Every finding on record at Avamere Rehabilitation of Oregon City

Based on interview and record review it was determined the facility failed to provide adequate supervision and assistance to prevent a fall with injury for 1 of 2 sampled residents (#8) reviewed for falls. As a result, Resident 8 sustained a fractured arm. Findings include:Resident 8 was admitted to the facility in 5/2025, with diagnoses including neck fracture.Resident 8's 5/27/25 Care Plan revealed the resident had limited mobility due to her/his neck fracture and required a two-person transfer assist for toileting. Resident 8's 5/31/25 MDS revealed she/he was cognitively intact and had a BIMS of 15 out of 15.A 6/25/25 Facility Investigation Report (FRI) revealed Resident 8 fell and sustained a fracture of her/his right arm after Staff 20 (CNA) attempted to transfer Resident 8 from the commode by herself. The facility determined Staff 20 had not followed Resident 8's care plan, which indicated the resident was a two-person transfer assist for toileting.A 6/27/25 Hospital Discharge Summary revealed that Resident 8 sustained a right arm fracture as a result of her/his fall at the facility. On 8/20/25 at 2:40 PM, Resident 8 stated Staff 20 had attempted to assist her/him from the commode when she/he slipped and fell to the floor, causing her/him to fracture her/his arm. Resident 8 stated that per her/his care plan, she/he required two-person assistance for transfers and toileting. On 8/27/25 at 2:37 PM, Staff 3 (RCM) stated Resident 8 required two-person assistance with transfers and toileting, and confirmed Staff 20 failed to follow the resident's care plan, which led to Resident 8 sustaining a fracture of the right arm. The surveyor attempted to interview Staff 20 on 8/26/25 and 8/27/25 but was unable to reach them.On 8/29/25 at 10:00 AM, Staff 1 (Administrator) and Staff 3 confirmed Staff 20 did not follow Resident 8's care plan related to transfers with toileting, which led to Resident 8's fall, where she/he sustained a fractured right arm. The deficient practice was identified as Past Noncompliance based on the following:On 6/26/25, the deficient practice was identified by the facility to be corrected when the facility completed a root cause analysis of the incident and determined there was a failure to follow a resident's care plan. The Plan of Correction included:Resident 8's care plan was reviewed and revised to address any additional risk factors.A facility-wide audit of all residents with fall risk care plans was conducted to ensure interventions were current and being followed by staff.All nursing staff were re-educated on the importance of following the individualized resident care plans.Supervisors conducted random spot checks to verify compliance with care plans.The DNS performed weekly audits of care plan implementation for residents at risk for falls for three months. Results were reviewed in the Quality Assurance and Performance Improvement (QAPI) committee meetings, and corrective actions were taken as needed, including ongoing monitoring.

Based on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely for 1 of 3 sampled medication carts reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals. Findings include: The facility's 11/2020 Storage of Medications Policy specified the following: -Drugs and biologicals are stored in the packaging in which they are recieved. -Drugs and biologicals used in the facility are stored in locked compartments. The facility's 11/2020 Administering Medications Policy specified the following: - The individual adminstering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right route of adminstration before giving the medication. A review of Resident 13, 14, 18, 31, 32 and 38's 5/2025 MARs revealed the following: - Resident 13 received atorvastatin (lowered cholesterol levels), gabapentin (reduced nerve pain), and sertraline (anti-depressant). -Resident 14 received simvastatin (lowered cholesterol levels), docusate (stool softener), Topiramate (calmed overactive nerves in the body), and Dicyclomine (relaxed muscles in the stomach and bowel). - Resident 18 received atorvastatin (lowered cholesterol levels), Prazosin (lowered blood pressure), Senokot (stool softener), trazodone (anti-depressant), buspirone (anti-anxiety), gabapentin (reduced nerve pain). - Resident 31 received Tylenol (pain relief), atorvastatin (lowered cholesterol levels), Calcium supplement (maintained bone strength), Icosapent (controlled fat-like substance in the blood), baclofen (muscle relaxor), and gabapentin (reduced nerve pain). -Resident 32 received Prilosec (reduced acid in the stomach), Tylenol (pain relief), hydroxyzine (anti-anxiety), Risperdal (anti-psychotic), simvastatin (lowered cholesterol levels), sucralfate (treated ulcers), PRN morphine (narcotic pain relief) and Dilaudid (narcotic pain relief). - Resident 38 received aripiprazole (anti-psychotic), atorvastatin (lowered cholesterol levels), mirtazapine (anti-depressant), and tamsulosin (treated symptoms of an enlarged prostate). On 6/4/25 at 3:50 PM, six plastic medication cups filled with medications and labeled with resident room numbers were observed in the top drawer of the medication cart in hall 100. In the same cart, one medication cup filled with medication pills and unlabeled was observed in the narcotic locked box of the medication cart. On 6/4/25 at 3:52 PM, Staff 25 (CMA) acknowledged she prepped evening scheduled medications early for Residents 13, 14, 18, 31, 32 and 38. Staff 25 stated she left prepped medications in the medication cart prior to leaving on a lunch break. She labeled plastic medication cups with the resident room number and placed the resident's medications that were scheduled to be administered between 4:00 PM to 8:00 PM and left the medication cups in the top shelf and in the narcotic drawer. Staff 25 stated that was her usual process because administering medication in a timely manner was challenging. Staff 25 acknowledged it was not best practice to pre-prep medications. On 6/4/25 at 4:18 PM, Staff 2 (Director of Nursing) confirmed the presence of pre-prepped medications for residents in the medication cart and acknowledged pre-prepped medications stored in the medication cart was not proper medication storing.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed transmission-based precautions for 1 of 5 sampled residents (#260) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 260 was admitted to the facility on [DATE] with diagnoses including clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon). Resident 260 on transmission-based precautions - enteric precautions at time of admission. An undated Avamere Contact Enteric Precautions facility procedure: -Everyone Must: Clean hands with sanitizer when entering room. Wash with soap and water upon leaving room. -Gown and glove before entering the room after hand hygiene has been completed. -Doctors and Staff Must: use resident dedicated or disposable equipment. -Clean and disinfect shared equipment between residents and before removing it from the resident's room. On 6/2/25 at 11:48 AM observed Staff 9 (CNA) enter Resident 260's room without donning PPE. On 6/2/25 at 11:51 AM observed Staff 9 exit Resident 260's room with the lunch tray, returned the tray to the meal cart, proceeded to kitchenette at front dining room then walked to main kitchen to retrieve a soup for Resident 260. Staff 9 did not wash or sanitize her hands after exiting Resident 260's room. On 6/2/25 at 12:01 PM Staff 9 stated she was aware Resident 260 was on transmission-based precautions for c-diff and staff was required to wear a mask, gown and gloves when providing care but thought PPE was not needed when delivering meals. Staff 9 acknowledged she did not wash her hands after leaving Resident 260's room. On 6/3/5 at 12:51 PM observed Staff 10 (CNA) wearing gloves and no PPE gown while placing a blanket on Resident 260. Staff 10 stated she had completed peri-care and had doffed her gown and mask when Resident 260 had asked for blanket. Staff 10 acknowledged she should have completed all care for Resident 260 before doffing all PPE. On 6/05/25 at 3:07 PM Staff 5 (LPN, IP) stated education was provided to all staff regarding transmission-based precautions and signs were posted outside of Resident 260's room. Staff 5 stated all staff were supposed to wear PPE when going into the room whether including answering the call light, dropping of the meal tray, placing on a blanket on the resident. On 6/5/25 at 3:09 PM observed Resident 260 without wearing any PPE ambulating in the hallway during a therapy session. On 6/5/25 at 3:11 PM Staff 5 stated Resident 260 was still on transmission-based precautions and was supposed to remain in her/his room until cleared of c-diff. On 6/5/25 at 3:15 PM Staff 2 (DNS) stated she expected all staff to follow all transmission-based precautions at all times.

Based on observation, interview and record review it was determined the facility failed to offer restorative services to increase range of motion for 1 of 1 sampled resident (#4) reviewed for rehabilitation and restorative. This placed resident at risk for decrease in range of motion. Findings include: The facility's Restorative Policy, dated 11/11/05, indicated the following: -It is the policy of this facility to provide its residents the restorative services in an effort to maintain the resident's highest level of self-care and independence, physically and psychosocially. Resident 4 was admitted to the facility in 1/2025 with diagnoses including pleural effusion (a excessive fluid build up in between the lungs and chest wall). Review of Resident 4's PT Discharge Summary on 2/28/25 indicated Resident 4 was seen for PT from 1/7/25 to 2/28/25. A 4/11/25 Care Conference Note indicated Resident 4 expressed interest to continue physical therapy and/or restorative services. A 4/17/25 Progress Note indicated Resident 4 would be a good fit for a restorative program to regain strength. No evidence was found in Resident 4's clinical record to indicate she/he received restorative services. On 6/2/25 at 3:22 PM, Resident 4 stated when she/he was admitted , she/he was able to stand and pivot onto a wheelchair and was able to ambulate. Resident 4 stated she/he had not received physical therapy services for over two months. Resident 4 thought she/he no longer qualified for PT but wanted to participate in restorative services. Resident 4 stated she/he was not offered ROM exercises. On 6/4/25 at 12:36 PM, Staff 16 (CNA) stated Resident 4 was dependent and required maximum assistance from staff to complete physical activity. Staff 16 stated she thought Resident 4 received restorative services but did not observe the resident participate. On 6/4/25 at 12:44 PM, Staff 22 (CNA) stated Staff 23 (Restorative Aide) provided a list of residents to the CNAs which included the residents enrolled in restorative services. Staff 22 stated Resident 4 was not enrolled. On 6/4/25 at 1:00 PM, Staff 23 stated all residents were discussed in monthly meetings to determine who would benefit from restorative services. Staff 23 stated Resident 4 was discussed at one point but did not receive an RA program because her caseload was full. On 6/4/25 at 2:10 PM, Staff 3 (RNCM) stated when a resident voiced interest in restorative services, she connected with the restorative assistant and conducted an assessment. Staff 3 stated she was unsure why the Resident 4 was not added to the caseload. On 6/4/25 at 3:20 PM, Staff 24 (Regional Administrator) stated she expected staff to offer residents restorative services to residents who expressed interest. Staff acknowledged Resident 4 needed restorative services.

Based on observation, interview and record review it was determined the facility failed to ensure hearing aids fit properly and worked for 1 of 1 sampled resident (#45) reviewed for communication. This placed residents at risk for decreased quality of life. Findings include: Resident 45 was admitted to the facility in 1/2025 with diagnoses including bipolar disorder. Resident 45's 1/31/25 Admission MDS indicated Resident 45 could hear adequately with the assistance of aids or other hearing appliance. A 1/28/25 progress note indicated resident 45's hearing aid did not work. A 3/4/25 progress note indicated Resident 45 needed a new hearing aid as it was broken. On 6/3/25 at 8:58 AM, the State Surveyor interviewed Resident 45 and had to speak loudly, clearly, and close to Resident 45's face in order to be heard. On 6/3/25 at 8:58 AM, Resident 45 stated she/he was hard of hearing and could not hear well unless she/he wore hearing aids. Resident 45 stated she/he had hearing aids, but they no longer worked. Resident 45 stated she/he told Staff 15 (CMA) & Staff 20 (RN) her/his hearing aids did not work and wanted them replaced. On 6/4/25 at 3:08 PM Staff 17 (CNA) stated Resident 45 did not like it when people talked loudly to her/him because she/he got overstimulated. On 6/5/25 at 10:56 AM Resident 45 was asked to show her/his hearing aids as she/he was not wearing them. The hearing aids were stored in a red cup in her/his bedside table. Four batteries were sitting in the cup; no sound was coming from the hearing aids. Resident 45 stated she/he lost a lot of weight (100 lbs), and the hearing aids haven't fit since admission. Resident 45 noted the last time the hearing aids were worn was about a week ago because they were broken. Resident 45 stated Staff 15 tried to fix them about a week ago and could not fix them. On 6/5/25 at 10:40 AM Staff 14 (CNA) stated Resident 45 utilized hearing aids, and her/his hearing aids did not work, and have not fit or worked since admission to facility. On 6/5/25 at 11:00 AM Staff 15 (RN) stated Resident 45 had hearing aids that never fit her/him or worked appropriately. On 6/5/25 at 3:32 PM with Staff 5 (Social Services Director) and Staff 6 (Social Services Coordinator), Staff 5 stated she did not know Resident 45 needed hearing aids. Staff 6 indicated she was aware Resident 45's hearing aids did not fit or work correctly since 1/2025; efforts were not made to get hearing aids repaired or replaced. On 6/5/25 at 4:16 PM Staff 2 (DNS) stated she expected staff to report broken or ill-fitting hearing aids to herself and social services and that social services would make efforts to get them repaired or replaced. Staff 2 stated she was unaware Resident 45's hearing aids did not fit and were broken.

Based on observation, interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening and Resident Review for individuals with a mental disorder and individuals with intellectual disability/developmental disability) was completed for 1 of 1 sampled resident (#30) reviewed for PASARR Level II. This placed residents at risk for not receiving specialized services. Findings include: Resident 30 was admitted to the facility in 12/2023 with diagnoses including schizoaffective disorder, bipolar type. A 6/24/24 PASARR Mental Health Evaluation was completed for Resident 30 which recommended a PASARR Level II be completed for a serious mental illness (SMI) and intellectual disability (ID)/Developmental Disability (DD). A 6/27/24 hospital discharge summary record indicated that Resident 30 had probable developmental delay. No evidence was found in Resident 30's medical record to indicate a PASARR Level II for ID/DD was completed. On 6/5/25 at 2:47 PM Staff 6 (Social Services Director) and Staff 5 (Social Services Coordinator) were present for an interview. Staff 6 stated she did not request a PASARR Level II for ID/DD for Resident 30. Staff 5 stated she did not know when to request a PASARR Level II for ID/DD. Both Staff 5 and Staff 6 stated they did not know when to request a PASARR Level II. On 6/5/25 at 3:51 PM Staff 1 (Administrator) stated he expected a PASARR Level II to be completed within 30 days if a PASARR Level I indicated the need for further evaluation. Staff 1 confirmed Resident 30 did not receive a PASARR Level II and needed one completed.

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of mental abuse for 1 of 2 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 admitted to the facility in 7/2024 with diagnoses including major depressive disorder and post-traumatic stress disorder. Resident 2's 2/16/25 Quarterly MDS indicated a BIMS score of 15 which indicated she/he was cognitively intact. On 6/2/25 at 12:10 PM Resident 2 stated she/he witnessed staff on several occasions mock and make fun of her delusions. Resident 2 stated she/he reported the incidents to someone in April, but nothing was done. Resident 2 stated the mocking and laughing took a mental toll on her/him, made her/him angry and made her/him not want to report the delusions anymore. On 6/5/25 at 12:52 PM Staff 6 (Social Services Director) and Staff 7 (Social Services Coordinator) stated Resident 2 reported the floor staff were making fun and laughing at her/him. Staff 6 stated Resident 2 did not want to file a grievance because she/he feared staff would retaliate against her/him. Staff 6 and Staff 7 stated a progress note was not made, and the concerns were not brought to facility administration to investigate. On 6/5/25 at 1:35 PM Staff 1 (Administrator) stated he was not aware of Resident 2's allegations. Staff 1 acknowledged all reports of abuse were to be investigated, even if a resident did not want to file a grievance.

Based on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 1 of 4 sampled residents (#15) reviewed for environment. This placed residents at risk for lessened quality of life. Findings include: Resident 15 admitted to the facility in 2024 with diagnoses including asthma and congestive heart failure. The 5/18/24 Care Plan indicated Resident 15 had asthma and interventions to minimize contact with known offending allergens. Staff were to assist in identifying asthma triggers and strategies for prevention. On 6/2/25 at 11:14 AM the wall behind Resident 15's bed was observed to have a large section of missing sheet rock scattered across the wall. A significant amount of sheet rock pieces and sheet rock dust was observed scattered across the base board ledge and on the floor. Resident 15 stated the debris was caused by the bed hitting the wall and it had not been fixed. On 6/4/25 at 8:46 AM Staff 11 (CNA) stated damage to Resident 15's wall was due to the bed sliding into the wall. Staff 11 stated the wall had been in disrepair for about eight months. On 6/5/25 at 10:33 AM Staff 12 (CNA) stated Resident 15's wall was damaged for as long as he worked in the facility, about five and half months. On 6/4/25 at 9:05 AM Staff 8 (Maintenance Director) stated he was the Maintenance Director for two weeks but assisted the previous Maintenance Director for several weeks prior. Staff 8 stated he noticed Resident 15's wall was in disrepair but was not yet repaired due to having other projects. On 6/5/25 at 10:38 AM Staff 1 (Administrator) acknowledged Resident 15's wall was in despair, was not repaired in a timely manner and should have been repaired.

