which started at 10:00 PM. She recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 got the resident up in the sit to stand machine and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either. Staff 40 had to go a little farther down the hall to get a second battery and that one was also not working. She indicated the batteries were often dead in the sit-to stand machine you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower the resident back down onto the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about two minutes before she and Staff 40 lowered the resident to the ground manually, and they took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer sling that was not underneath the resident when they lowered the resident manually to the floor, so they log rolled the resident on the floor to get the Hoyer sling underneath the resident. They then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand machine prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time, that she/he was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 came into the room and sent the resident out to the hospital. On [DATE] at 8:00 AM Staff 17 (CNA) stated she worked night shift and worked on the evening of [DATE] when Resident 5 had her/his fall, however she was assigned another hallway. She indicated she had worked with the resident on multiple occasions and the resident was alert and oriented and on occasion would have some confusion. Staff 17 stated the resident did not scream and holler to her knowledge during the night shift. The resident was a two person sit to stand transfer and indicated the batteries for the sit to stand machine were located at the front of the hallway next to the scale and the resident's room was at the very end of the hall. She indicated when the batteries start to run low the machine would stop and go. She always carried an extra battery pack with her for a back up. On [DATE] at 9:29 AM Staff 5 (CNA) stated she worked with Resident 5 on multiple occasions, however was not present on [DATE]. She stated the resident was a two person sit to stand transfer. She stated they utilized an under arm sling for the resident when in the sit to stand, the resident bared weight with her legs, although could not for very long. If the batteries in the sit to stand ran low the machine would get more sluggish and a few of them would make a chirping noise. She stated if the batteries died the sit to stand had an emergency lever to utilize and you could get the resident back to a safe area and lower the resident back down safely. She indicated the batteries were to be changed at beginning of every shift, however this did not always happen. An observation on [DATE] at 8:34 AM revealed the sit to stand, and hoyer lifts, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. Resident 5's room was at the very end of the hallway on the right hand side. On [DATE] at 9:11 AM Witness 18 (Family Member) visited Resident 5 often and indicated she went to the hospital after Resident 5 had a fall on [DATE] and Witness 18 was told the resident needed to use the bathroom and only one CNA was present. The CNA attempted to get the resident up in the sit to stand machine, which the resident required two CNAs for a transfer. She stated Resident 58, who was up that night, heard what was going on and recorded the incident. Witness 18 stated apparently the batteries went dead on the sit to stand machine and the resident was only half way in the sit to stand machine and screaming she was falling. Resident 5 was 300 pounds and there would be no way the resident would have a graceful fall to the floor. Witness 18 stated a call was placed to Witness 5 regarding the resident having a possible infection and the facility sent the resident out to the hospital. Witness 18 indicated she found the facts disturbing and not adding up. The recording she listened to she could hear the resident screaming in pain and only heard one CNAs voice on the recording. On [DATE] at 5:17 PM Staff 44 worked night shift, was familiar with Resident 5 and indicated she/he was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. She did not recall seeing any other staff with Staff 43 at that time. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her/his low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. In an interview and observation on [DATE] at 8:39 AM Staff 41 (CNA) stated she was familiar with Resident 5 and indicated she/he could direct her/his own care but at times could be forgetful. She was not present when the fall occurred on [DATE] though indicated the resident was a two person sit to stand for all transfers. They would utilize the sit to stand to get the resident to the bathroom. The resident could bear weight on her/his feet when in the sit to stand and also utilized her/his arms for support. She indicated the sit to stand lifts are battery operated and she would personally change the batteries out at the beginning of her shift. When the batteries are getting low some would make a beeping noise. She further stated they also had an emergency lever you could utilize to lower the resident down safely if the battery went dead. Staff 41 showed the surveyor the sit to stand machine and the red emergency lever that was on each one and demonstrated how to utilize the button. The machine lowered down once a CNA pressed the emergency lever. On [DATE] at 2:09 PM Resident 58 stated she/he was awake the night of [DATE] when Resident 5 fell . She/he stated her/his door was partially cracked open and she/he saw Staff 43 walking in front of the resident who was in her/his electric wheelchair and they were going to the resident's room. Resident 58 stated she/he was across the hall and down a couple doors. She/he indicated she/he could hear the resident hollering I am falling, I am falling and Staff 43 stated your not falling, you always say this. She/he then heard Staff 43 hollering that she needed help and stated this a couple of times. The resident saw Staff 40 running down the hall towards the resident's room. The resident was crying out in pain and asking for Witness 5 so Resident 58 phoned the witness and alerted her of what she/he heard. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 and Staff 43 reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the batteries died in the sit to stand machine and they had to manually lower the resident to the floor. Staff 36 stated as the CNAs lowered the resident to the floor, the resident's hip could have spontaneously fractured. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. Staff 36 further indicated both CNAs got the resident back into bed and Staff 44 administered pain medication to the resident and the resident had pain for approximately ,[DATE] minutes and then the resident started screaming in pain and the resident was sent out to the hospital. On [DATE] at 11:33 AM Staff 2 (DNS) was present and Staff 1 (Administrator) stated he helped with the investigation and interviews. Staff 40 and 43 had similar statements regarding the controlled fall on [DATE]. He indicated neither Staff 40 or 43 explained how they removed Resident 5 from the sit to stand machine other than they manually lowered the resident to the floor. He acknowledged they did not have a system in place to ensure batteries were charged appropriately or changed out after each shift by CNAs. He also indicated maintenance should check the batteries on a regular basis but was unable to find any documentation this occurred. On [DATE] at 3:14 PM Staff 1 stated maintenance did weekly checks to assure batteries were working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated that was implemented the week prior to [DATE].

