Every finding on record at Avamere Riverpark of Eugene

Based on observation, interview, and record review, it was determined the facility failed to ensure narcotic drug records were in order and a count of all controlled drugs was maintained for 6 of 6 medication carts reviewed for medication administration. This placed residents at risk for drug diversion. Findings include:The 1/2023 Ordering and Receiving Controlled Medications policy indicated, The pharmacy or nursing care center prepares an individual resident-controlled substance log for each controlled substance medication prescribed for a resident. This log is placed in the Narcotic book to be counted after every shift.On 1/31/26, the North Hall narcotic book revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct.On 2/24/26, the North Hall narcotic book revealed 29 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct.On 1/31/26, the South Hall narcotic logbook revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct.On 2/24/26, the South Hall narcotic logbook revealed 57 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct.On 1/31/26, the Central Hall narcotic logbook revealed 17 times out of 186 counting opportunities facility staff did not verify the narcotic count was correct.On 2/24/26, the Central Hall narcotic logbook revealed 29 times out of 150 counting opportunities facility staff did not verify the narcotic count was correct.On 2/25/26 at 1:10 PM, Staff 2 (DNS) acknowledged two staff members were to count the narcotics after every shift and sign the narcotic logbook together verifying the narcotic count was correct.

Based on interview and record review it was determined the facility failed to ensure a resident was informed in writing of the risks and benefits of a restraint and service dog denial for 2 of 9 sampled residents (#s 98 and 99) reviewed for accidents and choices. This placed residents at risk for not being informed. Findings include: 1. Resident 98 was admitted to the facility in 12/2025 with diagnoses including Parkinson's disease (progressive nerve disorder resulting in uncontrolled muscle tremors), anxiety, and panic disorder. The facility's undated admission Packet indicated before any service animal may be denied access to the facility or allowed to remain with their Patient/handler, a detailed written assessment of the reasons for the denial must be completed including all reasons why the service animal may not remain.The 12/9/25 Medication Profile by hospice revealed no documentation Resident 98 had a service animal.The 12/15/25 admission MDS revealed Resident 98 had a BIMS score of 15 (cognitively intact). A 12/18/25 Hospice Note revealed Resident 98 requested medications every two hours to address the resident's anxiety because she/he was anxious without her/his dog. A revised 12/19/25 care plan indicated animals were very important to have around for Resident 98 and interventions for the resident's negative behaviors and trauma included speaking to her/him about her/his dog. An undated Request to have Service Animal at Facility document identified Resident 98's care plan and abilities were reviewed, and it was determined the resident was not safe to care for her/his service animal in the facility. An attendant was required to meet the needs of her/his service animal during visits. On 2/24/26 at 11:15 AM, Witness 1 (Complainant) stated Resident 98 received no written notification why her/his service animal was not allowed to remain in the facility. On 2/26/26 at 9:40 AM, Staff 15 (LPN) stated Resident 98's service animal visited weekly, the service animal was for the resident's emotional support, and the resident was unsteady and a fall risk. On 2/27/26 at 9:27 AM, Staff 14 (Admissions Coordinator) stated she had a conversation with hospice prior to Resident 98's admission and verbally explained the resident's service animal could not remain in the facility. Staff 14 stated she was unsure if the verbal denial for the service animal was communicated to Resident 98 and indicated the resident had different expectations about her/his service animal once she/he arrived. Staff 14 acknowledged no written information about the denial for Resident 98's service animal was provided, and the facility was responsible to provide adequate communication to Resident 98. On 2/27/26 at 1:19 PM, Staff 1 (Administrator) confirmed communication to hospice or Resident 98 about the denial for the resident's service animal was not in writing and she expected the facility to follow their own policy.2. Resident 99 was admitted to the facility in 10/2025 with diagnoses including brain cancer and personality disorder. A 10/16/25 facility Elopement Risk Evaluation revealed Resident 99 was a moderate risk for elopement. The 10/22/25 admission MDS revealed Resident 99 used a Wander Guard (electronic alarm system) daily and had a BIMS score of 6 (severely cognitively impaired). The 10/2025 TAR revealed Resident 99 had orders for a Wander Guard and to verify placement on the resident's left ankle every shift. A review of Resident 99's clinical record revealed no evaluation or consent for the resident's Wander Guard.On 2/27/26 at 1:09 PM, Staff 2 (DNS) stated Resident 99's Wander Guard was attached to the resident because she/he was at risk of exiting the building which was unsafe for the resident due to her/his cognition. Staff 2 confirmed Resident 99 was able to consent and was not evaluated or provided the option to consent to have a Wander Guard. On 3/2/26 at 9:11 AM, Staff 3 (Regional Director of Clinical) acknowledged the use of the Wander Guard for Resident 99 was a potential restraint and required an evaluation and consent for use.