Based on interview and record review it was determined the facility failed to ensure residents were informed of the risks and benefits of psychotropic medications for 1 of 5 sampled residents (#14) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 14 was admitted to the facility in 11/2024 with diagnoses including depression. Resident 14's 12/2024 Physician Orders indicated the resident was prescribed use of duloxetine and Wellbutrin (antidepressant medication) for depression. Resident 14's 5/2025 MAR revealed the resident received duloxetine and Wellbutrin daily. Review of Resident 14's medical record revealed no indication the resident was informed in advance of the risks and benefits of the duloxetine or Wellbutrin. On 6/6/25 at 9:58 AM, Staff 2 (Director of Nursing) acknowledged Resident 14 was not informed of the risks and benefits of the use of duloxetine or Wellbutrin.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#2) reviewed for diabetic medication management. This placed residents at risk for complications from diabetes. Findings include: Resident 2 was admitted to the facility in 1/2024 with diagnoses including diabetes, unspecified fracture of the right femur (largest leg bone) and dementia. No observations were made of Resident 2. Resident 2 was discharged . Resident 2's 1/17/24 Care Plan revealed the resident had impaired swallowing with risk for aspiration and was on a one to one assist with all meals. Resident 2's 1/19/24 MDS revealed the resident was moderately cognitively impaired. Resident 2's 1/29/24 physician orders revealed the resident was on two different insulin for her/his diabetes. The insulin order for Humalog (lispro) read: -Humalog 100unit/ml (lispro). Give 6 units SQ (subcutaneous, under the skin) with meals. -Humalog 100 unit/ml (lispro). Inject as per sliding scale (before meals and at bedtime): If capillary blood glucose (CBG) test indicated: CBG 0-150 =0 (no insulin needed) CBG 151-200=1 units CBG 201-250=2 units CBG 251-300=3 units CBG 301-350=4 units CBG 351-400= 5 units and call MD. Resident 2's February 2024 DAR indicated the following times the physician was not notified: On 2/6/24 at 6:30 AM CBG = 355 On 2/8/24 at 6:30 AM CBG = 355 On 2/11/24 at 4:30 PM CBG = 399 On 2/13/24 at 9:00 PM CBG = 390 On 2/14/24 at 4:30 PM CBG = 389 On 2/22/24 at 6:30 AM CBG = 379 On 2/22/24 at 4:30 PM CBG = 382 On 2/23/24 at 4:30 PM CBG = 550 On 2/29/24 at 6:30 AM CBG =361 On 1/16/24 at 10:31 AM, Staff 10 (LPN) reviewed Resident 2's February 2024 DAR and acknowledged she did not notify the resident's physician when the resident's blood sugar levels exceeded 351, as per the physician's orders. On 1/16/24 at 1:38 PM, Staff 3 (RNCM) reviewed Resident 2's February 2024 DAR, which revealed the resident's physician was not notified on nine occasions when the resident's blood sugar exceeded 351. Staff 3 acknowledged Resident 2's physician should have been notified and was unable to find records the physician was notified.

Based on interview and record review it was determined the facility failed properly orientate and sufficiently prepare a resident for a facility-initiated discharged for 1 of 3 sampled residents (#11) reviewed for safe discharge. This placed residents at risk for unsafe, facility-initiated discharges. Findings include: Resident 11 admitted to the facility in 9/2024 with diagnoses including depression, anxiety, alcohol abuse and cannabis dependence. A 11/5/24 Social Service Note stated a list of assisted living facilities was provided to Resident 11 via email and indicated the resident should follow up to inquire if a facility had a vacancy. A 11/7/24 Progress Note stated Resident 11 left the faciity on [DATE] and did not return until dinner time on 11/6/24; over 24 hours out of the facility. Resident 11 was discharged AMA (against medical advice). There was no documented evidence the facility provided Resident 11 sufficient preparation and orientation for her/his discharge. On 1/13/25 at 10:17 AM, Staff 3 (RNCM) stated since Resident 11 was out past midnight the facility discharged her/him AMA. On 1/13/25 at 11:01 AM, Staff 1 (Administrator) verified the discharge was facility initiated. Staff 1 stated he was unaware an AMA needed to be initiated by the resident. Staff 1 stated Resident 11 was discharged without her/his medications and her/his discharge was based on the resident's voluntary absence from the facility.

Based on observation, interview and record review it was determined the facility failed to provide palatable food for 4 of 5 sampled residents (#s 3, 9, 12 and 13) reviewed for dietary services. This placed residents at risk for unmet nutritional needs. Findings include: Resident 3 was admitted to the facility in 6/2023 with diagnoses including unspecified severe protein-calorie malnutrition and Vitamin D deficiency. Resident 9 was admitted to the facility in 11/2024 with diagnoses including malnutrition and hepatic encephalopathy (a loss of brain function when a damaged liver doesn't remove toxins from the blood). Resident 12 was admitted to the facility 5/2024 with diagnoses including hypertension and chronic kidney disease. Resident 13 was admitted to the facility 1/2025 with diagnoses including diabetes and Vitamin D deficiency. On 1/9/24 at 12:20 PM, a test tray was delivered to two members of the survey team. The lunch tray consisted of chicken fried steak, mashed potatoes with gravy and cooked spinach. The lunch meal was not palatable. The chicken fried steak was tough and dry. On 1/13/25 at 12:42 PM, an additional test tray was delivered to two members of the survey team. The lunch tray consisted of ham, cooked carrots and macaroni noodles. The lunch meal was not palatable. The food temperature was warm. The ham was salty and the noodles were bland. On 1/13/25 at 9:57 AM, Resident 3 stated the food was shitty.' On 1/13/25 at 10:03 AM, Resident 12 stated the meat was tough and not easy to chew, the food was spicy and she/he eats very little because of the taste. Resident 12 stated she/he did not fill out a grievance form but a family member was calling the corporate office today to complain about the food. On 1/13/25 at 10:05 AM, Resident 13 stated she/he didn't eat the carrots because they were overcooked and the pasta had no flavor and the ham was too salty. On 1/13/25 at 1:03 PM, Resident 9 stated she/he did not eat the lunch today and stated she/he never eats the food here because it was nasty. The 4/2/24, 5/14/24 and the 6/11/24 Food Committee Meeting Notes revealed the following residents complaints: -The seasoned potatoes sometimes too peppery; -Pork is typically tough; -Fries are cold, hard or soggy/rubbery; and -All the meat, all the time and every meat item is all overcooked. On 1/9/25 at 12:30 PM, Staff 1 (Administrator) sampled the test tray. Staff 1 stated the potatoes looked like instant potatoes, had a weird texture and thought the chicken could have been better. On 1/13/25 at 12:50 PM, Staff 2 (DNS) sampled the test tray. Staff 2 stated the noodles were bland and the food was not warm.

Based on interview, and record review it was determined the facility failed to provide the necessary care to prevent pressure ulcers, and accurately assess and provide timely treatment and repositioning to promote healing of pressure ulcers for 2 of 2 sampled residents (#s 2 and 46) reviewed for pressure ulcers. Resident 2 developed a preventable Stage 3 pressure ulcer. Findings include: CMS Appendix PP defined a Stage 3 pressure ulcer as: Full-thickness skin loss. Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead cells that accumulate in the wound) and/or eschar (a dry, dark scab or falling away of dead skin) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. 1. Resident 2 admitted to the facility in 2018 with diagnoses of multiple sclerosis and depression. A care plan dated 2/11/21 revealed Resident 2 was at high risk of impairment to skin integrity related to fragile skin, incontinence, decreased mobility, progressive multiple sclerosis, and chronic recurrent MASD (Mostiure Associated Skin Damage). Resident 2 was totally dependent on staff and was to be repositioned in bed every two hours. Staff were to keep the resident's skin clean and dry. Resident 2 had an alternating pressure relieving air mattress for pressure reduction. An 10/14/23 Skin Incident Report revealed Resident 2 had a history of multiple old wounds to her/his buttocks region, and the skin was fragile. Staff 34 (LPN) was called into the room and determined the resident's wound had some scant bleeding with two rounded mountain peak shapes that joined together in an oval pattern. The wound was approximately 4.0 cm x 1.5 cm, and the wound site exhibited full-thickness skin loss to the right gluteal area due to bowel incontinence, friction, and shearing. On 10/16/23 Staff 5 (RN MDS Coordinator) inspected the wound and the wound appeared to be full-thickness skin loss caused by bowel incontinence and friction. Resident 2 had fragile skin to the buttocks area, increased susceptibility for skin breakdown due to immobility in bed, constant bowel incontinence due to neurogenic bowel function secondary to multiple sclerosis, history of prior skin impairments and ongoing chronic issues. Resident 2 preferred to be positioned in a Semi [NAME] (head is an upright position 90 degrees high or 30-45 degree low to promote oxygenation via maximum chest expansion, and implemented during events of respiratory distress). The resident often slid down on the air mattress causing friction and shearing from the drawsheet to the skin. An 10/14/23 Skin and Wound Evaluation revealed Resident 2 had MASD to the right gluteal area which was facility acquired. The wound measured 3.6 cm x 1.6 cm, had slough, sanguineous/blood (thin liquid that oozes from wound), and edges were attached and appeared flush with the wound bed or as a sloping edge. The Evaluation noted Placed foam for protective dressing to site. Three days later an 10/17/23 Wound Clinic Note written by Staff 49 (Nurse Practitioner) revealed Resident 2 had a full-thickness ulcer to her/his right medial ischium (pelvic region) near the rectum. The area was exposed to frequent stools, friction, and shearing. The wound exhibited characteristics consistent with a Stage 3 pressure ulcer were often present. The resident and staff were educated on off-loading techniques to reduce shearing and friction. A physician order dated 10/17/23 directed staff to cleanse the open ulcer to the left gluteal cleft, pat dry and apply silver nitrate (an antibacterial topical for skin wound) two times a day for 14 days. Staff were to notify the provider of poor wound healing or progression. 10/2023 TARs revealed the order was not implemented until 10/20/23, three days after it was ordered, and on 10/27/23 wound treatment was not completed on evening shift. The last treatment was completed on 11/2/23. A new physician order was not implemented until 11/7/23, five days after the completion of the 10/17/23 physician order. A physician order start date of 11/21/23 and end date of 11/28/23 directed staff to clean the right medial gluteus with wound cleanser and pat dry, apply skin prep and allow to dry, apply calcium alginate (an antibacterial used to absorb any exudate (fluid that is secreted) in a wound) cut to size of the open wound base and cover with occlusive dressing (a transparent dressing), and skin prep edges down to promote seal. The order noted to change the dressing daily and PRN for soiling, saturation or accidental removal every day shift until resolved. 11/2023 TARs revealed no treatment was completed on 11/24/23 or 11/25/23. The Quarterly MDS dated [DATE] revealed Resident 2 was at risk for pressure ulcers and had MASD. A physician order start date of 11/29/23 and end date of 1/23/24 directed staff to clean the right medial ischium with wound cleanser and pat dry, apply skin thin dusting of stoma powder (absorbs moisture from broken skin) to the open wound and then apply zinc-based barrier cream two times a day and PRN after peri-care two times a day. 12/2023 TARs revealed no treatment was completed on 12/3/23 evening shift, 12/8/23 day shift and 12/15/23 day shift. On 2/5/24 at 9:39 AM and 2/12/24 at 12:16 PM Resident 2 stated she/he had a wound to her/his buttocks and staff did not always reposition her/him every two hours due to long call light wait times. Resident 2 stated I know my routine and staff were excessively late at times and she/he contacted her/his family to notify staff she/he needed to be repositioned. On 2/5/24 at 9:45 AM Staff 25 (LPN) stated Resident 2 had very fragile skin, an open sore to her/his buttock region and was to be repositioned every two hours. Staff 25 stated on evenings and weekends the resident was not always repositioned timely due to staff shortages and weekends were the worst. On 2/5/24 at 5:55 PM and 2/14/23 at 1:06 PM Staff 34 (LPN) stated she discovered the wound on 10/14/23 and there was a delay with an RN assessment because of the weekend. Staff 34 stated Resident 2 had some standard creams in place for her/his buttocks region and any new or additional wound orders were to be implemented and followed. Staff 34 stated Resident 2 was dependent on staff to be repositioned every two hours but at times the resident was not positioned for three or four hours and she often repositioned her/him on her own due to staff shortages. On 2/7/24 at 1:31 PM Staff 50 (CNA) stated Resident 2 was dependent on staff for repositioning and she/he had a touch pad placed by her/his left upper chest area because of her/his limited mobility. Staff 50 stated repositioning the resident every two hours was difficult due to staff shortages. Staff 50 stated the resident called her/his family due to long call light wait times. On 2/7/24 at 5:42 PM Staff 51 (CNA) stated Resident 2 was to be repositioned and her/his brief change every two hours, but this did not always happen, especially on evenings and weekends. Staff 51 stated Resident 2 had a touch pad alarm that needed to be near her/his upper chest and she witnessed the call pad out of her/his reach at times. On 2/9/24 at 1:41 PM Staff 5 (RN/MDS Coordinator) stated he evaluated Resident 2's wound on 10/16/23, but he was uncertain how to classify the wound and requested the wound clinic to come to the facility to assess the wound. Staff 5 acknowledged the 11/22/23 Quarterly MDS and the Skin and Wound Evaluations were inaccurate. On 2/12/24 at 9:17 AM Witness 5 (Complainant) stated Resident 2 acquired a wound on her/his buttocks in 10/2023 due to staff not repositioning her/him. Witness 5 stated she received calls from Resident 2 because her/his call light went unanswered for long periods of time. Witness 5 stated this was an ongoing concern. On 2/12/24 at 9:38 AM Staff 14 (CNA) stated Resident 2 was to be repositioned every two hours, but at times it was every three to four hours due to staff shortages resulting in long call light wait ties. Staff 14 stated family members called staff to complain because of the resident not being repositioned timely. On 2/12/24 at 9:55 AM Witness 6 (Family Member) stated in 10/2023 Resident 2's buttocks wound was due to facility staff not repositioning the resident timely. Witness 6 stated she received multiple calls from the resident regarding her/his call light being on for over an hour and it occurred a lot. Witness 6 stated this was discussed on multiple occasions, but nothing was done. On 2/13/24 at 11:00 AM Staff 2 (DNS) stated Resident 2's wound was correctly identified and should not have indicated MASD. Staff 2 stated facility staff were expected to implement and follow physician orders, and acknowledged the delay in assessment and missed treatments. Staff 2 stated staff were expected to follow the care plan and reposition Resident 2 every two hours and staff were expected to answer call lights within 10 to 15 minutes. On 1/16/24 at 12:03 PM Staff 49 (Nurse Practitioner Wound Clinic) stated she initially assessed Resident 2's Stage 3 pressure ulcer in 10/2023, the depth and presentation on her first assessment was not MASD because the wound had slough present. Staff 49 stated the resident had fragile skin, frequent stooling at times and the wound was close to the rectum area. Staff 49 stated Resident 2 expressed at times she/he had difficulty with call light response times on evening and night shifts and these concerns were brought to Staff 2. Refer to F725. 47000 2. Resident 46 admitted to the facility in 10/2023 with diagnoses including chronic kidney disease. Resident 46's 10/31/23 Admission MDS indicated the resident was moderately cognitively impaired, was at risk to develop pressure ulcers and did not have any pressure ulcers. Resident 46's 11/18/23 Braden Scale for Predicting Pressure Sore Risk revealed the resident was at risk for the development of pressure ulcers. Resident 46's 11/2023 Physician Orders revealed the resident was to receive a weekly skin audit, and any new skin issues were to be documented in the resident's clinical record. Resident 46's 11/2023 TAR revealed the weekly skin audit scheduled for 11/25/23 was not completed. A review of Resident 46's 11/2023 Bathing/Shower Task Form revealed the resident did not receive a shower from 11/19/23 through 11/27/23, additional opportunities during which the resident's skin was not assessed. A 11/27/23 Progress Note written at 1:52 PM revealed Resident 46 fractured her/his right femur and she/he was transferred to the hospital. A 11/28/23 Summary of Patient Status Note completed during Resident 46's hospitalization identified the resident had a Stage 2 pressure ulcer (open wound) to her/his sacrum that was present at the time of the resident's admission to the hospital on 11/27/23. A 11/28/23 Inpatient Skin Wound Care Consult identified the wound to Resident 46's sacrum as a Stage 3 pressure ulcer (an open wound that extends through the skin into deeper tissue and fat but does not reach muscle, tendon, or bone) that was present on her/his admission to the hospital. Resident 46 was readmitted to the facility on [DATE] with diagnoses including a Stage 3 pressure ulcer of the sacrum. Resident 46's 12/3/23 Nursing Admission Database Form indicated the resident had a pressure ulcer to her/his coccyx and wound care orders were in place. No additional details regarding the wound, including the length, width, depth, type of wound, shape, wound edges, wound bed description, presence of drainage, signs of infection, odor, condition of surrounding tissue and presence of pain were noted. Resident 46's Wound Evaluations completed on 12/5/23 and 12/12/23 by Staff 3 (RNCM) identified the wound to the resident's sacrum as Incontinence Associated Dermatitis. Resident 46's 12/12/23 Wound, Ostomy and Continence Progress Note completed by Staff 52 (Wound Nurse) indicate the resident had an unstageable pressure injury to her/his sacrum/coccyx. Resident 46's 12/19/23 Wound, Ostomy and Continence Progress Notes completed by Staff 53 (Wound Nurse) indicated the resident had an unstageable pressure injury to sacrococcygeal that continu[ed] to deteriorate. Resident 46's 12/26/23 Wound, Ostomy and Continence Progress Notes completed by Staff 53 indicated the resident had an unstageable pressure injury with full thickness tissue loss with slough. A review of Resident 46's 12/2023 MAR revealed the resident received wound care treatment according to physician orders for the pressure ulcer to her/his sacrum. Resident 46's 1/2/24 Wound Evaluation completed by Staff 3 identified the wound to the resident's sacrum as Incontinence Associated Dermatitis. This evaluation included information about the wound's dimensions and indicated the wound decreased in size. A 1/2/24 Wound, Ostomy and Continence Progress Note completed by Staff 53 indicated the wound to Resident 46's sacrum was at least a stage three, possibly stage four pressure injury, which would be determined once the wound was debrided (removal of dead, damaged or infected tissue). No changes were made to the resident's wound care plan at this time. A 1/9/24 Wound Evaluation completed by Staff 3 identified Resident 46's wound on her/his sacrum as a Stage 4 pressure ulcer. Resident 46's 1/11/23 Physician Orders directed the following related to the care of the resident's sacrum wound: -Gently cleanse/irrigate wound and undermining with normal saline or wound cleanser and pat dry; -Apply no-sting skin barrier to intact peri (surrounding) wound skin and allow to air dry; -Gently fill/cover wound with moistened gauze, cover with dry gauze and secure with tape; and -Change BID and PRN related to drainage, incontinence care or odor. A review of Resident 46's 1/2024 and 2/2024 TARs revealed no wound care was provided to the wound on the resident's sacrum on the following days: -1/12/24 at 6pm; -1/13/24 at 6am; -1/15/24 at 6am; -1/18/24 at 6pm; -1/19/24 at 6pm; -1/20/24 at 6pm; -1/24/24 at 6pm; -1/25/24 at 6pm; -1/26/24 at 6pm; and -2/3/24 at 6pm. On 2/8/24 at 9:21 AM Staff 33 (LPN) stated Resident 46 was to receive wound care to her/his sacrum twice daily and PRN. Staff 33 stated she thought the resident's missing wound treatments were related to the facility's use of agency nurses. On 2/9/24 at 12:20 PM Staff 3 stated she incorrectly identified Resident 46's wound on her/his sacrum as Incontinence Associated Dermatitis on the 12/5/23, 12/12/23 and 1/2/24 Wound Evaluations but stated the appropriate treatments for a Stage 3 pressure ulcer were in place. On 2/9/24 at 1:28 PM and 2/12/24 at 1:26 PM Staff 12 (Regional RN) acknowledged Resident 46 did not receive a shower or skin assessment from 11/19/23 through 11/27/23, the resident's wound was incorrectly identified on the 12/5/23, 12/12/23 and 1/2/24 Wound Evaluations completed by Staff 3 and the resident did not receive wound treatments as ordered in both 1/2024 and 2/2024. Staff 12 agreed the resident's wound on her/his sacrum was acquired at the facility prior to the resident's hospitalization on [DATE].

Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to implement and oversee appropriate plans of action to correct identified deficiencies related to: investigation of abuse, sufficient staffing, inaccurate daily staff postings, medication error rate and reference checks. This placed residents at risk for lack of quality of life and quality of care. Findings include: 1. A review of four residents for investigation of abuse revealed two were not thoroughly investigated. -This deficiency was also cited on the 1/13/23 recertification survey. 2. A review of 12 of 14 sampled residents (#s 2, 8, 10, 15, 19, 23, 26, 28, 33, 34, 42, 46, 157 and 259) and 3 of 3 halls reviewed for call light wait times and staffing revealed sufficient nursing staff was not provided to attain or maintain residents highest practicable level of well-being. -This deficiency was cited on the 1/13/23 recertification survey. 3. A review of the daily staff posting information revealed inaccurate daily staff postings. -This deficiency was also cited on the 1/13/23 recertification survey. 4. A review of reference checks revealed four out of five newly hired staff did not have reference checks completed. -This deficiency was also cited on the 1/13/23 recertification survey. 5. A review of medication administration revealed three errors in 26 opportunities; a 11.54% error rate. -This deficiency was also cited on the 1/13/23 recertification survey. On 2/13/24 at 1:29 PM Staff 1 (Administrator) stated they were aware of sufficient staffing and had been working on these areas. Staff 1 stated the facility was working on reducing agency staff and incentives for long term employees. Refer to F610, F725, F732 and F759

Based on interview and record review it was determined the facility failed to follow physician orders for 4 of 5 sampled resident (#s 26, 34, 52 and 259) reviewed medications. This placed residents at risk for side effects and of lack medication efficacy. Findings include: 1. Resident 34 was admitted to the facility in 7/2023 with diagnoses including chronic heart failure and strain of the right quadriceps muscle and tendon. The 1/4/24 Annual MDS revealed Resident 34 had a BIMS score of 15, which indicated the resident was cognitively intact. A physician's order dated 1/25/24 directed staff to administer hydroxyzine (an anti-anxiety) every four hours for anxiety. Administration times were 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. A review of the 1/2024 MAR and the Medication Audit Report revealed the following: -1/27/24 8:00 AM dose was given at 11:13 AM (over three hours late). -1/27/24 12:00 PM was marked as given in the MAR however the Medication Audit Report did not show the medication was administered on 1/27/24 at 12:00 PM. -1/28/24 8:00 AM dose was given at 9:15 AM (one hour and 15 minutes late). -1/28/24 4:00 PM was given at 5:13 PM (one hour and 13 minutes late). On 2/5/24 at 3:50 PM Resident 34 stated staff were either late with her/his anti-anxiety medications or she/he did not receive them at all. Resident 34 stated she/he reported her/his concern to staff. On 2/7/24 at 3:24 PM Staff 33 (LPN) stated she did not pass medications but Resident 34 voiced concerns she/he did not received her/his medication on the weekends from Staff 31 (CMA) and this was reported to Staff 2 (DNS). On 2/8/24 at 2:27 PM Staff 31 stated she worked evenings and weekends and struggled at times to keep up with passing medications timely. Staff 31 stated she had a two-hour window to pass medications before they were considered early or late, but still struggled with keeping within the timeframe. Staff 31 stated she worked on the 100 and 300 hall and both halls had residents with PRN pain medications which could be difficult to address timely. On 2/9/24 at 12:39 PM Staff 30 (CMA) stated she worked weekends and was able to administer medications timely, but indicated residents reported to her about not receiving medications timely on the weekend of 1/27/24. On 2/13/24 at 10:36 AM Staff 2 (DNS) indicated Staff 31 struggled with medication administration and it was an ongoing concern. Staff 2 stated staff were expected to be within the two-hour window before the medication was considered early or late and if Staff 31 struggled with passing medication timely and she should report her concerns to the charge nurse. 2. Resident 26 was admitted to the facility in 2/2018 with diagnoses including chronic kidney disease and chronic heart failure. a. The 1/13/24 Quarterly MDS revealed Resident 26 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. A physician's order dated 10/16/23 directed staff to administer 25 mg of trazodone (an antidepressant) by mouth at 9:00 PM at bedtime for insomnia. A physician's order dated 1/16/24 directed staff to ask the resident about her/his pain level and offer the PRN if indicated. The resident requested to be asked at 9:00 AM and 9:00 PM two times a day for a pain level assessment. A physician's order dated 2/3/24 directed staff to administer 2.5 mg of hydromorphone (an opioid pain medication) in the evening every Saturday and Sunday for pain not scheduled on weekdays Monday through Friday. A review of the 1/2024 MAR and the Medication Audit Report revealed the following: -1/28/24 Staff 31 (CMA) was to ask the resident about her/his pain level at 9:00 AM but did not ask the resident until 10:50 AM (one hour and 50 minutes late) and the resident did not receive any pain medication. -1/28/24 Staff 31 was to ask the resident at 9:00 PM about her/his pain level but did not ask the resident until 11:21 PM and trazodone was administered (two hours and 21 minutes late). A 1/29/24 Grievance Communication Form revealed Resident 26 complained about her/his medications not being administered timely or not receiving her/his pain medications over the weekend. This occurred on 1/28/23 when Staff 31 (CMA) passed medications. Staff 2 (DNS) interviewed Staff 31 and encouraged her to pass medications on time and to document medications received appropriately. On 2/9/24 at 12:39 PM Staff 31 (CMA) stated she worked weekends and was able to administer her medications timely, but indicated residents reported to her about not receiving medications timely on the weekend of 1/27/24. On 2/13/24 at 10:36 AM Staff 2 (DNS) indicated Staff 31 struggled with medication administration and it was an ongoing concern. Staff 2 stated staff were expected to be within the two hour window before the medication was considered late and if Staff 31 struggled with passing medication timely she should report to her charge nurse. b. A physician's order dated 10/16/23 directed staff to administer 25 mg of trazodone (an antidepressant) by mouth at 9:00 PM at bedtime for insomnia. A physician's order dated 2/3/24 directed staff to administer 2.5 mg of hydromorphone (an opioid pain medication) in the evening every Saturday and Sunday for pain not scheduled on weekdays Monday through Friday. A review of the 2/11/24 MAR indicated Staff 32 administered the hydromorphone at 7:38 PM and the trazodone at 8:26 PM. On 2/12/24 at 9:28 AM Resident 26 stated on Sunday 2/11/24 Staff 32 (LPN) came into her/his room at 5:00 PM and asked if she/he wanted to take her/his trazodone and hydromorphone and she/he stated, no I don't want to fall asleep this early. Resident 26 stated at around 10:00 PM she/he asked Staff 20 (LPN) because she/he was ready for her/his medications. Staff 20 entered her/his room and indicated she/he already received the medications, which she/he told Staff 20 that was not true. Resident 26 stated Staff 20 placed a call to Staff 32 about the trazodone and hydromorphone which was found in a cup on the medication cart. Resident 26 stated Staff 20 brought her/his medications around 11:30 PM way late and it was frustrating. On 2/12/24 at 12:57 PM Staff 32 stated he worked 2:00 PM to 10:00 PM on 2/11/24 and did not recall what time he asked Resident 26 when she/he wanted her/his trazadone and hydromorphone medications, but the resident refused to take the medication and he never followed back up with her/him. Staff 32 stated he put the medications, which were in a small cup, in the medication cart and forgot to pass the information onto the next staff person at 10:00 PM. Staff 32 stated Staff 20 administered the medications to Resident 26 later in the evening. On 2/12/24 at 3:32 PM Staff 20 stated he started his shift at 10:00 PM on 2/11/24 and Resident 26 reported she/he did not receive her/his trazadone or hydromorphone. Staff 20 stated when he reviewed the electronic medical record both medications were check marked green which indicated they were administered, and the record indicated they were administered by Staff 32. Staff 20 stated the resident was upset because Staff 32 attempted to administer the two medications at 5:00 PM. Staff 20 stated he called Staff 32 to find out where the medications were and found them locked in the medication cart. Staff 20 stated he did not administer the medications to Resident 26 but they were already marked as given. On 2/13/24 at 10:36 AM Staff 2 (DNS) stated he was not aware of the 2/11/24 incident regarding Resident 26's medications. Staff 2 stated staff were expected to ensure residents were available and wanted to take their medications prior to dispensing medications or completing the documentation in the electronic medication record medications were administered. Staff 2 stated staff were expected to implement and follow physician orders and communicate with oncoming staff regarding any concerns around medication administration. 47005 3. Resident 259 was admitted to the facility on ,d+[DATE] with diagnoses including lumbar radiculopathy (inflammation of a nerve root in the lower back). A 1/25/24 Admission MDS indicated Resident 259 had a BIMS score of 15, which indicated the resident was cognitively intact. A physician's order dated 1/31/24 revealed tizanidine (muscle spasm medication) was to be administered to Resident 259 every eight hours as needed for muscle spasms. On 2/7/24 at 3:04 PM Resident 259 stated on 2/5/24 before 6:00 AM she/he requested tizanidine from Staff 20 (LPN) who stated he could not find the tizanidine in the medication cart and to ask the next shift for the medication. Resident 259 stated she/he requested tizanidine from the Staff 42 (CMA) at the next shift after 6:00 AM. Staff 42 stated the MAR revealed Resident 259 received tizanidine at 5:57 AM and she/he had to wait for eight hours for the next dose. Resident 259 stated she/he did not receive the medication. On 2/8/24 at 12:04 PM Staff 42 stated when Resident 259 stated she/he did not receive the tizanidine, Staff 42 informed Staff 3 (RNCM), and Staff 3 gave her the approval to administer the tizanidine at 10:55 AM. On 2/9/24 at 1:58 PM Staff 12 (Regional RN) stated she expected the nurse to notify the physician and receive approval for early administration of the tizanidine medication and staff were expected document the incident. On 2/12/24 at 12:31 PM Staff 3 stated she attempted to call Staff 20 but the was unsuccessful. Staff 3 and Staff 42 counted Resident 259's PRN tizanidine and it appeared the medication was not given even though the medication was signed out in the MAR. Staff 3 stated she gave approval for the early administration of the tizanidine medication and the physician was notified. 4. Resident 52 was admitted to the facility in 1/2024 with diagnoses including right hip fracture and delirium. A physician's order dated 1/15/24 revealed staff were directed to administer mesalamine (medication used to treat and prevent inflammation in the lining of the intestines) delayed release daily in the morning for Lymphocytic Colitis (inflammation of the large intestine). On 2/8/24 at 12:04 PM Staff 42 (CMA) stated she crushed all of Resident 52's medications because of the resident's delirium. On 2/8/24 at 2:17 PM Staff 46 (CMA) stated she was assigned to administer Resident 52 her/his medication and initially administered the medication whole as ordered but was directed by a nurse to crush all the medications for Resident 52. On 2/9/24 at 10:22 AM Staff 30 (CMA) stated she crushed all of Resident 52's medications. The surveyor observed Staff 30 crush all of Resident 52's medications including mesalamine and place the contents in applesauce. On 2/9/24 at 10:33 AM Staff 25 (LPN) stated Resident 52's medication was crushed per a physician's standing order because Resident 52 was an aspiration risk. Staff 25 assumed the CMAs would not crush any delayed release medications and notify the nurse if the CMAs had any questions. On 2/9/24 at 2:02 PM Staff 12 (Regional RN) stated she expected CMA staff to seek clarification from a nurse regarding any crushed medications.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 19, 21, 22 and 23) reviewed for staffing. This placed residents at risk for lessened quality of care. Findings include: Performance reviews were requested on 2/12/24 for Staff 19 (CNA), Staff 21 (CNA), Staff 22 (CNA), and Staff 23 (CNA). Staff 1 (Administrator) was unable to produce the documentation. On 2/13/24 at 1:15 PM Staff 1 acknowledged Staff 19, Staff 21, Staff 22, and Staff 23 annual performance reviews were not completed.