Based on interview and record review it was determined the facility failed to implement, follow and maintain pressure ulcer treatments for 3 of 4 sampled residents (#15, 20 and 23) reviewed for pressure ulcers. Resident 20 admitted to the facility with a DTI (deep tissue injury) to the coccyx (tailbone), and the treatment was not implemented timely resulting in a worsening of the pressure ulcer wound. Findings include: 1. Resident 20 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. In an interview on 5/21/19 at 11:06 AM Witness 19 (Complainant) stated he was in the building often to check on Resident 20 and it was difficult finding staff for assistance. He felt Resident 20 was not repositioned enough, had to wait longer than 20 minutes before getting her/his brief changed and the brief would often be soaked. Witness 19 stated the wound on the resident's bottom got worse as a result. A 4/29/19 Admission Nursing Data Base indicated a dark blanchable spot to the coccyx, measuring 0.5 cm x 0.5 cm with shearing to the crease. A 5/7/19 Pressure Ulcer CAA indicated Resident 20 admitted with a DTI to her/his coccyx, she/he was at risk for skin breakdown related to urinary incontinence, decreased mobility and diabetes. The resident required extensive assist of two staff with bed mobility. Preventative measures were in place to protect the resident's skin. The coccyx wound was being monitored by nursing. A Skin and Wound Evaluation Dated 5/14/19 indicated an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer with slough (dead tissue) and eschar (dry, dark scab) to the sacrum. The wound was present upon admission. Wound measurements were 4.6 cm x 3.2 cm x 0.3 cm, the wound bed was 20 percent granulation, 60 percent slough and 20 percent eschar. A moderate amount of serous (pale yellow fluid) exudate (fluid) was noted. The resident was noted to have intermittent pain. Additional notes indicated suspected DTI upon admission opened to reveal a Stage 3 (full thickness tissue loss, slough may be present but does not obscure the depth to tissue loss). A skin and Wound Evaluation was not completed until 15 days after Resident 20 admitted to the facility. A Skin and Wound Evaluation dated 5/21/19 indicated an unstageable pressure ulcer with slough and eschar. Wound measurements were 3.3 cm x 2.5 cm x 0.5 cm. The wound bed had 60 percent granulation, 30 percent slough and 10 percent eschar. There was evidence of infection with increased drainage, a moderate amount of exudate, and [MEDICAL CONDITION] (a mixture of serum and pus). Odor was moderate after cleansing. The resident was noted to have intermittent pain. Additional notes indicated a moderate purulent odor after cleansing the wound when performing the weekly wound assessment. The provider was notified and a new order was placed for Keflex (antibiotic). Resident 20 was referred to a wound center. A 5/2019 TAR instructed staff to complete the following treatment to the coccyx: - Order date of 5/13/19 directed staff to cleanse pressure wound to the coccyx with wound cleanser place calcium alginate (an absorbent wound dressing) to the wound bed and cover with a [MEDICATION NAME] (a moist dressing/bandage)every three days on day shift with a discontinue date of 5/14/19. -The treatment was not completed until 5/14/19 and no treatment was in place until 15 days after Resident 20 admitted to the facility. On 6/5/19 at 1:19 PM Staff 11 (RNCM) acknowledged no wound orders, treatments or weekly skin wound evaluations were in place for Resident 20 until 5/14/19 (15 days after the resident admitted to the facility). She acknowledged the wound worsened since the residents admission. She further stated Staff 15 (LPN) should have put an order in for the treatment of [REDACTED]. 2. Resident 15 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. a. A 4/19/19 Admissions MDS revealed Resident 15 was at risk for pressure ulcers and she/he did not have any wounds. Interventions included a pressure relieving device for the chair and the bed. A 5/1/19 Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx that reached both the left and right buttocks. The scabbed shearing was a 2 x 7 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks, the bed pan was changed to a fracture pana (shallow vessel used for defecation or urination by patients confined to bed). A 5/2019 TAR instructed staff to complete the following treatments to the bilateral buttocks/coccyx: -Order date of 5/2/19 monitor healing every shift and report signs and symptoms of infection or worsening with a discontinue date of 5/8/19. -Order date of 5/8/19 cleanse shear wound with wound cleanser and cover with foam dressing. No treatments were completed as resident was out of the facility on 5/9/19. A 5/8/19 Skin and Wound Evaluation revealed Resident 15 had a facility aquired unstageable pressure ulcer to the coccyx with a start date of 5/1/19 covering an area of 9.4 square cm. Measurements were 6 cm length x 4.4 cm width x .3 cm depth, with slough (a layer or mass of dead tissue). Notes stated it was likely due to a shear injury from using a slide-board to transfer the resident. No documentation was found in the clinical records an assessment was completed for the skin impairment before 5/8/19 by an RN. On 6/5/19 at 10:43 AM Staff 11 (RNCM) stated she would look for additional information on the wound. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated there were discrepancies in the wound description and the first staff member who described the wound was an LPN, who was not authorized to stage pressure ulcers. b. A 5/1/19 Skin Impairment investigation revealed Resident 15 was found to have an open area to the coccyx that reached both the left and right buttocks. The 5/7/19 notes described the wounds as scabbed shearing with a 2.0 x 7.0 area which appeared to be nearly resolved with a small area of bloody drainage to the left buttocks. On 6/5/19 at 10:40 AM Staff 11 (RNCM) stated the investigation was completed on 5/7/19 and she would expect an investigation to be completed within five days of the start of the investigation. 3. Resident 23 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. a. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 Physician order [REDACTED]. A 4/2019 TAR instructed staff to cleanse the coccyx wound, apply skin prep and medicated gel then cover with foam dressing every day shift every other day. On 4/27/19 the treatment was not completed. A 5/2019 TAR instructed staff to cleanse the coccyx with wound cleanser, apply collagen to the wound base then cover with foam dressing every day shift every other day with a order date of 4/29/19. On 5/5/19 the treatment was not completed. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. b. A 3/20/19 physician progress notes [REDACTED]. A 4/7/19 physician order [REDACTED]. A 4/12/19 Skin and Wound Evaluation revealed Resident 23 had a facility acquired Stage 2 pressure ulcer to the left heel with an area of 6.4 square cm and measurements of x 3.5 cm length x 2.6 cm width x .2 cm depth with 40 percent granulation (new tissue), 50 percent slough (dead tissue) and 10 percent eschar (cast off dead tissue). A 4/2019 TAR instructed staff to cleanse the left heel with wound cleanser, apply medicated gel and cover with foam dressing every day shift every other day, with an order date of 4/5/19. On 4/9/19 the TAR indicated to refer to nurses notes. On 4/18/19 the treatment was not completed to the left heel. A 4/9/19 Nurses Note revealed Resident 23 was not in her/his room. No documentation was found in clinical records Resident 23 received physician ordered treatment to her/his left heel on 4/9/19 and 4/18/19. On 6/5/19 at 10:49 AM Staff 11 (RNCM) stated she would expect staff to complete the treatment as physician ordered. Multiple attempts should be completed for wound care and if missed the physician should be notified. c. A 3/20/19 physician progress notes [REDACTED]. No documentation was found in clinical records Resident 23's Stage 2 pressure ulcer was investigated within the five days as per policy. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed. d. A 3/20/19 Skin Impairment revealed upon assessment by the physician Resident 23 was found to have a suspected deep tissue injury on her/his left heel measuring 4 cm by 2.2 cm by unknown depth. Notes dated 6/3/19 included in the investigation revealed on 4/2/19 there was an open area to the left heel. On 4/5/19 the RNCM assessed the wound and a new order for routine wound care implemented. Abuse and neglect was not substantiated. On 6/5/19 at 10:54 AM Staff 11 (RNCM) confirmed the investigation was not completed within the five days as per policy. e. A 3/14/19 Admissions MDS revealed Resident 23 was at risk of developing a pressure ulcer, did not have a pressure ulcer with interventions of pressure reducing device for the chair and the bed. A 3/20/19 physician progress notes [REDACTED]. A 4/26/19 physician order [REDACTED]. A review of the resident's clinical record revealed no explanation, root cause analysis or investigation related to the development of the Stage 2 pressure ulcer identified on 3/20/19 to rule out abuse or neglect. On 6/11/19 at 7:17 AM Staff 1 (Administrator) stated on 2/7/19 nursing identified redness present on the buttocks. On 3/20/19 nursing staff were unaware an incident report needed to be completed due to the affected area still was closed.