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 12 of 14 sampled residents (#s 2, 8, 15, 19, 23, 26, 28, 33, 34, 42, 46, and 157) and 3 of 3 halls reviewed for call light wait times and staffing. This placed residents at risk for delayed care. Findings include: 1.On 2/5/24 the facility provided lists of residents who: -Required assistance with eating: 10 -Required two-person assistance with transfers: 9 -Required a mechanical lift for transfers: 22 -Required assistance with dressing: 45 -Required assistance with bathing: 39 -Required assistance with toileting: 33 -Residents who were incontinent: 33 -Had wandering behaviors: 1 -Had behavioral healthcare needs: 2 Interviews with residents revealed the following concerns: On 2/5/24 at 9:05 AM Resident 2 indicated call light response wait times were a concern and were ongoing as far back as 5/2023. Resident 2 stated she/he was dependent on staff and call light wait times were 30 minutes or greater. A review of call light wait times for Resident 2 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 365 opportunities for call light responses: * A total of 21 calls which reflected an 11 to 15 minute wait time. * A total of 15 calls which reflected a 16 to 25 minute wait time. * A total of 14 calls which reflected a 26 to 34 minute wait time. * A total of five calls which reflected a greater than 35 minute wait time. On 2/5/24 at 9:53 AM Resident 8 indicated the facility was short-staffed all the time and she/he did not always receive a shower. Resident 8 indicated call light wait times were long. A review of call light wait times for Resident 8 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 150 opportunities for call light responses: * A total of 13 calls which reflected an 11 to 15 minute wait time. * A total of 17 calls which reflected a 16 to 25 minute wait time. * A total of three calls which reflected a 26 to 34 minute wait time. * A total of two calls which reflected a greater than 35 minute wait time. On 2/5/24 at 9:54 AM Resident 28 indicated call light wait times were long and took forever to answer. A review of call light wait times for Resident 28 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 183 opportunities for call light responses: * A total of 16 calls which reflected an 11 to 15 minute wait time. * A total of 15 calls which reflected a 16 to 25 minute wait time. * A total of 15 calls which reflected a 26 to 34 minute wait time. * A total of nine calls which reflected a greater than 35 minute wait time. On 2/5/24 at 9:59 AM Witness 9 (Family member) stated Resident 46 was not always able to use her/his call light and the roommate called for assistance on Resident 46's behalf. Witness 9 stated Resident 46 sat in wet incontinence briefs and thought it was how Resident 46 sustained a wound on her/his back. A review of call light wait times for Resident 46 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 54 opportunities for call light responses: * A total of seven calls which reflected an 11 to 15 minute wait time. * A total of six calls which reflected a 16 to 25 minute wait time. * A total of three calls which reflected a 26 to 34 minute wait time. * A total of three calls which reflected a greater than 35 minute wait time. On 2/5/24 at 10:14 AM Resident 33 indicated she/he required assistance when getting into bed and call light response times were too long and cuased with her/him to experience pain. A review of call light wait times for Resident 33 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 106 opportunities for call light response times: * A total of 11 calls which reflected an 11 to 15 minute wait time. * A total of 12 calls which reflected a 16 to 25 minute wait time. * A total of three calls which reflected a 26 to 34 minute wait time. * A total of three calls which reflected a greater than 35 minute wait time. On 2/5/24 at 10:14 AM Resident 157 indicated call light wait times were 30 minutes or greater and weekends were the worst. Resident 157 stated on 2/4/24, Sunday, it took staff 3 hours to change her/him. A review of call light wait times for Resident 157 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 111 opportunities for call light response times: * A total of 16 calls which reflected an 11 to 15 minute wait time. * A total of 13 calls which reflected a 16 to 25 minute wait time. * A total of five calls which reflected a 26 to 34 minute wait time. * A total of one call which reflected a greater than 35 minute wait time. On 2/5/24 at 11:32 AM Resident 19 indicated the facility was always short-staffed. A review of call light wait times for Resident 19 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 121 opportunities for call light responses: * A total of 16 calls which reflected an 11 to 15 minute wait time. * A total of 13 calls which reflected a 16 to 25 minute wait time. * A total of five calls which reflected a 26 to 34 minute wait time. * A total of seven calls which reflected a greater than 35 minute wait time. On 2/5/24 at 11:33 AM Resident 26 indicated call light wait times on evening shift were 45 minutes and weekends were terrible. Resident 26 indicated she/he sat in a soaked incontinent brief and bed on more than one occasion. Resident 26 further stated her/his pain medications were often late. On 2/5/24 at 12:22 PM Resident 42 indicated the facility was constantly short-staffed and she/he waited at least an hour for help on night shift and on weekends on more than one occasion. A review of call light wait times for Resident 42 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 145 opportunities for call light responses: * A total of 13 calls which reflected an 11 to 15 minute wait time. * A total of 14 calls which reflected a 16 to 25 minute wait time. * A total of eight calls which reflected a 26 to 34 minute wait time. * A total of two calls which reflected a greater than 35 minute wait time. On 2/5/24 at 3:30 PM Resident 15 indicated the facility was short-staffed mainly on evening shift and weekends. Resident 15 indicated she/he waited at least an hour for staff to assist her/him or to receive medications. A review of call light wait times for Resident 15 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 70 opportunities for call light responses: * A total of 10 calls which reflected an 11 to 15 minute wait time. * A total of three calls which reflected a 16 to 25 minute wait time. * A total of two calls which reflected a 26 to 34 minute wait time. * A total of two calls which reflected a greater than 35 minute wait time. On 2/5/24 at 4:24 PM Resident 34 indicated the facility was short-staffed constantly on the weekends. Resident 34 stated she/he sat in wet and soiled incontinent briefs on more than one occasion. A review of call light wait times for Resident 34 from 1/15/24 through 2/7/24 (23 days) revealed the following: * 406 opportunities for call light responses: * A total of 53 calls which reflected an 11 to 15 minute wait time. * A total of 22 calls which reflected a 16 to 25 minute wait time. * A total of 16 calls which reflected a 26 to 34 minute wait time. * A total of 10 calls which reflected a greater than 35 minute wait time. Interviews with staff revealed the following concerns: On 2/7/24 at 9:52 AM Staff 24 (CNA) stated the facility faced staff shortages since 5/2023. Staff 24 stated call lights were supposed to be answered with in five to 15 minutes and when she worked day shift, she found many residents with soaked incontinent briefs and their bedding from the night shift. Staff 24 stated several residents complained about the lack of staff and discomfort of being in wet incontinent briefs and soaked bedding. Staff 24 stated the facility had high acuity residents who required two-person assistance for transfers and ADL care, which made it hard to provide ADL care timely. On 2/7/24 at 3:55 PM Staff 33 (LPN) stated the facility faced staff shortages since 5/2023. Staff 33 stated call lights were supposed to be answered within five to 15 minutes. Staff 33 stated that it was sometimes hard to give residents their medications on time and residents often had to sit in wet and soiled incontinent briefs because of the lack of staff. On 2/7/24 at 5:55 PM Staff 34 (LPN) stated the facility experienced staff shortages since 5/2023, particularly CNAs. Staff 34 stated during the Summer months there were instances when she was the sole nurse in the entire building on weekends. Staff 34 stated call lights remained unanswered for extended periods, and residents frequently complained about being in soiled and wet incontinent briefs. The call light response times ranged from 30 minutes to an hour, primarily due to the combination of staffing shortages and the presence of high-acuity residents within the facility. On 2/5/24 at 9:45 AM Staff 26 (LPN) reported the facility was consistently understaffed on all shifts, with weekends being the most challenging. Staff 26 stated the expectation was to answer call lights within five minutes, but this was not feasible due to the staffing situation. Staff 26 stated residents frequently complained about prolonged periods of sitting in wet and soiled incontinent briefs because of the staff shortage. Staff 26 further stated on 2/7/24 multiple residents were found to be soaked and were not provided incontinent care again due to the ongoing staffing shortages. On 2/8/24 at 12:04 PM Staff 37 (Former/CNA) stated the facility frequently experienced short staffing during evening and night shifts. Staff 37 indicated it was a challenge of splitting halls (100 and 200), which made it difficult to observe and respond to call lights. Staff 37 indicated residents expressed dissatisfaction due to lengthy call light wait times and remaining in wet and soiled incontinent briefs for extended periods of time, particularly during evening and night shift. Staff 37 stated this was reported multiple times to management, but, unfortunately, no action was taken. Staff 37 further indicated call light response times often exceeded 30 minutes due to staff shortages. On 2/12/24 at 9:38 AM Staff 14 (CNA) stated the facility frequently faced short staffing during evening, night and weekend shifts. Staff 14 stated call lights were active for extended periods, and residents often sat in wet and soiled incontinent briefs for more than 30 minutes. Staff 14 stated on 2/11/24 the facility was short-staffed, resulting in the resident in room [ROOM NUMBER] screaming because they were soaked. Staff 14 indicated one of the residents in room [ROOM NUMBER] had a bowel movement, leading to her/his buttocks being sore and red. Staff 14 further indicated in room [ROOM NUMBER], another resident had a bowel movement and sat in her/his bowel movement for an extended period because it was dry and crusted to her/his buttocks and legs by the time she/he received incontinent care. Staff 14 further stated the facility consistently struggled with staff shortages on weekends and encountered challenges on evening shift. On 2/12/24 at 11:17 AM Staff 25 (LPN) stated the facility experienced staff shortages for some time and she was responsible for over 30 residents, depending on the census. Staff 25 stated it was challenging to prioritize her workload and was unable to consistently complete wound or skin treatments. Staff 25 stated insufficient staff in the building made it difficult to address the acuity needs of the resident, and the facility had multiple residents who required mechanical lifts but there were only two available, which was insufficient to assist all residents timely. Staff 25 stated call light response times often exceeded 20 minutes, depending on the severity of staff shortages. On 2/13/24 at 1:15 PM Staff 1 (Administrator) stated the staff schedule was tailored to the facility's census and acuity of residents in the building. Staff 1 stated he expected all staff to respond to call lights within the following timeframes: - Day shift: within five minutes. - Evening shift within 10 to 15 minutes. - Night shift within 15 to 20 minutes. Staff 1 stated the facility strived to meet the minimum state required staffing levels and considered acuity when creating the staff schedule. 2. Resident 23 admitted to the facility on ,d+[DATE] with diagnoses including inflammatory left knee prosthesis and obesity. A FRI dated 12/16/23 revealed Resident 23 was left on her/his bedside commode on 12/5/23 by Staff 37 (Former/CNA) unattended for roughly an hour without her/his call light. Resident 23 called a family member who alerted the facility. Staff 43 (LPN) assisted Resident 23 off the bedside commode, assessed the resident and no injuries or psychosocial harm occurred from the incident. Staff 2 (DNS) determined Staff 37 did not ensure Resident 23 had her/his call light within reach and did not check in with the resident timely. Staff 37 was terminated on 12/6/23. On 2/6/24 at 9:13 AM Resident 23 recalled the incident on 12/5/23 and stated Staff 37 left her/him on the bedside commode for greater than 20 minutes without her/his call light and ignored her/his request to stay in the room. Resident 37 stated she/he called a family member, who notified the facility, and another staff person helped her/him off the bedside commode. Resident 23 stated she/he had no injuries, it was a one-time incident, and Staff 37 never worked with her/him again. On 2/8/24 at 11:24 AM Staff 43 (LPN) stated she remembered the 12/5/23 incident involving Resident 37. Staff 43 stated she helped the resident off the bedside commode after a family member called the nurses' station. Staff 43 stated the resident did not have her/his call light in reach and was stuck on the commode. Staff 43 stated Resident 23 did not have any injuries from the incident but was upset. Staff 43 further stated Staff 37 no longer worked for the facility. On 2/8/24 at 12:04 PM Staff 37 stated she recalled the incident on 12/5/23 and it was not intentional. Staff 37 stated she had two halls (100 and 200) to cover and forgot about Resident 23 being on the bedside commode. Staff 37 stated another staff member helped the resident off the bedside commode which was greater than 20 minutes. Staff 37 stated she apologized to Resident 23 but was let go after the incident. On 2/13/24 at 11:23 AM Staff 2 indicated he completed the FRI and determined Resident 23 was left on the bedside commode for greater than 45 minutes. Staff 2 indicated Staff 37 did not ensure the resident had her/his call light prior to leaving the room and lost track of time. Staff 2 indicated Staff 37 no longer worked for the facility.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 21, 22, and 23) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: - Staff 21 (CNA) received 6.5 hours of annual training. - Staff 22 (CNA) received 7.0 hours of annual training. - Staff 23 (CNA) received 3.0 hours of annual training. On 2/13/24 at 1:15 PM Staff 1 (Administrator) confirmed Staff 21, Staff 22 and Staff 23 lacked the required 12 hours of in-service training.

Based on observation, interview, and record review it was determined the facility failed to ensure the Direct Care Daily Staff Reports (DCSDR) were accurate for 79 of 188 days reviewed for staffing. This placed residents and the public at risk for lack of knowledge of accurate staffing. Finding include: A review of the DCSDR from 7/1/23 through 7/31/23, 8/1/23 through 8/31/23, 9/1/23 through 9/30/23, 10/1/23 through 10/31/23, 11/1/23 through 11/30/23 and 1/1/24 through 2/4/24 revealed 79 instances where the actual number of RNs working was not recorded accurately. On 2/9/24 at 2:02 PM Staff 38 (Staffing Coordinator) and Staff 39 (Business Office Manager and Human Resources) indicated they did not realize they were to include all RNs on the DCSDR. On 2/13/24 at 1:15 PM Staff 1 (Administrator) confirmed the DCSDR did not reflect the actual count of RNs working and those available to staff.

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#33) reviewed for self-administration of medications. This placed residents at risk for adverse side effects. Findings include: Resident 33 was admitted to the facility in 2023 with diagnoses including respiratory failure. On 2/7/24 at 12:35 PM Resident 33 was observed to have a bottle of lidocaine (anesthetic) lotion on her/his bedside table. Resident 33 stated she/he applied the lotion to her/his rashes to help reduce her/his pain. A review of Resident 33's medical record did not reveal a self-administration of medication assessment was completed. On 2/8/24 at 12:38 PM Staff 4 (LPN-RCM) acknowledged Resident 33 had lidocaine lotion in her/his room and a self-administration of medications assessment was not completed for the resident.

1. Based on interview and record review it was determined the facility failed to follow physician's orders for a timely post-operative follow-up appointment for 1 of 1 sampled residents (#98) reviewed for quality of care. This delay resulted in Resident 98 being sent from the physician's clinic, directly to the hospital for surgery. Findings include: Resident 98 was admitted to the facility in 11/22/22 with diagnoses including amputation and diabetes. Resident 98's hospital Skilled/Intermediate Nursing Facility Transfer Orders dated 11/22/22 included: - Operations/Major Procedures: right partial first ray (toe) amputation. - No changes to the right foot dressing until podiatry follow-up. - Schedule an appointment as soon as possible for a visit in one week. Please make the appointment with [the resident's surgeon] at [a specific office location]. A Transportation Request Checklist dated 11/23/22 indicated Resident 98 had a podiatry appointment scheduled for 12/7/22 [with a different provider and location than what was ordered]. A Progress Note dated 12/7/22 at 10:07 AM indicated Resident 98 stated her/his follow-up appointment was supposed to be with a specific physician and at a specific clinic location. [The resident's appointment was made for her/him at a different clinic location and different provider.] A Progress Note dated 12/7/22 at 1:53 PM indicated Resident 98 had a follow-up appointment for her/his right foot. Witness 3 returned to the facility without the resident because the resident was readmitted to the hospital for further surgery. Resident 98's Hospital Emergency Department Encounter Note dated 12/7/22 revealed: - The most recent vascular study indicated the affected area had adequate arterial flow. - Photos of the surgical site showed blackened tissue to the right great toe amputation site. Resident 98's Hospitalist History and Physical dated 12/7/22 revealed: - On 11/19/22 the resident had a right great toe amputation. - On 12/7/22 the resident was at an out-patient follow-up visit with her/his podiatrist and was found to have gangrene (Dead tissue with symptoms including discolored skin, severe pain, numbness and foul discharge. Urgent care is required, including removal of the dead tissue and antibiotics.) [to the surgical site] and was sent to the hospital for further surgical care (The hospital notes did not indicate the specific surgical intervention provided). On 1/9/23 at 9:14 AM Resident 98 stated the facility made her post-surgical follow-up appointment late and the appointment was not with her provider or at the correct clinic location. The resident stated she/he lost a week of time because the appointment was late and her surgical wound had gangrene. Resident 98 stated there was no pain because the foot was dead. On 1/12/23 at 12:10 PM Witness 3 (Family) stated when Resident 98 went to her/his follow-up appointment the resident's incision area was black, and red around it with flaky skin. The physician said the resident needed to go to the hospital emergency department. Witness 3 stated the physician at the hospital stated the resident's foot would need to be amputated. On 1/12/23 at 10:09 AM Staff 2 (DNS) verified Resident 98's surgical follow-up appointment was made for 12/7/22 (eight days later than ordered by the surgeon) and the appointment was made at a different location, with a different provider than ordered. On 1/12/23 at 10:32 AM Staff 6 (RNCM) stated she and Staff 33 (Receptionist) made numerous attempts to schedule Resident 98's follow-up appointment and were told by the clinic an appointment time was not available with the ordered provider or at the ordered clinic location. On 1/12/23 at 10:44 AM Staff 33 was asked why Resident 98's follow up appointment was not made until 12/7/22 and if she had any documentation regarding her attempts to make an appointment. Staff 33 stated Staff 6 told her she had up to two weeks after the week the resident was admitted to the facility to get a follow-up appointment scheduled. The only documentation Staff 33 had was the Transportation Request Checklist dated 11/23/22. On 1/12/23 at 10:59 AM Staff 6 was asked if she told Staff 33 she had two weeks after the week Resident 98 admitted to the facility to make the follow-up appointment. Staff 6 refused to answer the question. 2. Based on interview and record review it was determined the facility failed to provide ordered bowel care and ensure a resident did not receive another resident's medications for 2 of 6 sampled residents (#s 15 and 45) reviewed for medications. This placed residents at risk for constipation and adverse side effects. Findings include: a. The facility's Bowel Care Protocol dated 10/2020 indicated if a resident had not had a bowel movement for three consecutive days an escalating bowel care medication regime would be started until the resident had a bowel movement. If the resident did not have a bowel movement then the resident would be assessed and the physician notified. Resident 15 was readmitted to the facility in 2020 with diagnoses including dementia and kidney disease. Resident 15's 12/2022 bowel record revealed the resident did not have a bowel movement for four days from 12/15/22 through 12/18/22 and 12/26/22 through 12/29/22. Resident 15's 12/2022 MAR revealed the resident had the following PRN bowel care medications available but none were administered in 12/2022: - bisacodyl suppository - bisacodyl tablet - fleet enema - Miralax On 1/11/22 at 11:20 AM Staff 30 (RN) stated every morning a bowel care report was ran to identify residents who did not have a bowel movement in 72 hours and those residents were administered bowel care medication. On 1/11/22 at 12:21 PM Staff 3 (Corporate Nurse Consultant) verified the resident went four days without a bowel movement twice in 12/2022 and the resident was not administered bowel care medication. 40767 b. Resident 45 admitted to the facility in 12/2022 with diagnoses including a stroke and aphasia (communication disorder). The 12/20/22 Admission MDS indicated the resident was cognitively intact but had moderate difficulty hearing. On 1/8/23 at 12:48 PM Resident 45 stated she/he previously received her/his roommates medications but was unwilling to answer further questions. A 1/6/23 Nursing Care Note indicated Resident 45 received her/his roommate's (Resident 46) AM medications. The note indicated Resident 45 did not have a picture attached to her/his electronic profile and when asked if Resident 45's name was her/his roommates name, Resident 45 agreed. The physician was notified and Resident 45 was monitored for adverse side effects. A 1/6/23 Physician's Progress Note indicated the physician was called to report Resident 45 had a medication error when she/he was given another patient's medications. The physician called three times and was unable to reach a nurse, so a message was left for Staff 2 (DNS). A 1/6/23 Medication Error investigation indicated Resident 45 received her/his roommate's medication. The investigation did not include which medications Resident 45 received. The investigation indicated the resident was monitored for adverse side effects. On 1/12/23 at 1:11 PM Staff 2 (DNS) acknowledged the medication error for Resident 45. Staff 2 stated the expectation for medication administration was for staff to ensure medications were administered to the right patient, and residents were given the right type and route. Staff 2 and Staff 3 (Corporate Nurse Consultant) stated Resident 45 received atorvastatin calcium (cholesterol medication) 40 mg and losartan K+ (hypertension blood pressure medication) 25 mg. Staff 2 stated Resident 45 did not experience any adverse side effects from receiving her/his roommate's medications.

Based on interview and record review it was determined the facility failed to ensure a thorough investigation was completed related to an allegation of physical abuse for 1 of 1 sampled resident (#25) reviewed for abuse. This resulted in Resident 25 experiencing increased agitation post event and placed residents at risk for continued abuse. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease and major depressive disorder. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and staff interviews indicated the resident experienced memory deficits. An 11/1/22 Abuse Investigation indicated Staff 6 (RNCM) was informed that morning by Staff 28 (CNA) that on 10/31/22 he was assisting Resident 25 to bed with the help of Staff 27 (Former CNA). Staff 28 reported Staff 27 became upset with Resident 25 after the resident called her a derogatory word and swatted [the resident] with the back of her hand. After the resident was assisted into bed Staff 27 then put the covers over Resident 25's face for a few minutes. Staff 27 was suspended pending the investigation and the police were notified. Staff 28 reported the incident to the board of nursing on the evening of 10/31/22. There were no injuries observed to Resident 25 and the resident was unable to state any details due to the resident's diagnosis of dementia. Resident 8 (Resident' 25's roommate and spouse) was not in the room at the time of the alleged incident but stated Resident 25 and Staff 27 had good moments and bad moments. Resident 8 reported Staff 27 would state things to Resident 25 such as Are you going to fight me tonight? and felt the statement was putting the idea into [Resident 25's] head. Resident 8 stated Resident 25 had previously struck Staff 27 related to the way Staff 27 approached Resident 25. Staff 27 denied hitting Resident 25 and stated the Resident used the derogatory word towards her all the time and she joked with the resident. Staff 27 further stated she pulled Resident 25's top sheet up and it went over the resident's face briefly but she did not put it over the resident's face intentionally. Two other residents (Resident 4 and a resident who discharged in 11/2022) were interviewed and denied witnessing or experiencing abuse or neglect. The investigation summary indicated the allegation of abuse was not substantiated and Staff 27 was unsuspended from working at the facility as per other staff and residents Staff 27 had not been physically, verbally or otherwise abusive, aggressive or neglectful. The investigation did not include staff statements (besides Staff 27 and Staff 28) or additional resident interviews. Resident 25 was not placed on alert charting to monitor potential physical or psychosocial effects related to the allegation of abuse. Utilizing the reasonable person concept, it was reasonable to assume Resident 25's diagnoses of Alzheimer's disease and major depressive disorder, Resident 25 would have suffered from agitation and depression from Staff 27's verbal and physical abuse. The facility failed to provide supervision and monitor to ensure Resident 25 did not suffer any physical or psychosocial harm post 10/31/22 alleged physical abuse incident. On 1/11/23 at 11:06 AM Staff 2 (DNS) confirmed the investigation for alleged physical abuse was not thorough. Refer to F600.

Based on interview and record review it was determined the facility failed to protect the residents right to be free from physical abuse by staff for 1 of 1 sampled resident (#25) reviewed for abuse. This resulted in Resident 25 experiencing increased agitation post event. This placed residents at risk for physical and psychosocial harm. Findings include: Resident 25 admitted to the facility in 2018 with diagnoses including Alzheimer's disease and major depressive disorder. The 11/30/22 Quarterly MDS indicated Resident 25 was rarely/never understood and staff interviews indicated the resident experienced memory deficits. An 11/1/22 Abuse Investigation indicated Staff 6 (RNCM) was informed that morning by Staff 28 (CNA) that on 10/31/22 he assisted Resident 25 to bed with the help of Staff 27 (Former CNA). Staff 28 reported Staff 27 became upset with Resident 25 after the resident called her a derogatory word and swatted [the resident] with the back of her hand. After the resident was assisted into bed Staff 27 put the covers over Resident 25's face for a few minutes. Staff 27 was suspended pending the investigation and the police were notified. Staff 28 reported the incident to the board of nursing on the evening of 10/31/22. There were no injuries observed to Resident 25 and the resident was unable to state any details due to the resident's diagnosis of dementia. Resident 8 (Resident 25's roommate) was not in the room at the time of the alleged incident but stated Resident 25 and Staff 27 had good moments and bad moments. Resident 8 reported Staff 27 would state things to Resident 25 such as are you going to fight me tonight? and felt the statement was putting the idea into [Resident 25's] head. Resident 8 stated Resident 25 had previously struck Staff 27 related to the way Staff 27 approached Resident 25. Staff 27 denied hitting Resident 25 and stated the resident used the derogatory word towards her all the time and she joked with the resident. Staff 27 further stated she pulled Resident 25's top sheet up and it went over the resident's face briefly but she did not put it over the resident's face intentionally. Two other residents (Resident 4 and a resident who discharged in 11/2022) were interviewed and denied witnessing or experiencing abuse or neglect. The investigation summary indicated the allegation of abuse was not substantiated and Staff 27 was unsuspended from working at the facility as per other staff and residents Staff 27 had not been physically, verbally or otherwise abusive, aggressive or neglectful. There was no evidence found in the electronic medical record Resident 25 was placed on alert charting after the alleged incident on 10/31/22 to monitor for physical or psychosocial harm/changes. On 1/8/23 at 11:55 AM Resident 25 was unable to be interviewed. Resident 8 stated she/he was Resident 25's spouse and responsible party. Resident 8 stated she/he was informed of the alleged incident by Staff 28 on 11/1/22. Resident 8 stated when Staff 27 assisted with incontinence care Resident 25 she/he felt Staff 27 was rough but was unsure if it was intentional. Resident 8 reported when Staff 27 came in the room she would ask Resident 25 questions such as, are you going to hit me tonight? Resident 8 stated Staff 27 was antagonizing [Resident 25] and the resident had dementia. Resident 8 stated Staff 27 was very loud, and Resident 25 did not like loud noises, so Resident 25 would cuss at Staff 27. Resident 8 stated when she/he told Staff 27 to not be so loud Staff 27 would get mad at her/him. Resident 8 stated after the alleged incident Resident 25 was not worse off .but agitated. Resident 8 stated she/he asked Staff 2 (DNS) why Staff 27 still worked at the facility and was told Staff 28 retracted his statement related to the allegation. Resident 8 further stated there were times when Resident 25 and Staff 27 screamed at each other off and on when Staff 27 provided ADL care. Resident 8 stated Staff 27 had not worked with her/him or Resident 25 since the alleged incident. On 1/10/23 at 10:07 AM Staff 27 (Former CNA) stated she stopped working at the facility on 12/22/22 after finding another job. Staff 27 stated she assisted Staff 28 on 10/31/22 with Resident 25 and provided incontinence care because Resident 25 fights. Staff 27 stated Resident 25 called her a derogatory word, but it did not bother her as the resident had dementia and often called her names. Staff 27 denied she hit or slapped Resident 25 even jokingly. Staff 27 denied pulling a blanket or sheet over Resident 25's head. On 1/10/23 at 10:43 AM Staff 28 (CNA) stated on 10/31/22 Resident 25 called Staff 27 a derogatory name during ADL care due to her/his dementia. Staff 28 stated Staff 27 proceeded to slap Resident 25 with an open palm on the right cheek, hard enough to leave a mark, but did not leave a lasting mark that he was aware of. Staff 27 then pulled the bedsheet up over Resident 25's head for a second or so, and made it seem, like she was joking but Staff 28 did not take it that way. Staff 28 stated after ADL cares he immediately reported the incident to an agency nurse. Staff 28 stated immediately after the incident Resident 25 was more agitated and yelled out more. Staff 28 stated he previously witnessed Staff 27 raise her voice to other residents but was unable to recall specific residents. Lastly, Staff 28 stated he did not retract his witness statement from the alleged incident on 10/31/22. On 1/10/23 at 2:04 PM during a Resident Council interview, Resident 24 mentioned concerns about witnessing a staff member slap Resident 25. Resident 24 stated she/he was going to report the incident at the time, but the facility already looked into the concern. On 1/10/23 at 2:35 PM during a follow-up interview with Resident 24, the resident stated she/he was walking down Resident 25's hall and witnessed a CNA slap Resident 25 a few months ago. When asked, Resident 24 confirmed the CNA was Staff 27. Resident 24 stated she/he heard Resident 25 call Staff 27 a derogatory word and Staff 27 became irate, screamed you have no right to call me that! and Staff 27 slapped Resident 25 hard enough for the resident to say ouch. Resident 24 could not recall if another staff member was present but believed Resident 8 was in the room with Resident 25 and Staff 27. Resident 24 stated during personal interactions, Staff 27 was short with her/him, loud and abrasive, and the same issues were reported by others in Resident Council. Resident 24 further stated Staff 27 thought she [was] funny but does not come off that way. Lastly, Resident 24 stated no one at the facility interviewed her/him regarding the incident between Staff 27 and Resident 25. On 1/11/23 09:14 AM Resident 4 stated she/he had no concerns of abuse but did not leave her/his room or mingle with other residents so had not seen or heard anything. The following interviews were conducted with additional staff from 1/8/23 through 1/13/23 and indicated: *1/8/23 at 1:27 PM Staff 11 (CNA) stated Staff 27 had no bedside manners and returns the same attitude a resident gives her. Staff 11 stated she witnessed Staff 27 being rough with Resident 1 month ago. Staff 11 stated Resident 1 told Staff 27 to get away when Staff 27 tried to wipe the resident's face, so Staff 27 held Resident 1's hands down and wiped the resident's face. Resident 1 denied any abuse concerns. *1/11/23 at 12:59 PM Staff 17 (CNA) stated Staff 27 could be loud, obnoxious, and blunt but never saw Staff 27 mistreat a resident. Staff 17 stated she had heard from other staff that Staff 27 was rude to Resident 25 but was unable to provide further information. *1/13/23 at 10:16 AM Staff 19 (CNA) stated Staff 27 had a bedside manner that was cold, dry and Staff 27's attitude was apparent. Staff 19 stated for example a resident would request incontinence care again after assisted with incontinence care 30 minutes earlier and Staff 27 would have an attitude of annoyance. Staff 19 stated Staff 27 was loud and loud voices agitated Resident 25. Staff 19 stated she never witnessed Staff 27 be physical towards other residents, but other residents complained to her about Staff 27. Staff 27 was unable to provide specific resident names or examples. Staff 19 stated she worked with Resident 25 after the incident and the resident had severe dementia so she was not sure if the resident would remember anything that happened. *1/13/23 at 10:41 AM Staff 18 (CNA) stated residents reported to her that Staff 27 was rude, forceful, and would tell residents, this is the way things are going to be. Staff 18 stated she never witnessed any incidents between Staff 27 and residents. Staff 18 stated she heard about the 10/31/22 incident between Staff 27 and Resident 25 from Staff 28 himself and that Staff 28 told her Staff 27 slapped the resident after the resident called Staff 27 a derogatory name. Staff 18 further stated she and Staff 28 were informed by Resident 8 that Staff 28 changed his story and was why Staff 27 worked in the building after the 10/31/22 incident, but Staff 28 denied changing his story of the alleged event. Utilizing the reasonable person concept, it was reasonable to assume based on Resident 25's diagnoses of Alzheimer's disease and major depressive disorder, Resident 25 would have suffered from agitation and depression from Staff 27's verbal and physical abuse. The facility failed to provide supervision and monitor to ensure Resident 25 did not suffer any physical or psychosocial harm post the 10/31/22 abuse incident. On 1/11/23 11:06 AM and 1/12/23 01:22 PM Staff 2 (DNS) stated based on the facility investigation abuse was unable to be substantiated. Staff 2 stated administrative staff were aware Resident 25 called Staff 27 derogatory names but Staff 27 liked working with Resident 25 and the resident and Staff 27 would banter back and forth. Staff 2 confirmed Resident 24 was not interviewed and stated she interviewed multiple staff and residents, but the statements were not written down. Staff 2 confirmed a staff member slapping a resident met the definition for physical abuse. Refer to F610.

a. Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 5 residents (# 2) identified at risk for aspiration and who was to be supervised while eating. Resident 2 was observed to be left unattended with her/his meal tray two times during continuous observations. Resident 2 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed Resident 2 at risk for aspiration and death. Findings include: Resident 2 was admitted to the facility in 2018 with [DIAGNOSES REDACTED]. Resident 2's 1/18/21 physician order [REDACTED]. The 1/26/21 physician note indicated Resident 2 was severely demented and was unable to perform ADLs due to dementia. The 1/30/21 MDS indicated Resident 2 had a BIMS of 10 (indicating moderate cognitive impairment). On 2/3/21 Resident 2 was observed to have a pink sign above the bed indicating the resident was on aspiration precautions and required 1:1 supervision with meals, was on a soft and bite size diet, alternate liquids and solids, small bites and sips, and to remain upright 30 minutes after meals. On 2/3/21 the following was observed during continuous observations: *8:08 AM Staff 17 (CNA) was observed to set Resident 2's meal tray on the table in front of the resident. Staff 17 explained what the resident had for breakfast and Resident 2 stated she/he did not like it. Staff 17 then asked Resident 2 if she/he wanted a bite of food. *8:10 AM Staff 17 exited the room and left Resident 2 unsupervised with the meal tray within reach. Resident 2 was not observed to eat while staff was out of the room. *8:11 AM Staff 17 returned to the room with coffee for Resident 2. Staff 17 offered Resident 2 breakfast again and Resident 2 stated she/he did not like it. *8:13 AM Staff 17 exited the room again leaving Resident 2 unsupervised with the meal tray within reach. Resident 2 was not observed to eat while staff was out of the room. *8:15 AM Staff 2 (DNS) came down the hall to deliver this surveyor requested paperwork. Staff 2 was asked by this surveyor to enter Resident 2's room and if Resident 2 should be left unattended with the food tray in front of her/him. Staff 2 stated she was unsure of Resident 2's care plan. Staff 2 stood by the resident conversed with her/him and eventually removed the food tray. *8:18 AM Staff 17 returned to the room with an alternative meal and acknowledged she should not have left the food tray in reach of Resident 2 who was to be supervised with meals. The resident was observed to use her/his utensils and eat eggs independently while Staff 17 observed. On 2/3/21 at 9:03 AM Staff 19 (RNCM) stated Resident 2 was on aspiration precautions and required 1:1 assistance for cueing and aspiration precautions. Staff 19 further stated the resident aspirated a couple of times in the past and the resident was on 1:1 precautions for approximately the last year. On 2/3/21 at 9:37 AM Staff 17 stated she thought Resident 2 was on 1:1 supervision to cue the resident to eat. She stated she worked different halls and was unaware of the resident's care plan for aspiration precautions. Staff 17 stated she did not see the aspiration precautions sign above Resident 2's bed prior to serving the breakfast meal tray to Resident 2. On 2/3/21 at 11:30 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during 1:1 supervision for meals. An immediate plan of correction (POC) was requested. On 2/3/21 at 12:20 PM the facility submitted a plan of correction. The IJ Removal Plan included: - Education was completed for Staff 17. -The five residents on 1:1 aspiration precautions were audited and care plans and interventions were in place. -All staff will be in-serviced prior to the beginning of their next shift. -All new admissions will be assessed upon admit. -Administrator/DNS/designee will audit charts and care plans. -All residents will be evaluated no less than quarterly for aspirations risks and care plans will be updated to reflect any changes. -Staff will be education upon hire and annually on risk factors of aspiration. -Administrator/DNS/designee will audit five floor staff weekly for one month for aspiration risks and meal tray passes. On 2/4/21 an addendum was received for the removal plan and included: -All agency staff will be in-serviced, oriented and submit competencies prior to the beginning of their shift regarding any residents on aspiration precautions or requiring 1:1 feeding. This will be completed by the Administrator/DNS/designee. The agency staff will sign off on in-service and demonstrate back that they understand 1:1 aspiration precautions before their shift begins. On 2/4/21 a copy of the in-service training was received with staff signatures from 2/3/21. On 2/4/21 observations were completed during the meal tray pass at lunch. There were no concerns during the observation and it was determined the jeopardy immediacy was removed. On 2/4/21 Staff 1 was notified the immediacy was removed based on onsite verification that the IJ removal plan was implemented. The IJ removal plan included education for staff members responsible for identifying and assisting residents who were on aspiration precautions and required 1:1 assistance with meals. Observations on 2/4/21 during the lunch meal tray pass indicated staff were trained and assisting residents who required 1:1 assistance with meals due to aspiration precautions. b. Based on interview and record review it was determined the facility failed to ensure residents were free from accident hazards for 2 of 2 sampled residents (#s 2 and 12) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 2 was admitted to the facility in 2018 with [DIAGNOSES REDACTED]. The 4/29/20 diet order indicated Resident 2 was to receive a limited sodium soft and bite size texture diet. The 5/17/20 progress note indicated Resident 2 received a peanut butter sandwich with crust and did not comply with the resident's current dietary restrictions. The note further indicated Resident 2 was put on alert charting and monitored. On 2/2/21 Staff 3 (Registered Dietician) acknowledged a toasted peanut butter sandwich with crust was not an appropriate food for the soft and bite size texture diet. 2. Resident 12 admitted to the facility in 2018 with [DIAGNOSES REDACTED]. The 12/27/20 MDS indicated Resident 12 had a BIMS of 9 (indicating moderately impaired cognition). The 1/12/21 facility burn investigation indicated the following: *Staff 22 (LPN) was approached by a hospice CNA and was asked if she had seen Resident 12's thigh. Staff 9 (CNA) reported a couple of days ago Resident 12 spilled coffee on her/his leg and there was a burn there. *Staff 9 reported she worked on Resident 12's hall on 1/9/21 but did not provide direct care to the resident. She saw a towel on the resident's lap but did not look under it and assumed the resident spilled something. *Staff 24 (CNA) reported on 1/9/21 before lunch she exited a room and Staff 25 (Housekeeper) told her Resident 12 spilled hot water on her/himself. Staff 24 got a towel and put it over her/him and did other rounds. Staff 24 did not report the incident to the nurse. *Staff 25 reported he was walking down the hall and saw the resident spill a beverage on her/his lap and was said hot. Staff 25 then went to find someone, and found Staff 24 and notified her. On 2/5/21 at 1:17 PM and 2/8/21 at 2:52 PM Staff 24 stated one Saturday in mid January the facility was short staffed. She stated she was in the middle of helping a resident, Staff 25 reported to her that Resident 12 spilled hot water and burned her/his left outer side. She stated she had a lot going on, too much to handle and forgot to report it to anyone. She stated Resident 12 had a history of [REDACTED]. She stated staff often had to redirect the resident or remove the coffee cart out of her/his sight. She stated once Resident 12 would finish a cup of coffee she/he would go back for more. On 2/8/21 at 1:06 PM Staff 25 stated Resident 12 was right outside of her/his room and had spilled water on her/himself and he gave the resident a towel and notified Staff 24. On 2/8/21 at 2:52 PM Staff 22 stated she did not work the weekend when Resident 12 initially received a burn. She stated the hospice CNA asked her to look at Resident 12's leg on 1/12/21 and it looked like a burn. Staff 22 stated Resident 12 received brief changes and the skin issues located on her/his leg/hip would have been noticeable during brief changes. Staff 22 stated Resident 12 would attempt to make her/himself coffee and hot cocoa on a daily basis and staff were aware and watched the resident. She further stated the staff would attempt to keep the drink cart out of Resident 12's sight and sometimes move it down the hall so the resident was not able to see it. On 2/8/21 at 2:29 PM Staff 2 (DNS) stated she completed the investigation for Resident 12 who received a second degree burn. She acknowledged the investigation indicated the burn occurred on 1/9/21 and she was not made aware of it until 1/12/21. Staff 2 acknowledged the burn was noticeable and staff should have noticed it during incontinence care. She state the expectation was for staff to report skin incidents immediately to her.

Based on the immediate jeopardy in the areas of Accident Hazards it was determined the facility was not administered by the management team in an effective and efficient manner. Resident 2 and 16 eloped from the facility and were placed at risk in hazardous environments and avoidable accidents. Findings include: Resident 2 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Record review indicated Resident 2 eloped from the facility on nine occasions and staff interview indicated the resident eloped on multiple occasions. On 3/17/19 the resident was placed on alert charting to monitor her/him for elopement. After 3/19/19 Resident 2 eloped from the building on more than six occasions before her/his care plan was updated to identify the resident was an elopement risk. After the care plan update on 4/10/19 Resident 2 eloped from the facility on three more occasions. There was no documented evidence the facility evaluated Resident 2's elopements, analyzed the hazards and risks of those elopements or implemented new interventions to reduce the hazards or risks associated with her/his elopements. The facility failed to evaluate Resident 2's elopements and, failed to develop new interventions beyond monitoring the resident for elopements resulting in Resident 2 eloping from the facility near a heavily trafficked area. On 6/6/19 at 10:30 PM Staff 2 (DNS) stated Resident 2's elopements were not evaluated and no new interventions to reduce the risk of her/his elopements were developed. Staff 2 stated he did not know why they were not done and acknowledged they should have been. On 6/9/19 at 1:20 PM Staff 3 (Administrator) stated she was aware Resident 2 eloped from the building, thought interventions were in place and did not think the elopements required evaluations. On 6/6/19 at 9:55 PM and 10:35 PM Staff 2 indicated there were no current residents in the facility with recent elopements. If a resident eloped the resident information would be placed in the Pink book to ensure the staff were aware the resident was at risk to elope and the resident's care plan would be updated with interventions to prevent additional elopements. Staff 2 then acknowledged he was aware Resident 16 left the faciity on [DATE] and an investigation should have been done to determine the cause of the elopement. Staff 2 also acknowledged he did not follow up to insure an investigation was completed, the care plan was updated and the resident's information was placed in the Pink book. Refer to F-689