Based on interview and record review it was determined facility staff failed to ensure professional standards were followed related to equipment safety and medication administration for 2 of 8 sampled residents (#s 4 and 5) reviewed for medications and accidents. Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A physician order [REDACTED]. The resident received 70 units on [DATE] at 7:00 PM. A physician order [REDACTED]. The residents blood sugar at 9:00 PM was 427 and she/he was administered 12 units of Humalog per sliding scale. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the residents room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. Staff 30 checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and the hospital emergency department was contacted. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar level which was 118. At 5:50 AM Resident 4 left for the hospital. Hospital records dated [DATE] through [DATE] indicated the following: -Resident 4 admitted for significant hypoglycemic (low blood sugar), [MEDICAL CONDITION] activity with [DIAGNOSES REDACTED] (low potassium in the bloodstream). Resident 4 indicated she/he was given too much insulin at the nursing facility. - Resident 4 developed [MEDICAL CONDITION] (abnormal heart rhythm characterized by rapid and irregular beats) and her/his lactic acidosis (an overproduction of lactic acid) was elevated, likely due to her/his low blood sugar. On [DATE] at 9:31 AM Resident 4 stated she/he admitted to the facility on [DATE] from the hospital. During her/his hospital stay she/he recalled being administered 30 units of [MEDICATION NAME] two times daily. On [DATE] the nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what the order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how (she/he) called for help, but did. The same nurse that administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he feeling shaky. She stated she took the resident's blood sugar and the reading was low, that's when she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 not to administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. On [DATE] at 11:42 AM Staff 2 (DNS) stated she would expect staff to utilize subjective data especially related to physician orders. She stated when a resident tells the nursing staff a medication does not look right or dosage does not sound right staff should stop and follow up on the questioning before administering the medication. 2. Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. -The investigation indicated Staff 36 spoke with the Witness 5 (Complainant) and she reported Resident 5 was placed in the sit to stand (used to assist with mobility for patients that are unable to transition from a sitting position to a standing on their own) to be toileted and only one CNA, Staff 43 (CNA) was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called the witness and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed indicated Staff 43 (CNA) and Staff 40 (CNA) were both transferring the resident to the bed side commode when the battery on the sit-to-stand died . Staff 40 had to go down and exchange the batteries. Upon Staff 40's return the resident stated My legs are giving out and instead of using the sit-to-stand machine Staff 43 and Staff 40 both controlled lowered the resident to her knees and then laid the resident with pillows under her head . A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 (LPN) revealed Resident 5 continues to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist . Hospital records dated [DATE] revealed Resident 5 had a mildly displaced right [MEDICAL CONDITION]. On [DATE] at 9:51 AM Staff 43 (CNA) stated she worked night shift, which started 10:00 PM at night and she recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 (CNA) got the resident up in the sit to stand and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either, so Staff 40 had to go a little farther down the hall to get a second battery and that one was not good either. Staff 43 stated two sets of batteries and both were dead. She indicated the batteries were often dead in the sit-to stands you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower her back down into the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about 2 minutes before she and Staff 40 lowered the resident to the ground manually, we took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer (mechanical lift) sling (a device used to suspend a resident in the Hoyer and move them appropriately) that was not underneath the resident when they lowered her manually to the floor, so we had to log roll the resident on the floor to get the Hoyer sling underneath the resident. We then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand station prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time that she was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 (LPN) came into the room and sent the resident out to the hospital. An observation on [DATE] at 8:34 AM revealed the sit to stands, hoyers, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. On [DATE] at 5:17 PM Staff 44 (LPN) worked night shift was familiar with Resident 5 and indicated she was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 (CNA) and Staff 43 (CNA) reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the battery died in the sit to stand machine and they had to manually lower the resident to the floor as they lowered the resident to the floor, the resident's hip could have spontaneously fractured her/his hip. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. On [DATE] at 11:33 AM Staff 1 (Administrator) acknowledged they did not have a system in place at the time of the incident related to assuring batteries were charged out appropriately after each shift. On [DATE] at 3:14 PM he stated maintenance does weekly checks to assure batteries are working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated this was implemented last week. -Refer to F689, F908

Based on observation, interview and record review it was determined the facility failed to ensure resident's be informed, participated in treatment and were treated with dignity and respect for 2 of 8 sampled resident (#s 4 and 24) reviewed for medications and dignity. This placed residents at risk for lack of dignity and Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the Resident 4's room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. She checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and called the emergency department. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar and indicated a reading of 118. At 5:50 AM Resident 4 exited the building. On [DATE] at 9:31 AM Resident 4 stated she/he admitted to the facility on [DATE] from the hospital. During her/his hospital stay she/he recalled being administered 30 units of [MEDICATION NAME] two times daily. The nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what their order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how she/he called for help, but did. The same nurse which administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and her/his blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 (LPN) stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he felt shaky. She stated she took the resident's blood sugar and the reading was low, and then she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 (LPN) to not administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. 2. Resident 24 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] CAA revealed Resident 24 received both scheduled and PRN pain medication. Resident 24 had frequent pain with a nine pain level from a scale of one to 10 with 10 the highest level of pain. Resident 24 had shortness of breath with exertion or lying flat. It was hard for Resident 24 to stay asleep and to complete day to day activities. A [DATE] physician signed Skilled Nursing Facility Transfer Orders instructed staff to administer 1 to 3 tablets of [MEDICATION NAME] (to relieve pain) every three hours PRN for pain. A [DATE] at 1:54 PM Nursing Note revealed Resident 24's pain continued to be addressed with her/his PRN pain medications. A ,[DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 7:37 PM Staff 29 (LPN) stated to Resident 24 all of her/his [MEDICATION NAME] medications were discontinued. No documentation was found in the clinical record. Resident 24's [MEDICATION NAME] was discontinued. On [DATE] at 7:42 PM Staff 29's voice was raised and was heard two rooms down the hall from Resident 24's room. Staff 29 stated Resident 24 did not have an order for [REDACTED]. On [DATE] at 12:05 PM Resident 24 stated her/his pain was a seven out of 10 on [DATE] in the evening. Resident 24 stated Staff 29 was unprofessional and she/he went to Staff 2 (DNS) to complain. Resident 24 stated Staff 29 came back later on [DATE] and placed a cup with pills in it on her/his bedside table but she did not apologize. On [DATE] at 11:40 AM Staff 2 confirmed Staff 29 should have validated the medication and not argued with Resident 24.