1. Based on interview and record review it was determined the facility failed to ensure evaluations or interventions were developed, reviewed and/or revised for residents who eloped for 2 of 3 sampled residents (#s 2 and 16) reviewed for elopement. Resident 2 eloped on multiple occasions into heavily trafficked areas. This resulted in an immediate jeopardy situation which placed residents at risk in hazardous environments and for potentially avoidable accidents. Findings include: a. Resident 2 was admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 2/14/19 Nursing Home Database form indicated Resident 2 did not elope in the past 90 days. The 2/21/19 Admission MDS indicated Resident 2 was severely impaired cognitively and the resident did not wander. The 3/7/19 Care Plan did not indicate Resident 2 was an elopement risk. The 3/17/19 Progress Note indicated the resident woke up at approximately 4:30 am, got dressed, insisted she/he was going to work and ambulated in the building with an assistive device. The resident was placed on alert and information was placed in the elopement book. The resident's family member called later that morning concerned because the resident was looking for keys, thought she/he was at the parts store and was going to the marina. The family member stated they would come to visit the resident and take her/him outside of the facility for an activity. The undated Code PINK Resident Information Sheet (in the Elopement Book) included a picture of Resident 2 and indicated her/his behaviors included, wants to go to work and gets dressed ambulates by self. Staff were to re-orient and redirect the resident. The 3/19/19 through 4/15/19 TAR indicated Resident 2 was to be monitored for risk of elopement each shift and to document her/his behavior. Progress Notes revealed the following: * 3/24/19: The resident was found outside of the facility by a staff member, stated she/he wanted to walk outside because it was nice and she/he was tired of walking the halls. It was then explained to the resident that if she/he wanted to walk outside the resident would need to ask staff to walk with her/him. The resident agreed to let staff know if she/he was going outside but did not appear to understand that if she/he wanted to go outside that she/he needed someone with her/him. * 4/1/19: The resident called her/his ex-spouse to pick her/him up, left the building and proceeded to walk to the main road and wait for her/his ex-spouse. Staff 3 (Administrator) was able to get the resident back into the building. The resident expressed she/he was frustrated and wanted to go home. * 4/2/19: The resident walked out the front door using the door code, was followed by a CNA to the corner and escorted back into the facility. * 4/4/19 at 9:37 pm: The resident was found by staff near the hospital (next to the facility) and brought back into the facility without incident. * 4/7/19 at 8:30 pm: The resident was found walking outside of the facility several times during the shift, was re-directed and was walked outside with staff present. The resident was directed to walk in the outdoor fenced area on the facility grounds. *4/8/19 at 10:57 am: The resident was found packed and by the entrance of the facility and redirected back to her/ his room. *4/8/19 at 7:23 pm: At approximately 4:30 pm the resident went out front door. She/he was found by a staff member walking down the sidewalk and was brought back in without incident. * 4/10/19: A Physician Noted indicated during the resident's stay at the facility her/his cognitive deficits were more apparent and did not improve with cognitive therapy. The resident's memory was significantly impaired, her/his insight was poor and the resident required 24/7 supervision for a safe discharge. The Resident's Care Plan was revised on 4/10/19 to indicate Resident 2 was a very high elopement risk. Staff were to monitor her/his presence and alert Staff 5 (RNCM), Staff 2 (DNS), Staff 3 (Administrator) and Staff 10 (Social Service Director) for elopement. Progress Notes indicated the following: *4/11/19 at 4:48 pm: The resident was noted to have poor impulse control, got out of the facility twice during the shift and was found in the hospital parking lot next door. *4/12/19 at 5:35 pm: The resident was noted to have been seen by staff on the hospital premises. Staff spent several minutes looking for the resident and about ten minutes later was seen walking back to the facility. *4/13/19: The resident wanted outside several times and staff took turns walking with her/him outside. * 4/15/19: The resident discharged from the facility. On 6/6/19 at 8:45 pm Staff 28 (CNA) stated Resident 2 wandered most of the time, tried to take a taxi to get out of the facility and would come back when staff went and got her/him. Staff 28 further stated she would see the resident walking down the driveway (away from the facility) and the resident was not safe to be outside on her/his own because the resident did not know how to get back to the facility. On 6/6/19 at 8:50 pm Staff 33 (LPN) stated Resident 2 wandered, eloped and got out the front door during her shift but got out further to the street during the day shift. Staff 33 further stated Resident 2's elopements increased after she/he was no longer able to visit her/his ex-spouse. Staff 33 stated Resident 2 knew the code to the front door or would follow people out the door. Staff 33 further stated the protocol for elopment was to contact Staff 3 (Administrator), Staff 2 (DNS) and the family. On 6/6/19 at 9:10 pm Staff 34 (CMA) stated she recalled Resident 2 eloped from the building twice and one of those times was found around the side of the building. Staff 34 stated going for walks with the resident helped, she thought the resident was lonely and she offered her/him hot chocolate and would sit and talk with the resident. On 6/6/19 at 9:20 pm Staff 27 (LPN) stated Resident 2 was an elopement risk, left the facility a couple of time on his shift and staff would have to chase after the resident. Staff 27 further stated the resident would leave the building to get fresh air or to go to the hospital to get food. Staff 27 stated everyone knew the resident was an elopement risk and he would keep his treatment cart near the resident in order to keep a closer eye on the resident. Staff 27 stated the resident went to bed around 8:00 pm or 9:00 pm and eloped more during the day. On 6/6/19 at 9:30 pm Staff 30 (CNA) stated Resident 2 was an elopement risk, was constantly pushing the button to go outside and she would have to go out and bring the resident back inside. Staff 30 further stated the resident would usually make it out to the parking lot and would get mad when she tried to bring her/him back in. On 6/6/19 at 10:30 pm Staff 2 (DNS) stated the resident's elopements were not evaluated and no new interventions to reduce the risk of her/his elopements were developed. Staff 2 stated he did not know why they were not done and acknowledged they should have been. Record review indicated Resident 2 eloped from the facility on nine occasions and staff interview indicated she/he eloped on multiple occasions. On 3/17/19 the resident was placed on alert charting to monitor her/him for elopement. After 3/19/19 Resident 2 eloped from the building on more than six occasions before her/his care plan was updated to identify the resident was an elopement risk. After the care plan update on 4/10/19 the resident eloped from the facility on three more occasions. There was no documented evidence the facility evaluated Resident 2's elopements, analyzed the hazards and risks of those elopements or implemented new interventions to reduce the hazards and risk associated with her/his elopements. The facility failed to evaluate Resident 2's elopements and, failed to develop new interventions beyond monitoring the resident for elopements resulting in Resident 2 eloping from the facility near a heavily trafficked area. On 6/7/19 at 1:10 am Staff 2 (DNS) and Staff 2 (Administrator) were notified Resident 2's elopements constituted an immediate jeopardy situation. An acceptable plan to abate the immediate jeopardy situation was submitted by the facility on 6/7/19 at 2:58 am. The plan included: All current residents would be assessed for risk of elopement and a care plan would be established. All staff would be in-serviced prior to the beginning of their next shift, beginning 6/7/19 with the night and day shift CNAs, Licensed Nurses and CMAs to ensure that all staff were immediately re-educated on the risk factors of elopement and proper protocol for the situation. All residents would be evaluated no less often than quarterly for elopement risks and care plans would be updated to reflect any changes. The Administrator and the DNS would audit four resident records weekly for elopement risks to ensure the care plan was in place. Any not found in place would immediately be rectified. The audits would continue for three months with results brought to the Quality Assurance for two quarters or until substantial compliance was met. On 6/7/19 at 1:10 pm Staff 3 (Administrator) stated she was made aware of Resident 2's elopements, she thought things were in place in the resident's care plan and was not aware elopements required evaluation. On 6/7/19 at 1:55 pm the facility's implementation of the abatement plan was verified. b. Resident 16 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 3/4/19 Admission CAAs indicated Resident 16 was cognitively impaired and had a poor memory. The resident was not identified to be at risk for wandering/elopement. The 6/3/19 Progress Note indicated the resident attempted to elope and made it right outside the front doors before the receptionist attempted to stop the resident. Staff 6 (LPN) heard a resident yelling outside and observed the resident and receptionist outside. The resident indicated she/he saw her/his sister's car. The resident was assisted back into the facility. The chart did not have additional information to determine how the resident was able to leave the building. It did not indicate if the resident was able to read the posted code to unlock the doors, if the resident was able to input the code to unlock the doors or if there was potential for a visitor to assist the resident out the doors. There were no additional notes after the incident to indicate the resident was monitored to ensure the resident did not continue to attempt to elope. On 6/6/19 at 9:50 PM Staff 2 (DNS) indicated if a resident eloped the resident was to be monitored. Staff 2 acknowledged this was not completed for Resident 16. The resident's Care Plan initiated on 2/19/19 was not updated to address the resident's attempt to elope and did not have interventions to prevent the resident from continued elopements. On 6/6/19 at 9:55 PM Staff 2 (DNS) indicated if a resident eloped, the resident information was placed in the pink book. The pink book had resident information including a description of the resident and a photograph. Staff 2 acknowledged Resident 16 was not in the Pink book and the care plan was not updated. Staff 2 also indicated there should be an assessment to determine the cause of the elopement, how the elopement likely occurred and what interventions to implement to prevent additional elopements. Staff 2 acknowledged he was aware of the elopement but did not follow-up to ensure an investigation/evaluation of the elopement was completed. 2. Based on observation, interview and record review it was determined the facility failed to ensure a resident's wheel chair was locked during a staff transfer for 1 of 3 sampled residents (#16), failed to ensure falls were evaluated for 1 of 3 sampled residents (#17) and, failed to ensure care plan interventions were followed for 1 of 3 sampled residents (#20) reviewed for falls. This placed residents at risk for injury. Findings include: a. Resident 16 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 3/4/19 admission CAAs indicated the resident was at risk for falls related to a history of falls, cognitive impairment and her/his psychiatric disorder. The Care Plan initiated on 2/22/19 indicated the resident required the assistance of one staff for transfers. The resident was identified to be at high risk for falls related to poor judgement. Interventions included to ensure position change alarms were in place, the wheelchair was not by the side of the bed when the resident was in bed and to ensure the resident wore non-skid footwear. The 5/8/19 Fall investigation and associated Progress Notes indicated the resident's position change alarm was sounding. Staff 22 (CNA) entered the room. The wheelchair was against the wall away from the bed and the resident was attempting to self transfer. The CNA brought the wheel chair to the resident but did not lock the wheelchair breaks. As the resident sat the wheelchair rolled out from the resident and the resident was lowered to the floor. On 6/3/19 at 12:31 PM Staff 22 stated on 5/9/19 it was at the beginning of her shift, she heard Resident 16's position change alarm resident and found the resident was attempting to get out of bed. Staff 22 brought the resident's wheelchair to the resident but she did not lock one of the brakes, the wheelchair rolled back and Staff 22 had to assist the resident to the floor. On 6/3/19 at 11:55 AM Staff 14 (CNA) stated the wheelchair brakes should be locked before transfers. On 6/3/19 at 12:10 PM Staff 5 (RNCM) indicated the resident's wheelchair was not locked at the time Staff 22 transferred the resident. b. Resident 17 was admitted to the facility in with [DIAGNOSES REDACTED]. The 3/12/19 Quarterly MDS indicated Resident 17's BIMs score was a 3 (severe cognitive impairment) but she/he was able to make her/himself understood and could understand verbal content. The 3/12/19 Care Plan indicated Resident 17 was at moderate risk for falls. Interventions included non-skid foot wear, a pressure alarm and to keep the bed in a low position. The care plan further indicated Resident 17 was independent with toileting. The 3/26/19 Fall investigation indicated Resident 17 was found on the ground in her/his room at 10:20 pm wearing shoes, a t-shirt and a brief. The resident was found to have a dark purple bruise on her/his right outer elbow. The investigation did not indicate if the resident's bed was in a low position, if her/his call light was sounding, when the resident was last visualized or toileted or, if staff asked the resident what happened. On 6/3/19 at 11:30 am Resident 17 was observed sitting in a wheelchair with an alarm in place while visiting Witness 12 (Resident 17's spouse). Witness 12 stated Resident 17 tended to fall from her/his wheelchair when reaching for objects off the floor. Witness 12 further stated Resident 17 required staff assistance for toileting and would usually let them know when she/he needed help. On 6/3/19 at 2:00 pm Staff 14 (CNA) stated Resident 17 was a fall risk, very impulsive and required assistance with toileting. On 6/3/19 at 2:05 pm and 6/06/19 at 3:30 pm Staff 5 (RNCM) stated Resident 17 was incontinent at times, required assistance with toileting and acknowledged her/his care plan was not reflective of these needs. Staff 5 further stated Resident 17 was checked on during rounds, was able to use her/his call light and could verbalize how she/he fell when asked. On 6/6/19 at 3:00 pm Staff 30 (CNA) stated Resident 17 required toileting assist since the time she/he first admitted to the facility. Staff 30 further stated Resident 17 was a fall risk, she checked on her/him frequently and the resident did use the call light when in her/his room. On 6/6/19 at 3:00 pm Staff 31 (CNA) stated he worked with Resident 17 from the time the resident admitted to the facility. Staff 31 further stated Resident 17 was a fall risk, tried to stand and do things on her/his own, and required assistance with toileting. Staff 31 stated Resident 17 used her/his call light and if she/he fell would be able to tell staff what happened. On 6/6/19 at 3:30 pm Staff 5 (RNCM) acknowledged the investigation to Resident 17's fall was not thorough, did not indicate if Resident 17 utilized her/his call light, did not indicate when she/he was last checked on or offered toileting and, did not indicate if the resident was asked what happened. Staff 5 further stated the resident may have been trying to toilet or get dressed. c. Resident 20 admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Resident 20's 1/23/19 care plan indicated Resident 20 was at high risk for falls related to cognitive problems, a history of falls and lack of impulse control. Interventions included a low bed and a pressure safety alarm to the bed and chairs at all times and, to frequently check for placement and function of the alarms. The 3/4/19 fall investigation indicated Resident 20 was found on the floor in her/his room, her/his tab alarm was not in place and was immediately placed back under the sheet. The investigation further indicated the resident climbed out of bed and sustained a bruise to her/his right cheek. The care plan would be updated to include a safety pressure alarm while the resident was in bed and a padded fall mat to be placed on the floor while the resident was in bed. The investigation concluded abuse and neglect was ruled out. Resident 20's care plan indicated on 3/5/19 fall intervention revisions were made to include a safety pressure alarm to the resident's bed and to check placement and function of the alarm each shift and to place a padded fall mat at the bedside on the floor of the side of bed the resident was faced. The 3/9/19 fall investigation indicated Resident 20 was found lying on her/his left side on the floor next to the bed by Staff 36 (RN) The fall mat was on the floor but on the opposite side of the floor. No injuries to the resident were identified. The investigation indicated Resident 20 was believed to have self-transferred or rolled out of bed related to impulsive behavior. The investigation did not indicate if the bed alarm was sounding or what side of the bed the fall mat was placed when the resident was last seen in bed. Abuse and neglect was ruled out. The investigations to Resident 20's falls were not thorough and did not determine if Resident 20's care plan was followed. Additionally Resident 20 was noted to self-transfer or roll out of bed due to restlessness. After the 3/9/19 fall there was no documentation to indicate bilateral fall mats were considered. On 5/31/19 at 1:20 pm Resident 20 was observed lying in bed. Staff 35 (CNA) was in the room assisting the resident with eating her/his lunch. A padded fall mat was observed folded and leaned against the wall. Staff 35 stated the resident's fall interventions included a fall mat and tab alarm, the fall mat was not placed because she was currently with the resident. On 6/10/19 at 2:40 pm Resident 20 was observed lying in bed. Fall mats were placed on both sides of the resident's bed. The care plan directed staff to place only one care mat. On 6/18/19 at 11:00 am Staff 36 (RN) stated he could not recall if the resident's bed alarm was sounding when he found her/him on the floor on 3/9/19. Staff 36 further stated when he found the resident the fall mat was on the opposite side of the bed of the resident. On 6/18/19 at 11:25 am Staff 11 (RNCM) stated Resident 20's most recent falls were related to the resident swinging her/his leg over the edge of the bed, rolls and then fell . Staff 11 acknowledged he did not evaluate the fall mat intervention after Resident 20's fall and acknowledged the fall incidents were not thoroughly investigated.

Based on interview and record review it was determined the facility failed to clarify and follow physician orders, complete alert charting, and assess [MEDICAL CONDITION] for 4 of 7 sampled residents (#s 1, 3, 4, & 7) reviewed for care and services. Resident 1 was hospitalized for [REDACTED]. Findings include: 1. Resident 1 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. a. Resident 1's 8/2017 and 9/2017 physician orders [REDACTED]. The 9/14/17 Physician New Patient Note documented for treatment of [REDACTED]. Regarding the resident's [MEDICAL CONDITION] the physician documented Stop [MEDICATION NAME]. The New Orders section did not include the directive to stop the [MEDICATION NAME]. There was no documented clarification in the clinical record regarding the [MEDICATION NAME] on 9/14/17. The 9/2017 MAR documented on 9/15/17 and 9/16/17 Resident 1 received aspirin, [MEDICATION NAME], and Eliquis. There was no documentation in the clinical record of nursing staff clarifying the new administration of Eliquis along with the [MEDICATION NAME] and Aspirin. The 9/16/17 at 6:22 PM Progress Note disclosed Resident 1 had loose/soft/liquid stool that was dark burgundy in color. The physician was notified and a hemoccult (a test for hidden blood in stool) was positive. The physician directed staff to hold the Eliquis and monitor the resident for bleeding. The 9/17/17 at 9:08 PM and 9:58 PM Progress Notes disclosed the resident had another loose/[MEDICATION NAME] (thick/sticky consistency) burgundy colored stool, hemoccult shows positive. The resident was sent to the hospital. The 9/17/17 ED (Emergency Department) Provider Note documented the resident presented to the ED for evaluation of rectal bleeding. The ED physician noted the addition of Eliquis and the resident received aspirin, [MEDICATION NAME], and Eliquis together for a few days. The 9/23/17 Hospital Discharge Summary noted the resident had an acute gastrointestinal hemorrhage likely triggered by the administration of the [MEDICATION NAME] and Eliquis. The 10/24/17 Progress Note disclosed the resident was discharged to home. In interview on 1/8/17 at 3:30 PM Staff 3 (RNCM) stated upon return from physician appointments the nurse who received the physician notes/orders reviewed the documentation then gave it to Staff 3 for an additional review. Per Staff 3 Staff 10 (LPN) received the 9/1417 physician notes/orders. Staff 3 stated he did not see the physician documentation/orders until after the incident occurred. Staff 3 stated the physician's documentation was not clear regarding the [MEDICATION NAME]. When asked what staff were expected to do with the unclear information Staff 3 stated it should have been clarified. In interview on 1/9/17 at 10:44 AM Staff 10 (LPN) stated when residents returned to the facility after physician visits he reviewed the physician documentation to see if there were any new orders, then transcribe the new orders onto the MAR. Staff 10 stated on 9/14/17 the resident had physician orders [REDACTED]. When asked if he reviewed the 9/14/17 physician notes in addition to the orders Staff 10 stated there was usually a summary on the front page or a list of physician orders [REDACTED]. In interview on 1/10/18 at 1:55 PM Staff 2 (DNS) stated the resident returned from the 9/14/17 physician appointment with new orders for Eliquis. The physician documented to stop [MEDICATION NAME] in the visit summary but there was no accompanying order to stop the [MEDICATION NAME]. If I saw the stop [MEDICATION NAME] in the summary I would go back to the physician and check on it. Staff 2 stated it was good nursing judgement to make sure and there should have been a clarification. In interview on 1/29/18 at 1:53 PM Staff 7 (RN) stated she did not recall the resident receiving three anticoagulant medications. In interview on 1/29/18 at 2:44 PM Staff 8 (RN) stated the physician was notified of the resident's diarrhea with possible blood and the resident was sent to the hospital for internal bleeding concern. Staff 8 stated he did not recall knowing the resident was on three anticoagulant medications at that time. b. The facility's undated Charting In-Service noted alert charting should be completed every shift which focused on monitoring an acute change in the resident's status or needs. Alert charting may be triggered by a medical condition or an event such as a fall or skin impairment. On 9/1/17 Staff 34 (PT, Physical Therapist) and Staff 35 (OT, Occupational Therapist/Therapy Director) documented in their respective Treatment Encounter Notes the resident received co-treatment from occupational and physical therapy related to transfers. The resident was noted with significant weakness and postural control issues from [DIAGNOSES REDACTED]. During the Sara (sit to stand) lift transfer one side of the sling came unhooked while the resident was in a standing position in the lift. Staff 35 braced the resident while the lift was moved back to the resident's bed and Staff 34 and Staff 35 safely assisted the resident out of the machine. No injury was noted. Both Staff 34 and Staff 35 documented LN and RCM notified. There was no documentation in the nursing Progress Notes of the 9/1/17 transfer incident, nor was alert charting completed. On 9/4/17 Staff 35 (OT/Therapy Director) documented in Treatment Encounter Notes she observed a red/yellow discoloration on the resident's right side of her/his trunk. The resident's family member speculated the red/yellow discoloration was from the 9/1/17 incident when the strap from the lift came unlatched. RCM was notified on skin discoloration. The facility's correlating incident investigation completed by Staff 3 (RNCM) indicated Staff 35 (OT/Therapy Director) informed Staff 3 (RNCM) of the 9/1/17 transfer incident on 9/4/17. Staff 35 reported on 9/4/17 she visualized a yellow and red discoloration to the right side of the resident's flank area, possibly bruising from the 9/1/17 incident. The Immediate Action Taken noted Visually examined site of 9 cm x 8.5 cm bruise purple-red in color to the resident's right flank area. The resident reported no active pain upon palpation of the site. Will continue to monitor site for increased bruising related to [MEDICATION NAME] (an anticoagulant medication) injections. There was no documentation in the nursing Progress Notes of the 9/4/17 bruise observation, nor was alert charting completed. The 9/7/17 at 11:10 PM Progress Note disclosed redness on the resident's abdominal right side which appears to be from pressure. The 9/12/17 at 10:34 PM Progress Note documented Redness and [MEDICAL CONDITION] are present on the resident's right flank area. On 9/15/17 the physician ordered Keflex (an antibiotic) 500 mg three times a day for five days for [MEDICAL CONDITION] of the right abdomen. The 9/2017 MAR noted the Keflex was given as ordered. Except for the 9/7/17 and 9/12/17 Progress Notes there was no documented assessment of [MEDICAL CONDITION] and alert charting prior to and after initiating the Keflex. The resident was sent to the hospital on [DATE] for an unrelated concern. The lack of documentation regarding the 9/1/17 transfer incident and subsequent bruising including alert charting was discussed with Staff 1 (Administrator) on 1/4/18 at 9:08 AM. No additional documentation was provided. In interview on 1/4/18 at 9:34 AM Staff 34 (PT) stated on 9/1/17 the resident was transferred with a Sara Lift. During the transfer the left sling came off of the hook with the right side still intact. After the incident Staff 35 reported the incident to Staff 3 (RNCM) and a charge nurse. In interview on 1/8/18 at 3:33 PM Staff 3 (RNCM) stated he learned of the 9/1/17 incident on 9/4/17 during the daily morning meeting. Staff 3 stated therapy staff may have informed a different RNCM. When asked about the lack of documentation regarding the 9/4/17 bruise Staff 3 stated he may have forgotten to document the report of bruising in the Progress Notes. In further interview with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 on 1/12/18 at 2:24 PM Staff 3 stated he never saw the bruising as reported by Staff 35 (OT). In interview on 1/9/18 at 8:57 AM Staff 4 (RNCM) stated the 9/1/17 transfer incident was not reported to her and she had no information. In interview on 1/9/18 at 9:04 AM Staff 33 (RNCM) stated the 9/1/17 transfer incident was not reported to her, she heard about it in the daily morning meeting, and had no additional information. In interview on 1/9/18 at 9:15 AM Staff 7 (RN) stated she was not aware of the incident until Staff 3 (RNCM) talked to her about it during the past week. Staff 7 stated other shifts reported the resident had bruising on her/his side, however, she did not recall any information regarding alert charting. In interview on 1/9/18 at 9:35 AM Staff 9 (RN) stated the 9/1/17 transfer incident was not reported to her. In interview on 1/9/18 at 1:49 PM Staff 35 (OT/Therapy Director) stated on 9/1/17 while training family on using the Sara lift the strap came off the lift during the transfer. Staff 35 stated after getting the resident safely in a wheelchair she went directly to Staff 3 (RNCM) and Staff 7 (RN) and reported the incident. When asked about Staff 3 and Staff 7 stating they were not informed of the incident Staff 35 stated the incident scared her so she immediately reported it and would not have kept that information from nursing. On 9/4/17 she observed a yellowish-reddish bruise on the side of the resident's flank. After the therapy session ended she reported the bruising to Staff 3. The lack of assessment and alert charting related to [MEDICAL CONDITION] was discussed with Staff 2 (DNS) on 1/10/18 at 1:55 PM and Staff 1 (Administrator), Staff 2, and Staff 3 (RNCM) on 1/12/18 at 2:24 PM. No additional documentation was provided. In interview on 1/29/18 at 12:54 PM Staff 10 (LPN) stated there was redness, possible warmth to the site, and pain when palpating the resident's abdominal side possibly two days before the resident was treated for [REDACTED]. 2. Resident 3 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 8/31/17 at 10:50 PM Progress Note disclosed at 10:38 PM Staff 11 (RN) heard the resident call out for help. The resident was not in bed and was found on the floor. The resident sustained [REDACTED]. There was no documented alert charting for the 9/1/17 night shift through the 9/3/17 day shift. The lack of alert charting was discussed with Staff 1 (Administrator) and Staff 2 (DNS) on 1/31/18 at 1:56 PM. 3. Resident 4 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 1/2018 physician orders [REDACTED]. The 1/2018 MAR and correlating EMar (Electronic MAR) documented the resident did not receive the medication on 1/2/18 or 1/3/18 due to not being available. In interview on 1/3/18 at 1:03 PM Staff 38 (CMA) stated regarding refills of over the counter medications she informed Staff 2 (DNS) when there was one tablet left and the medication needed re-ordering. Staff 38 stated the medication was not available for administration on 1/2/18 or 1/3/18. In interview on 1/30/18 at 10:57 AM Staff 2 (DNS) stated staff generally informed him when medication was low or was out but they did not inform him about the [MEDICATION NAME]. Staff 2 stated he questioned the facility being out of [MEDICATION NAME] as there were three different medication carts in the facility. Staff 2 stated staff should have checked the other medication carts for the [MEDICATION NAME]. 4. Resident 7 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. The 12/26/17 at 9:43 PM Progress Note disclosed Resident 7 had an unwitnessed fall. Staff 39 (LPN) documented the staff member in attendance reported the resident was found with her/his feet wrapped up in blankets at the foot of the bed with the resident's upper body on the floor. When Staff 39 went in the room to investigate the situation she noted the resident was lying flat on the floor with pillow under head. The staff member stated I put the pillow under (Resident 7's) head. The resident stated yes when asked if she/he hit her/his head. The facility's 12/26/17 correlating investigation documented Staff 39 observed the resident lying on the floor next to the bed with her/his head on a pillow. When Staff 39 asked about the resident's positioning when found the staff member stated the resident's legs were wrapped up in the blanket, still on the bed with the resident's upper body on the floor. The resident was not able to give a clear description of what happened. Staff 39 assessed the resident and found no injuries. Staff 39 (LPN) no longer worked for the facility and not available for interview. In interview with Staff 1 (Administrator) and Staff 2 (DNS) on 1/31/18 at 8:37 AM Staff 2 stated staff were not to move residents before the nurse completed the assessment. In interview on 1/31/18 at 10:06 AM Staff 37 (CNA) stated she found the resident on the floor. Staff 37 stated she placed a pillow under the resident's head, made sure the resident was not bleeding and ran out to get the nurse. Staff 37 stated it was the facility's standard to not move residents before the nurse completed the assessment, however, she placed pillows under residents' heads after falls as the floor was hard, she did not see any blood or injuries, and she wanted to keep residents from getting hurt while getting help.