Based on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were appropriately assessed, monitored and interventions were implemented timely for 4 of 5 sampled residents (#s 11, 221, 223 and 319) reviewed for pressure ulcers. Resident 223 developed an unstageable (full thickness tissue loss which is covered by slough (devitalized tissue) and the depth of the wound cannot be determined) pressure ulcer. Findings include: 1. Resident 223 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Staff were to document an N for no skin issues or a Y for new skin issues and to document the findings. -A review of the 10/2018 and 11/2018 TARs revealed check marks were placed with no indication of Y or N on the following dates: 10/10, 10/17,10/24, 10/31, 11/14 and 11/21/18. On 11/7/18 the box was blank. An Investigation completed on 10/17/18 by Staff 3 (RNCM) revealed the following: - During peri care Resident 223 was found to have a unstageable (the depth cannot be determined) pressure ulcer on the inner coccyx (tail bone) that was 3.0 cm x 2.2 cm and was grayish black in color. The area was cleansed and barrier cream was applied. The resident complained of pain to the area. -The resident reported how she/he repositioned herself/himself in bed. Resident 223 indicated she/he placed her/his feet flat on the bed and then pushed her/his bottom towards the head of the bed. -On 10/17/18 Staff 3 (RNCM) indicated the resident performed her/his own peri care during toileting per the resident's preference and required one staff assist to transfer from the toilet. -Staff 3 (RNCM) educated the resident how to reposition in bed and encouraged the resident to use the call light. Staff 3 determined the repositioning caused friction and shearing to the skin/tissue over Resident 223's tailbone. -Treatment and orders were added. Resident 223 was added to weekly wound rounds. A Weekly Wound Assessment Details report dated 10/16/18 indicated the resident had a facility acquired unstageable pressure ulcer to the coccyx. The wound was 3.00 cm x 1.00 cm x Unknown (length x width x depth). The tissue was 10% bright pink or red and was 90% slough (devitalized tissue). A physician order [REDACTED]. -A review of the 10/2018 TARs revealed the treatment was not documented until 10/19/18 (two days later). A Comprehensive Care Plan initiated on 10/18/18 indicated Resident 223 had friction and shearing pressure ulcer development related to increased risk factors. Resident 223 was self-repositioning when in bed. Staff were directed to assist Resident 223 when she/he needed to be repositioned in bed to prevent friction and shearing to the coccyx area. -A revision to the Care Plan dated 10/30/18 indicated an air mattress was placed on her/his bed and trapeze bar was placed to the head of the bed for bed mobility to decrease pressure on her/his coccyx during repositioning. This occurred 14 days after the unstageable pressure ulcer was identified. A maintenance work order dated 11/5/18 indicated the trapeze bar was installed on 11/5/18 at 1:23 PM, 20 days after the unstageable pressure ulcer was identified. A Weekly Wound Assessment Details report dated 10/23/18 documented a facility acquired unstageable pressure ulcer to the coccyx. The wound was 3.20 cm x 1.00 cm x 0.70 cm. The tissue was 50% bright pink or red coloration and was 50% slough. A scant amount of serosanguinous (yellow colored blood tinged draining) with small amounts of drainage. The current plan and comments section completed by Staff 3 indicated the wound was worsening and to notify the physician if the wound continued to worsen and update treatments as ordered. A physician order [REDACTED]. Staff were to apply calcium alginate (a dressing) and foam dressing every day shift. -A review of the 10/2018 TARs revealed the treatment was completed per physician orders. The Weekly Wound Assessment Details report dated 10/30/18 and 11/6/18 documented a facility acquired unstageable pressure ulcer to the coccyx. The wound was 2.50 cm x 1.50 cm x 2.50 cm. The tissue was 50% bright pink or red and was 50% slough. A light amount of purulent (pus) and was malodorous drainage. Undermining (the damage to the tissue beneath the skin) and tunneling (damaged tissue that extend in a single direction into the subcutaneous tissue) was present which indicated worsening of the wound. The current plan and comments sections completed by Staff 3 indicated to continue updated treatment until Resident 223 went to the wound clinic, scheduled for 11/1/18. The 11/1/18 TAR indicated to turn the resident every two hours, monitor for fever and signs and symptoms of infection and update the on call provider. The TAR included family voiced concerns regarding the advancing coccyx wound and would like the resident sent to hospital with any deterioration of the wound. (This was implemented 16 days after the unstageable pressure ulcer was identified). -A review of the 11/2018 TARs indicated staff were repositioning Resident 223 per request. A wound clinic order dated 11/5/18 directed staff to cleanse the wound with normal saline apply [MEDICATION NAME] Advantage (a wound moisture-retention dressing) wound base and staff were to cover with a foam bandage as needed for wound care. A review of the 11/2018 TARs revealed the treatment was completed per physician orders. A Weekly Wound Assessment Details report dated 11/16/18 documented a facility acquired unstageable pressure ulcer to the coccyx. The wound was 2.50 cm x 1.50 cm x 2.20 cm. The tissue was 100% bright pink. A light amount of serosanguinous was present. Undermining and tunneling were present. A Weekly Wound Assessment Details report dated 11/20/18 documented a facility acquired unstageable pressure ulcer to the coccyx. The wound was 2.00 cm x 1.50 cm x 2.60 cm. The tissue was 100% bright pink. A light amount of serosanguinous was present. Undermining was present. The wound depth had increased. A review of the 11/2018 TAR (11/5/18 through 11/26/18) indicated the facility continued to follow wound care orders per physician recommendations. Resident 223 discharged on [DATE]. On 12/4/18 at 10:41 AM Staff 26 (CNA) indicated when the resident first admitted to the facility she/he had no pressure sores, needed assistance with transferring and getting to the toilet. She stated prior to the pressure sore the resident had complained about her/his buttocks being sore when wiping and that she reported this to the nurse. After the pressure sore started they assisted her/him with positioning in bed. On 12/4/18 at 4:12 PM Staff 27 (CNA) stated when Resident 223 first admitted to the facility she/he was more dependent and was a stand by assist in the bathroom and the resident let staff help her/him wipe. Staff 27 did not recall any pressure ulcers when the resident was first admitted and the wound was covered by the time she heard about the pressure ulcer on her/his buttocks. She further indicated she did not feel the resident was able to reposition herself/himself in bed on her/his own and staff would assist with repositioning. On 12/5/18 at 10:53 AM Staff 2 (Interim DNS) and Staff 3 (RNCM) stated the Resident 223's wound was discovered on 10/16/18 and was reported by a CNA due to the resident complaining of pain to the buttocks. Staff 3 indicated she completed the investigation initiated treatment and educated the resident on proper repositioning. Both Staff 2 and Staff 3 stated the resident was independent and could reposition herself/himself in bed and CNAs were following standards of practice. On 12/5/18 at 10:58 AM Staff 3 (RNCM) stated CNAs completed the resident's weekly skin checks when they showered residents and gave the shower skin sheets to the nursing staff and reported any concerns to the nurses. She indicated that was how the weekly skin audits were documented/completed in the TARs. Staff 2 (Interim DNS) was present and indicated his expectation related to the weekly skin audit policy was for weekly skin audits to be completed by nurses. The nurses should be doing a full visual body check on the residents weekly. He acknowledged this was not being completed correctly and the documentation was inaccurate. Staff 2 and Staff 3 acknowledged the care plan revision related to the air mattress and trapeze bar was not implemented timely. Staff 2 and 3 were unable to verify when exactly the air mattress was implemented but assumed it was placed the same day the trapeze bar was put in on 11/5/18. Additionally, Staff 2 could not confirm if Resident 223 was even able or strong enough to use the trapeze bar and that they should have had documentation about this as well. 2. Resident 221 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. The Admission Nursing Data Base form dated 9/21/18 indicated Staff 6 (RN) documented the resident's right (R) buttock had a 3 cm x 2 cm pressure ulcer and the coccyx had a circular 3 cm x 3 cm pressure ulcer. The wound assessment performed on admission did not indicate if there was a depth to the wounds or whether there was a full-thickness tissue loss (Stage 4). The physician's orders [REDACTED]. The Wound Assessment Details Report dated 9/25/18 included Staff 4's (RNCM) assessment of the resident's coccyx wound as a Stage 4 pressure ulcer and its size was 3.6 cm x 1.8 cm x 1.6 cm. The progress note dated 9/28/18 indicated the resident did not allow the nurse to change her/his wound dressing, but the resident allowed staff to change the dressing later that day. Staff 2's (Interim DNS) investigation dated 9/28/18 revealed the facility had transcribed the wound care order dated 9/21/18 onto the resident's TAR and the nurses inconsistently charted the wound care in the progress notes. A review of the resident's (MONTH) (YEAR) TAR showed the facility did not transcribe the 9/21/18 physician's orders [REDACTED]. The wound clinic note dated 10/5/18 indicated the resident's Stage 4 pressure ulcer was healing and there were no signs or symptoms of infection. In an interview on 12/3/18 at 8:12 AM Resident 221 indicated she/he was frustrated when the nurses did not come right away when she/he wanted the dressing change done. On 12/3/18 at 2:05 PM Staff 4 (RNCM) said the resident's initial wound assessment was done by Staff 6 (RN) when the resident was admitted to the facility. She stated during the 9/25/18 wound rounds she assessed the Stage 4 pressure ulcer wound which appeared as a single wound including the coccyx and R buttock. On 12/3/18 at 5:00 PM Staff 6 (RN) said she reviewed the resident's admission orders [REDACTED]. Staff 6 indicated on 9/21/18 she assessed the Stage 4 pressure ulcer on the coccyx and R Buttock, she cleansed the wound bed with normal saline, applied skin prep on peri-wound area, placed alginate with silver on the wound bed and covered the area with a foam dressing. Staff 6 indicated on 9/21/18 she gave a change of shift report to Staff 21 (LPN) and said the resident's admission orders [REDACTED] On 12/3/18 at 8:00 PM Staff 10 (LPN) stated she often did the resident's wound care, charted it on the progress notes and was not sure why the wound care was not on the resident's TAR. On 12/4/18 at 8:20 AM Staff 21 (LPN), when asked about transcribing the resident's admission orders [REDACTED]. 12/4/18 at 3:20 PM Staff 2 (DNS) acknowledged the resident's wound care order was not transcribed on the TAR for more than a week after the resident was admitted and normally the facility ensured admission orders [REDACTED] 3. Resident 319 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. The 4/6/18 Admission MDS indicated the resident was at risk for pressure ulcers related to her/his bilateral [MEDICAL CONDITION] and need for extensive assistance with bed mobility. The 8/1/18 comprehensive care plan indicated staff were to complete a skin assessment form as required and update at least weekly. It also instructed staff to follow physician's orders [REDACTED]. Resident 319's 11/2018 TAR instructed staff to provide wound care to a Stage 2 (partial thickness) pressure ulcer on the resident's sacrum (tail bone) every 2-3 days and as needed. The TAR also instructed staff to perform weekly skin audits and document them in Resident 319's clinical record. A review of Resident 319's clinical record did not reveal any documentation of a pressure ulcer or any other type of wound in the wound rounds (portion of the clinical chart where on-going assessment and monitoring of wounds is documented). On 11/29/18 at 9:44 AM Staff 9 (RN) reported pictures and measurements of Resident 319's wounds should be done weekly by the RNCM. On 12/3/18 at 1:57 PM Staff 4 (RNCM) stated she had not completed the weekly wound rounds for Resident 319 or documented information related to the wounds in the resident's clinical record. On 12/3/18 at 5:18 PM Staff 2 (Interim DNS) stated the weekly wound rounds for Resident 319 had not yet been done but should have been. 4. Resident 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11 had four admissions to the facility on [DATE], 4/12/18, 7/13/18, and 10/19/18. The facility's