Based on interviews and record review it was determined the facility failed to act timely to a resident's change of condition for 1 of 3 (#1) sampled residents with a catheter. This resulted in a hospitalization and kidney failure. Findings include: Resident 1 was admitted to the facility in January 2014 with [DIAGNOSES REDACTED]. The resident's care plan identified on 1/30/14 the resident was at risk for urinary discomfort and had a suprapubic catheter. Resident 1's May 2014 TAR indicated the resident had orders for suprapubic catheter management every shift. On 5/15/14 at 9:41 pm a nursing note identified the resident's suprapubic catheter was patent (unobstructed) and draining dark yellow urine. There were no documented observations of the resident's catheter in the nursing notes on 5/16/14. On 5/17/14 at 9:45 pm a nursing note identified the resident was alert and arousable and verbally responsive with staff. As the shift progressed the resident became more lethargic and slow to respond back verbally. The resident had no output to her/his suprapubic catheter throughout this evening shift. The resident was given pain medication at 3:00 pm and 15 minutes later she/he had a small emesis and regurgitated the medication. The resident's family requested the resident be sent out for evaluation. The note indicated the Physician would be informed and the resident was sent out at 9:30 pm to the hospital. On 5/18/14 at 7:10 am a "late entry" nursing note identified on 5/17/14 at 2:00 pm Resident 1 was observed with no urine in the catheter bag. The nurse (Staff 6) followed the catheter tubing from bag to entry site inferior to umbilicus with his hand. The tubing ran up the resident's pajama pant leg and was not visible except at umbilicus and at bag. The nurse noted that there was a scant amount of dried blood at the entry site, which was cleaned off. The resident was administered pain medication at 2:00 pm. The note indicated the nurse checked on the resident approximate every 40 minutes. The resident became less rousable around 7:00 pm. At 9:00 pm the resident's family arrived and the resident out to the hospital. The note indicated the resident had "no visible urine output up to time of call" for hospital transport. The Hospital's History and Physical (H&P) identified the resident was admitted to the emergency department with low urine output and they found the resident's suprapubic catheter was clamped and upon removal of the clamp, about 2 liters (2000 cc) of urine came out. The H&P identified the resident had [MEDICAL CONDITION] due to urinary tract infection and "acute kidney failure likely postobstructive due to catheter being clamped." On 5/22/14 the facility documented an investigation of the incident. They were unable to determine how the catheter tubing became clamped. Facility output records for Resident 1, dated 1/7/15 though 1/19/15, identified the resident averaged 666 cc of urine per shift. In interview on 1/20/15 at 12:30 pm Staff 4, RNCM, reported Resident 1 was interviewable and when she/he became ill, she/he got sick fast. Staff 4 stated at the time of the incident the facility was not recording catheter output as they currently do now. In interview on 1/20/14 at 12:41 pm Resident 1 reported she/he had no memory from the day of hospitalization (on 5/17/14) and stated she/he was "real sick." The resident reported neither nurses or CNAs clamped her/his catheter tubing for any reason and she/he was unsure how it became clamped shut. In interview on 1/20/15 at 12:58 pm Staff 6, RN, reported the resident had only a small amount of urine in the catheter bag on 5/17/14 at 2:00 pm so he felt the tubing through the resident's clothes but didn't feel anything wrong. Staff 6 stated that he observed the resident "a couple of times" before the resident left for the hospital and "didn't notice more urine in the bag." He stated the resident started getting more sleepy and the catheter bag wasn't filling up so he sent the resident out. In interview on 1/22/15 at 10:23 am Witness 2, RN, reported the facility failed to thoroughly assess Resident 1's suprapubic catheter when it stopped draining and failed to contact the resident's Physician when the resident had no urine output for seven hours. In interview on 1/26/15 at 1:47 pm Staff 2, DNS, reported she could not determine how Resident 1's catheter tubing became clamped. She stated she considered no output of urine a change in condition and "didn't think" the facility contacted the Physician regarding the resident's lack of output.

Based on observation, interview and record review it was determined the facility failed to assess and care plan potential accident hazards for the use of a shower chair and provide adequate supervision for 1 of 3 sampled residents (#1) reviewed for falls. Resident 1 fell and sustained fractures and lacerations. Findings include: Resident 1 admitted to the facility in 5/2010 with [DIAGNOSES REDACTED]. The 11/1/10 Occurrence Report disclosed the resident's roommate called out for help and Staff 5, LN, entered the room and found the resident on the floor. It was concluded the resident had poor safety awareness, leaned out of the wheelchair, falling out. Immediate action taken included placing an armrest on the left side of the wheelchair. The 11/14/10 Nursing FAX Communication to the physician revealed nursing requested an order for [REDACTED]. Staff also requested a wheelchair armrest to "promote posture and prevent leaning." The physician signed the order. In interview on 12/8/11 at 2:47 pm, Staff 5, LN, stated someone ordered the use of the armrest and therapies put it on the wheelchair. Staff 5 stated it would have been a different nurse that ordered the armrest, but did not remember who had written the order. In interview on 12/8/11 at 2:05 pm, Staff 8, DNS, stated it was not known who wrote the order, but that they no longer worked in the facility. There was no documented assessment of the armrest in the clinical record, nor was it addressed on the care plan. 11/16/11 IDT Note (Interdisciplinary Progress Note) indicated the resident had fallen in the shower room. 911 was called and the resident was sent to the hospital via ambulance. The corresponding Occurrence Report revealed Staff 4, CNA, was going to give the resident a shower. The resident was sitting in the shower chair with the water warming. Staff 4 turned around to the bathroom sink to grab washcloths, turned back around and the resident hit the floor face down. Staff 5, LN, heard the CNA yelling for help and observed the resident lying prone on the floor, with blood on the floor. The Occurrence Report noted due to the resident's prior CVA "with flaccid left side, aphasic, could not have spoken or attempted to break (resident) own fall. reclining wheelchair will need to be used for this patient moving forward." The 11/16/11 Emergency Department Clinical Report revealed the resident had sustained a head injury with concussion, a nasal fracture and three facial lacerations. An 11/17/11 IDT Note disclosed the resident returned from the hospital with three facial lacerations and sutures, swelling and bruising around the eyes and upper lip and a nasal fracture. An 11/17/11 IDT Note indicated the resident developed a bruise/edema to the pinky finger since the fall. The 11/17/11 x-ray revealed the resident had an acute fracture to the finger. IDT Notes for 11/17/11 at 3:10 am and 11/18/11 at 11:30 am, indicated the resident was given medication for facial pain. On 12/8/11 at 9:20 am and 10:57 am, the resident was observed to be in bed with her/his eyes closed. The resident did not respond to attempts to engage in conversation. There was no documented assessment of the resident's ability to sit in the shower chair, nor was it addressed on the care plan. In interview on 12/8/11 at 10:55 am, Staff 1, RNCM, stated the resident was stable when up in the wheelchair and not had any issues with leaning forward or to the side. In interview on 12/8/11 at 1:14 pm, Staff 1 stated the wheelchair armrest held the resident's arm up and kept the resident "in place." In interview on 12/8/11 at 11:28 am, Witness 1, Complainant, stated the resident sat "fine" in the wheelchair. However, the use of an armrest was added to the wheelchair. Witness 1 stated that two different staff, (Staff 2, CNA and an unidentifiable staff member) had reported to her about incidents involving the resident's balance. Staff 2 had reported to her that approximately two or three months prior, the resident had a similar incident of leaning while in the shower chair. In interview on 12/8/11 at 11:52 am, Staff 2, CNA, stated with the armrest in place on the wheelchair, the resident's balance was "fine." Without the armrest, the resident "can lean forward." and was not able to get herself/himself back. Staff 2 stated "maybe six months ago", the resident tipped forward and she had to catch the resident with her arm around the resident's neck to keep the resident from falling. Staff 2 stated she reported the incident to a nurse due to concerns of possible bruising. Staff 2 did not recall who she had reported the incident to. Staff 2 stated she did not report her concerns to other nursing staff. In interview on 12/8/11 at 12:05 pm, Staff 3, CNA, stated the resident was usually "pretty stable" in the wheelchair if positioned correctly, but would sometimes lean forward and rock. When asked about the resident's balance with the armrest not in place, Staff 3 stated the resident would lean more. When asked regarding the resident's positioning in the shower chair, Staff 3 stated "just as stable as the wheelchair." Staff 3 stated she had showered the resident once or twice and did not know if the resident leaned due to always keeping a hand on the resident. In interview on 12/8/11 at 12:25 pm, Staff 4, CNA, stated at the time of the incident, she had taken the resident to the shower room, turned on the water, turned to get a washcloth and the resident was on the floor. Staff 4 demonstrated the resident had been in the corner of the shower room and Staff 4 was approximately "two to three feet" from the resident and turned to the sink. When asked about the resident's balance in chairs, Staff 4 stated the resident had a special armrest on the wheelchair that helped her/his weakness and her/his balance was "okay" in the wheelchair. Staff 4 stated she had seen the resident "lean a little bit sideways" in the shower chair and repositioned the resident. Staff 4 stated she had not seen the resident lean forward in the shower chair and normally kept a hand on the resident, but did not this time due to getting washcloths. When asked if she had reported to nursing that the resident leaned at times, Staff 4 stated "no." In interview on 12/8/11 at 12:45 pm, Staff 5, LN, stated the resident had a tendency to lean towards the left while in the dining room. Staff 5 stated the resident could sometimes reposition herself/himself. When asked about the use of the wheelchair armrest, Staff 5 stated it helped the resident if she/he "scoots too far forward" and to keep the resident "from falling forward out of the wheelchair and keep (the resident's) arm positioned correctly." Staff 5 stated she did not normally see the resident in the shower chair, except in the hall with blankets covering her/him and had not seen the resident leaning while in the shower chair. Staff had not reported concerns of the resident leaning to her. Staff 5 stated the use of the recliner shower chair was much safer for the resident. When asked what she would expect staff to do while showering the resident, Staff 5 stated "to not leave (the resident) and have their hand and eye on (the resident) at all times." In interview on 12/8/11 at 1:00 pm, Staff 6, CNA, stated the armrest in the wheelchair restricted the resident from leaning forward and the resident did not lean forward when it was in place. Staff 6 stated while in the shower chair, the resident normally sat up straight and the resident did lean forward at times. Staff 6 would place his hand in front of her/him and ask the resident to lean back. Staff 6 stated the resident could respond and catch herself/himself if starting to fall. Staff 6 had to cue the resident to stay upright and to not lean forward. Staff 6 stated he kept a hand on the resident at all times when showering her/him. Staff 6 stated he had previously told other CNAs the resident was uncomfortable on the shower chair and had the "intention" to lean forward, however, he had not reported it to other nursing staff. In interview on 12/8/11 at 1:14 pm, when asked what she would expect staff to do while showering the resident, Staff 1, RNCM, stated for them to be by the resident's side due to balance and left sided weakness. Staff 1 expected staff to not turn and be away from the resident. Staff 1 was not aware of staff's observations of the resident leaning at times.