Skin and Wound Management Policy and Procedures manual included Skin Problem Guidelines which indicated upon admission the Admitting Nurse would complete a skin evaluation and document the resident's skin conditions on the Admission Nursing Data Base/ Re-entry Data Base and in the resident's clinical record. Directions on the form indicated nursing staff were to identify all body marks such as pressure ulcers, abrasions, bruises, soft heels, skin tears, cancer [MEDICAL CONDITION], any oozing areas, moles, scars, and surgical wounds. They were to indicate the location, size, depth, color and drainage of any areas as well as the site, type, length, width, depth and stage. Of the four Admission Nursing Data Base forms completed for Resident 11 none of them contained the complete information the form directed staff to provide. None of the forms contained an accurate representation of the resident's skin conditions upon admission or readmission to the facility. The 11/10/18 Annual MDS Pressure Ulcer CAA for Resident 11 failed to contain a comprehensive assessment of the resident's pressure ulcer status. There was no information on the locations of wounds, size/measurements of the wounds, surrounding skin conditions, signs of healing or worsening, history, current treatments, nutritional impact, comorbidities, pain issues, or impact of the Foley catheter, pe[DEVICE] and [MEDICAL CONDITION]. The CAA did not contain any information on the 11 current wounds identified in the wound rounds annotations. Additional CAAs which could impact the resident's pressure ulcers were reviewed in the areas of [MEDICAL CONDITION] Drug Use, ADL Functional Potential, Nutritional Status and Urinary Incontinence. The additional CAAs did not contain comprehensive assessments. A review of the Wound Assessment Details Reports for the weeks of 11/21/18 and 11/30/18 revealed several inconsistencies in the reports. There were Inconsistencies in the number of wounds, the measurements of the wounds, the tissue typing, the photographs of the wounds and the source of the wounds (present upon admission or facility acquired). In the reports six of the wounds were identified as facility acquired. On 12/4/18 at 3:26 PM Staff 2 (Interim DNS) acknowledged nursing staff were not staging wounds appropriately and the definitions were wrong. They did not stage correctly for six months. Staff 2 acknowledged the Wound Assessment Details Reports did not contain consistent information. The wound photographs did not have consistent anatomical positions, camera distance or angles and it was not easy to determine what part of the body was being observed. The wound measurements were not consistent for the size and area of the wounds and the tissue typing was not consistent. Staff 2 acknowledged nursing staff needed more training, so they would measure and identify the wounds consistently and accurately. On 12/4/18 at 4:27 PM Staff 2 acknowledged Resident 11's CAAs were not comprehensively assessed. On 12/5/18 at 10:53 AM Staff 2 indicated his expectation and the policy related to skin audits was for nurses to do a full skin assessment upon admission or re-entry and then weekly. The nurses were to do a full visual body check on the residents weekly. He acknowledged this was not being completed correctly and the documentation was inaccurate.

Based on interview and record review it was determined the facility failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: comprehensive assessment, accuracy of assessments, development of comprehensive care plans, quality of care, unnecessary medications, medical records, accidents, self administration and ADLs. This placed residents at risk for unidentified and unmet needs. Findings include: 1. A review of seven residents for medications revealed seven were not appropriately monitored related to behaviors to determine the continued ongoing use of [MEDICAL CONDITION] medications. This deficiency was also noted on the 8/11/17 recertification survey. 2. A review of three residents for development of comprehensive person centered care plans revealed three were not comprehensively developed person centered care plans. This deficiency was also noted on the 8/11/17 recertification survey. 3. A review of 23 residents for comprehensive assessment revealed eight were not comprehensively assessed. Residents were reviewed for accidents, ADLs, medications, pain management and pressure ulcers. This deficiency was also noted on the 8/11/17 refortification survey. 4. A review of 10 residents for accuracy of MDS assessments revealed five residents were not accurately assessed. Residents were reviewed for medications and MDS resident assessments. This deficiency was also noted on the 8/11/17 recertification survey. 5. A review of eight residents revealed seven residents were not provided adequate [MEDICAL TREATMENT] care, appropriate assessment of pressure ulcers, monitoring of pressure ulcers, resulting in Resident 223's developement of an unstageable (full thickness tissue loss which is covered by slough (devitalized tissue) and the depth of the wound cannot be determined), not following physician orders [REDACTED]. Quality of care deficiencies were also noted on the 8/11/17 recertification survey. 6. A review of three residents for accidents revealed one resident had a fall due to failure to staff follow the care plan. This deficiency was also noted on the 8/11/17 recertification survey. 7. A review of four resident's for accurate medical records revealed two residents' records were not accurate related to [MEDICAL TREATMENT] and falls. This deficiency was also noted on the 8/11/17 recertification survey. 8. A review of two residents for ADL care revealed two residents were not receiving appropriate ADL care. This deficiency was also noted on the 8/11/17 recertification survey. 9. A review of two residents for self administration of medication revealed one resident was not appropriately assessed to self administer medications. This deficiency was also noted on the 8/11/17 recertification survey. On 12/5/18 at 1:12 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the QAPI committee was aware of issues related to comprehensive assessments, pressure ulcers and medications but struggled with not having key staff in place to assist in those areas. Staff 1 and 2 further indicated a lot of new staff were hired and acknowledged more training and education overall was needed in the facility. Refer to F554, F636, F641, F656, F677, F684, F686, F689, F698 and F758.

Based on interview and record review it was determined the facility failed to ensure specific instructions for fall mat placement were in place for 1 of 3 sampled residents (#1) who were at risk for falls. Resident 1 sustained a brain hemorrhage after a fall on [DATE] and died two weeks later. Findings include: Resident 1 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's fall risk assessment dated [DATE] revealed she/he was a high fall risk. The care plan dated [DATE] included: fall mat (s) placed at bedside. The care plan did not specify whether one or two fall mats were needed or which side of the bed to place the fall mat if only one was needed. On [DATE] the admission MDS dated identified the resident required the assistance of two staff for bed mobility, toileting and transfers. An Incident Report dated [DATE] indicated at approximately 7:30 pm the resident was toileted, assisted back to bed, non-skid footwear was on and a call light was placed within reach before Staff 4 (CNA) left the room. The report revealed at 7:50 pm one fall mat was in place on the right side of the resident's low bed when Staff 4 saw the resident lying on the floor next to the left side of the bed. Staff 3 (LPN) documented Staff 4 asked her to assess the resident and there was a hematoma the size of a tennis ball on the left side of the resident's face. The report indicated orders were received to send the resident to the Emergency Department (ED) and paramedics transported the resident at 8:10 pm. The ED record indicated on [DATE] the resident's head CT (Computerized Tomography) showed evidence of a traumatic Subarachnoid Hemorrhage (SAH, brain bleed) and she/he was hospitalized . On [DATE] the facility documented the following actions were taken in response to Resident 1's fall: -The care plans for residents who had a fall mat were reviewed to be certain there was specific information as to which side of a resident's bed a fall mat was placed. -An inventory was completed to ensure fall mats were available at all times. -An in-service on fall prevention and interventions was completed for all nurses, CNAs and CMAs. -An in-service on following the care plan was completed with all nurses, CNAs and CMAs. -Audits of up to five care plans per week were to performed by the Administrator, DNS and/or designee to ensure fall interventions were in place per the care plans. -Findings were to be reported to the facility's Quality Assurance committee. On [DATE] the facility's investigative report revealed Resident 1's care plan did not include specific information as to whether one or two fall mats were needed and/or which side of the bed a fall mat was to be placed. The hospital's Discharge Summary dated [DATE] listed SAH as the resident's primary [DIAGNOSES REDACTED]. On [DATE] at 12:16 pm Staff 2 (DNS) stated after Resident 1's fall the facility did audits which involved at least five residents a week to ensure the care planned fall prevention measures were in place and if a care plan needed to be revised. On [DATE] at 12:15 pm Staff 1 (Administrator) indicated they put actions into motion as a response to Resident 1's fall, the staff in-services were done, audits were going well and the actions were part of the facility's quality assurance program. On [DATE] at 11:37 am Staff 4 stated the resident had left-sided weakness from a stroke and he put a fall mat on the right side of the low bed. Staff 4 indicated he toileted the resident, helped her/him back to bed, put a call light within reach, made sure a fall mat was on the right side of the low bed about 15 minutes before he found the resident lying on the left side of the bed. He stated the care plan indicated one or two fall mats were needed, he placed one as the resident could not use the left side. On [DATE] at 4:25 pm Staff 3 indicated she planned to change the resident's computerized care plan so it had a fall mat on each side of the bed but the resident fell before she got a chance to do so. Staff 4 indicated after the resident fell on [DATE] she performed a neurological assessment which showed a slow pupil response to light and an inability to follow simple commands. She stated there was a hematoma on the resident's face and the facility received orders to send her/him to the ED. On [DATE] at 3:50 pm Staff 5 (RNCM) indicated after the resident's fall on [DATE] she met with Staff 3 and reviewed how to write care plan interventions for falls which were specific to what a resident needed. On [DATE] at 4:00 pm Staff 2 acknowledged Staff 3 initiated Resident 1's computerized care plan and it did not specifically address how many fall mats the resident needed and/or which side of the bed staff were to place a fall mat if only one was needed.

Based on observation, interview and record review it was determined the facility failed to accurately identify and monitor pressure ulcers for 1 of 3 (#7) sampled residents. Resident 7's right heel blister became a Stage 3 pressure ulcer (full-thickness tissue loss). Findings include: Resident 7 was admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. The Resident Status Form (pocket care plan) dated 12/11/15 directed staff to float the resident's heels. The Admission MDS dated [DATE] documented the resident did not have a pressure ulcer. The Weekly Wound Progress Note dated 12/19/15 indicated the resident's right heel had a closed blister which was 3 cm x 3 cm. The note did not identify the intact blister as a Stage 2 pressure ulcer (can manifest as an intact blister). The MDS dated [DATE] did not document the resident had a Stage 2 pressure ulcer. The December 2015 physician's orders [REDACTED]. The orders dated 12/31/15 indicated a foam dressing was to be applied every three days and as needed (PRN) on the opened blister on the resident's right heel. There were no Weekly Wound Progress Notes from 12/20/15 through 1/3/16 for the facility's assessment of Resident 7's right heel. The Weekly Wound Progress Note dated 1/4/16 documented the resident's right heel blister became an unstageable pressure ulcer (wound bed covered with devitalized tissue known as eschar or slough). The note indicated the wound was 4 cm x 3 cm and moon boots were used for heel protection. The January 2016 physician's orders [REDACTED]. There was no Weekly Wound Progress Note documented by the facility staff from 1/5/16 through 1/24/16. The Weekly Wound Progress Note dated 1/25/16 revealed the resident's right heel wound was described as a Stage 3 pressure ulcer with slough and purulent drainage with no odor detected. The physician's orders [REDACTED]. The Weekly Wound Progress Notes dated 2/2/16 and 2/16/16 documented the resident's Stage 3 pressure ulcer on the resident's right heel was 2 cm x 2 cm with evidence of purulent drainage. On 3/9/16 at 10:40 am Resident 7's right heel was observed to be resting directly on the overlay mattress. On 3/9/15 at 10:41 am Staff 21 (RN) indicated the moon boot was on, it must have shifted when the resident was in bed and he readjusted it for better heel protection. On 3/9/16 at 2:45 pm Staff 4 (LPN) stated in early January, 2016 the resident's left heel was described as a Deep Tissue Injury (DTI, discolored intact skin or fluid-filled blister), staff applied zinc oxide and the area healed in a few weeks. Staff 4 indicated the facility staff did not document the resident's left heel pressure ulcer on their Weekly Wound Progress Notes. On 3/15/16 at 10:00 am Staff 2 (DNS) acknowledged the facility staff did not document a wound assessment for the resident's left heel wound. She stated the resident's intact right heel blister should have been identified as Stage 2 pressure ulcer on 12/19/15 and the facility should have documented their assessments of the resident's pressure ulcers on their Weekly Wound Progress Notes. On 3/15/16 at 10:40 am Staff 17 (CNA) indicated the resident did not like pillows or a bolster and the resident preferred moon boots. On 3/15/16 at 10:45 am Staff 18 (LPN) was observed when he removed the moon boot on Resident 7's right foot, cleansed the right heel wound, applied mesalt to the wound bed and covered the area with a foam dressing. There was evidence of yellow-colored slough and no odor was detected. On 3/15/16 at 2:40 pm Staff 19 (CNA) stated the resident was frequently repositioned and heels were protected. On 3/16/16 at 10:30 am Staff 20 (LPN) stated she saw a closed blister on the resident's right heel around mid-December 2015 and applied skin prep. She indicated staff turned the resident frequently and provided incontinence care. She stated pillows were used, the resident removed them; and the same thing happened with a bolster which was used to float the resident's heels. Staff 20 indicated the resident adjusted to wearing the moon boots and kept them on.

Based on observation, interview and record review it was determined the facility failed to administer pain medication as ordered by the Physician and provide ongoing pain assessment for 1 of 3 sampled residents (# 1) who received pain medication. Resident 1 experienced unrelieved pain. Findings include: Resident 1 was readmitted to the facility in August, 2010. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had moderate pain daily. The resident's medical record did not contain a pain assessment. The comprehensive care plan last reviewed and up-dated on 9/28/10 did not include directives to monitor for pain. The 7/27/10 Resident Care Instructions, used by the CNAs to provide care, directed staff to "report any signs of pain they noted while providing care" for Resident 1. The monthly physician's orders [REDACTED]. On 9/10/10 an order was received for [MEDICATION NAME] (liquid) 7.5 mg to be given two times a day, as needed for pain. The MARs for August, September and October, 2010 included the scheduled [MEDICATION NAME] to be administered two times a day for "generalized pain." During the month of August, Resident 1 received his scheduled doses of [MEDICATION NAME]. For September the resident received 26 out of 46 scheduled doses. The 20 missed doses were circled as not given. Review of the MARS from 10/1/10 through 10/19/10 revealed all 38 scheduled doses were circled as not being given. The 10/1/10 documentation on the back of the MAR indicated no sign of pain." There were no other entries on the back of the MAR. On 10/19/10 at 8:35 am, Staff 7 (CNA) and Staff 8 (CNA) were observed providing personal care for Resident 1. While the resident was placed in a flat position he appeared agitated and his breathing became rapid. Staff 7 stated he did not like to be turned and cared for. When asked, Staff 7 stated she thought the resident was painful. On 10/19/10 at 11:20 am, Staff 11 (CNA) and Staff 9 (CNA) were caring for Resident 1. Both CNAs felt the resident was generally very painful when cared for and due to the large wound on his coccyx. On 10/19/10 at 1:40 pm, Staff 6 (LPN) stated that Witness 1 (family member) did not want the resident to have pain meds. On 10/19/10 at 2:50 pm, Staff 4 (RN) stated the resident was "probably painful" but added that Witness 1 (family member) did not want the resident to receive narcotic pain medication. On 10/19/10 at 5:00 pm, Witness 2 (family member) stated the resident "did well" on the two times a day [MEDICATION NAME]. Witness 2 was not aware that Resident 1 was not receiving the pain medication. Witness 1 (family member) stated s/he had not asked for the [MEDICATION NAME] to be discontinued.

Based on observation, interview and record review it was determined the facility failed to provide ongoing assessments and interventions to prevent weight loss for 1 of 9 sampled residents (#15) who experienced weight loss. Resident 15 had a weight loss of 40 pounds (lbs) from March 2010 through July 2010. Findings include: Resident 15 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. According to the admission MDS dated [DATE], Resident 15 required assistance from staff to eat his meals and his weight on admission was 156 lbs. According to the facility's Medical Nutrition Therapy assessment dated [DATE], the resident weighed 158 lbs. His ideal body weight (IBW) range was documented as between 133-163 lbs. The assessment also included the information that he had difficulty chewing and his diet order was mechanical soft. The goals listed on the assessment included "monitor and evaluate change in appetite, behavior and weight." The facility's Weight History form for March, 2010 indicated the resident weighed 158 lbs on 3/9/10 and 3/15/10, 153 lbs on 3/25/10 and 148 lbs on 3/31/10. This was a loss of 10 lbs or a 6% loss of body mass in 15 days. There was no evidence in the record of assessment of the cause of the weight loss or nutritional interventions added to the resident's plan of care for the month of March, 2010. The facility's Weight History form indicated the resident continued to lose weight in April. Documented weights included 147 lbs on 4/4/10, 143 lbs on 4/11/10, 140 lbs on 4/18/10 and 138 lbs on 4/25/10. The resident developed a [MEDICAL CONDITION] on or about 4/23/10 which the facility assessed as the cause for a 6-7 lb weight loss. The total weight loss for April was 9 lbs or a 6% loss of body mass. According to a physician's orders [REDACTED]. According to the CNA Flow Sheet Record for May, 2010, snacks were documented as provided three times. The facility's Weight History form documented weights for the month of May as: 138 lbs on 5/2/10, 132 lbs on 5/9/10, 128 lbs on 5/18/10 and 123 lbs on 5/23/10 for a loss of 13 lbs or a 10.8% loss of body mass. There was no evidence in the record of any assessment of the cause of the weight loss or additional nutritional interventions other than the supplement added in May, 2010. The facility's Weight History form documented the resident's June weights as: 125 lbs on 6/6/10, 118 lbs on 6/22/10 and 121 lbs on 6/29/10. The July weights were: 122 lbs on 7/4/10 and 7/13/10 and 118 lbs on 7/21/10 for a total of a 7 lb weight loss for June and July, 2010. There was no evidence in the record of an assessment of the cause of the continued weight loss or new interventions. According to the facility's Medical Nutrition Therapy Review dated 6/30/10, the resident's serum [MEDICATION NAME] was 3.3. [MEDICATION NAME] is a protein made by the liver. Low [MEDICATION NAME] may be explained by a diet low in protein or [MEDICAL CONDITION]. (http://www.nlm.nih.gov/medlineplus.) The same note indicated that snacks and supplements were not ordered. The note continued with the information that the resident had "consistent undesirable weight loss and was now below his IBW." On 7/28/10 at 7:20 am, Resident 15 was in the dining room eating breakfast. He was observed to eat independently. At 11:45 am, the resident was in the dining room eating lunch. He ate 75% of the meal. On 7/28/10 at 11:20 am, Staff 6 (Dietary Manager, Registered Dietician) stated that residents who experience weight loss are followed at the facility's At Risk Interdisciplinary Team (IDT) meetings. Staff 6 stated the IDT meetings had only been held for the past couple of months. A review of the notes from the At Risk IDT meetings for 6/9/10, 7/13/10 and 7/20/10 revealed that Resident 15 was not reviewed at those meetings. There were no other meeting notes available. On 7/28/10 at 11:30 am, these issues were discussed with Staff 2 (DNS) who agreed that the At Risk IDT meetings had been "scanty for the last three to five months." The resident experienced a total weight loss of 40 lbs from 3/8/10 through 7/21/10, equal to a 25% loss of body mass. There was no evidence of an assessment of the cause of the weight loss and the only intervention was the addition of a nutritional supplement and snacks in May, 2010.