Based on observation, interview and record review the facility failed to facilitate the resident's right to make choices about their diet for 1 of 4 (#5) residents reviewed for choices. This put residents at risk for lack of self-determination. Findings include: Resident 5 was admitted to the facility in 2023 with a diagnosis of chronic respiratory failure.A review of Resident 5's 12/2025 BIMS Assessment revealed she/he was cognitively intact. On 2/23/26 at 10:46 AM, Resident 5 stated she/he requested multiple times to be re-evaluated by the speech therapist because she/he was prescribed a minced and moist diet, which included many pureed foods. Resident 5 stated she/he refused to eat pureed foods and wanted a diet with no pureed foods. Resident 5 stated she/he had been waiting several months to be re-evaluated by the speech therapist. A review of the resident's clinical record revealed she/he requested her/his diet be re-evaluated at Care Conferences completed in 7/2025 and 1/2026.A Progress Note on 7/30/25 revealed Resident 5 reported she/he did not like his/her current diet. Resident 5's Annual MDS completed 10/2025 revealed Resident 5 had declined weight and mid-arm circumference checks and was at risk for weight loss, muscle loss, weakness and delayed wound healing. An 11/25/25 Progress Note revealed the resident reported poor appetite due to disliking her/his food.On 2/27/26 at 12:35 PM, Staff 32 (SLP) stated she had not re-evaluated Resident 5's swallowing. Staff 32 stated she had not completed a Risk/Benefit Assessment with the resident. On 2/27/26 at 1:40 PM, Staff 6 (Resident Care Manager/LPN) stated she had not completed a Risk/Benefit Assessment with Resident 15 related to her/his diet. She stated a Risk/Benefit Assessment should have been completed. On 2/27/26 at 1:59 PM, Staff 2 (DNS) stated when a resident wants something that is medically contraindicated staff should try and reach a mutually agreeable solution with the resident and a Risk/Benefit Assessment should be completed with the resident.

Based on interview and record review it was determined the facility failed to conduct a Significant Change MDS assessment for 1 of 4 sampled residents (#47) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include:Resident 47 was admitted to the facility in 7/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS is a disease that destroys the connection between the brain and muscles).An 10/2025 Quarterly MDS indicated Resident 47 did not have swallowing issues and did not have significant weight loss.A 12/19/25 Progress Note indicated Resident 47 was not safe to swallow and recommendations were made for Resident 47 to be NPO (have nothing by mouth) and have a nasal gastric (NG) tube (a tube placed down the nose, to the stomach) placed for alternate means to obtain nutrition.A 1/12/26 Progress Note indicated Resident 47 was NPO since 12/19/25 which included food and medications, Resident 47 refused an NG tube, and Resident 47 lost 20 pounds since 10/2025.A review of Resident 47's weight indicated she/he weighed 140.6 pounds on 10/7/25 and 121 pounds on 1/7/26.A 1/20/2026 Quarterly MDS indicated Resident 47 had issues with swallowing and significant weight loss.A 2/13/26 Progress Note indicated Resident 47 had an NG tube placed and tube feeding was started.A review of Resident 47's medical record revealed no indication a Significant Change MDS was completed.On 2/26/26 at 12:49 PM, Staff 23 (RN MDS Coordinator) stated a Significant Change MDS is completed when a resident had a decline in two or more areas that did not resolve in two weeks. Staff 23 stated she was unsure if Resident 47 had a change in swallowing ability.On 2/26/26 at 1:24 PM Staff 24 (SLP) stated Resident 47 had a change in her/his ability to swallow safely in 12/2025.On 2/27/26 at 12:31 PM, Staff 2 (DNS) stated a Significant Change MDS was expected to be completed when a resident had a decline in two or more areas that do not resolve in two weeks. Staff 2 stated Resident 47 had a change in swallowing ability in 12/2025 and significant weight loss in 1/2026. Staff 2 acknowledged Resident 47 should have had a Significant Change MDS completed in 1/2026.

Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain oral hygiene for 1 of 5 sampled residents (# 3) reviewed for ADLs. This placed residents at risk for reduced oral health. Findings include: Resident 3 was admitted to the facility in 11/2016 with diagnoses including epilepsy (seizure disorder).The 8/6/25 Care Plan for Resident 3 indicated a need for reminders and set up for oral care.A 2/11/26 quarterly MDS assessment revealed Resident 3 required setup or cleanup assistance for oral hygiene and had a BIMS score of 15, indicating she/he was cognitively intact. On 2/23/26 at 12:41 PM Resident 3 stated staff were directed to help her/him with brushing her/his teeth twice a day but did not. Resident 3 indicated she/he no longer requested oral hygiene assistance because she/he was told no by staff so frequently.On 2/24/26 at 10:35 AM Resident 3 estimated the last time she/he received help brushing her/his teeth was 1/2026. Resident 3 stated she/he had no idea where a toothbrush was since she/he had not used one recently. On 2/24/26 at 10:41 AM Resident 3's overbed table, nightstand, restroom, and in-room sink were searched but no toothbrush was located. Atop the nightstand was an oral care basin containing toothpaste.On 2/25/26 at 10:31 AM Resident 3 reported it didn't happen when asked if she/he got her/his teeth brushed in the evening of 2/24/26 or the morning of 2/25/26. Resident 3 indicated she/he still did not have a toothbrush. The oral care basin was again observed on top of Resident 3's nightstand and contained toothpaste but no toothbrush.On 2/25/26 at 12:47 PM Staff 27 (CNA) reported he had not yet assisted Resident 3 with oral hygiene that day. Staff 27 was unable to locate a toothbrush in Resident 3's room or bathroom. Staff 27 indicated oral hygiene supplies were usually kept in or on the nightstand. On 3/2/26 at 11:22 AM, Staff 2 (DNS) stated the expectation was for staff to offer oral hygiene opportunities at least twice a day to residents. Staff 2 confirmed Resident 3 was not provided oral hygiene as expected.

Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain grooming and oral hygiene for 2 of 5 sampled residents (#s 5 and 57) reviewed for ADLs. This placed residents at risk for unmet ADL needs. Findings include: Resident 5 was admitted to the facility in 2023 with a diagnosis of chronic respiratory failure. Resident 5's 10/2025 Annual MDS indicated she/he was cognitively intact. A review of Resident 5's Care Plan completed 1/2026 indicated she/he required the assistance of staff for personal hygiene. On 2/23/26 Resident 5 was observed with unbrushed, matted hair. On 2/23/26 at 10:48 AM, Resident 5 stated staff do not brush her/his hair daily. Resident 5 stated she/he wanted the knots brushed out of the hair on the back of her/his head and she/he could not do it. On 2/27/26 at 9:28 AM, Staff 23 (CNA) stated he cared for Resident 5 that morning and the previous day and did not brush Resident 5's hair. On 2/27/26 10:46 AM, Staff 33 (CNA) stated she never brushed Resident 5's hair when providing care for her/him. On 2/27/26 at 11:01 AM, Staff 34 (CNA) stated she never brushed Resident 5's hair when providing care for her/him. On 2/27/2026 at 1:59 PM, Staff 2 (DNS) stated her expectation was for staff to offer to brush residents' hair daily. 2. Resident 57 admitted to the facility in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. The 7/3/25 Care Plan indicated Resident 57 required reminders and setup assistance with oral care. A 12/22/25 quarterly MDS revealed Resident 57 required setup or cleanup assistance for oral hygiene and had a BIMS score of 15 indicating intact cognition. On 2/23/26 at 2:50 PM Resident 57 stated staff did not assist her/him with oral hygiene despite requests. On 2/24/26 at 11:34 AM, Resident 57 stated she/he required total assistance from staff with tooth brushing. When asked where the oral hygiene supplies were located, the resident indicated she/he did not know and had never seen a toothbrush in her/his room. On 2/24/26 at 11:41 AM and 2/25/26 at 10:59 AM no toothbrush or toothpaste were located on Resident 57's overbed table, in the nightstand, or at a sink in resident's room or restroom. A dry toothbrush and facility issued toothpaste were located at the bottom of a large plastic bin on the top shelf of the closet across the room. The oral hygiene items were not visible as the bin was filled with large personal care items including body wash, deodorant, and an unopened box of toothpaste brought by the resident's family for her/his use. On 2/25/26 at 12:48 PM Staff 27 (CNA) stated so far in the shift (6:00 AM to 2:00 PM) he had not assisted Resident 57 with brushing her/his teeth. Staff 27 was not able to locate oral hygiene items in Resident 57's room. Staff 27 acknowledged brushing teeth is an expected part of daily care for residents. On 3/2/26 at 11:22 AM, Staff 2 (DNS) stated the expectation was for staff to offer oral hygiene opportunities at least twice a day to residents. Staff 2 confirmed Resident 57's experience did not meet this expectation.

Based on interview, observation, and record review it was determined the facility failed to follow physician orders for 3 of 8 sampled residents (#s 10, 11, and 57) reviewed for edema, care planning, and unnecessary medications. This placed residents at risk for unidentified conditions. Finding include: Resident 57 was admitted to the facility in 6/2025 with a diagnosis of type 2 diabetes mellitus. A review of Resident 57s clinical record revealed an order for hydrocodone-acetaminophen, a pain reliever, to be administered up to twice daily as needed for pain. The resident's MAR for 2/20/26 revealed two doses of hydrocodone-acetaminophen were recorded on 2/20/26. A review of the facility's narcotic administration log revealed Resident 57 received 3 administrations of hydrocodone-acetaminophen on 2/20/26. Resident 57 was not available for an interview. On 3/2/26 at 7:49 AM, Staff 39 (LPN) stated she administered a dose of hydrocodone-acetaminophen to Resident 57 at 10:49 PM on 2/20/26. Staff 39 stated she was able to enter the administration in the resident's MAR, so she was not aware two doses of the medication had already been administered to Resident 57 for the day. On 3/2/26 at 8:55 AM, Staff 38 (CMA) stated he administered hydrocodone-acetaminophen to Resident 57 at 2:49 PM and just before Resident 57 went to bed at approximately 8:30 PM. Staff 38 stated he neglected to enter his second administration of hydrocodone-acetaminophen to Resident 57 in the MAR. On 3/2/26 at 12:40 PM, Staff 2 (DNS) stated her expectation was staff would immediately enter all medications into the MAR when they were administered. 2. Resident 10 was admitted to the facility in 10/2025 with diagnoses including heart failure and a stroke. A 1/8/26 Physician Order revealed orders for daily weights and to call the provider if Resident 10 gained two to three pounds over a two-day period or five pounds in one week. A review of Resident 10's weights revealed the following: -2/7/26 weight was 176.6 pounds -2/9/26 weight was 180.2 pounds -2/13/26 weight was 181.4 pounds -2/14/26 weight was 186 pounds A review of Resident 10's medical record revealed no evidence the provider was notified of Resident 10's weight gain. On 2/25/26 at 12:23 PM, Staff 9 (LPN) stated from 2/7/26 through 2/9/26 Resident 10 gained 3.6 pounds and from 2/13/26 through 2/14/26 Resident 10 gained 4.6 pounds. Staff 9 stated Resident 10's provider was not notified of the weight gains. On 3/2/26 at 12:07 PM, Staff 2 (DNS) stated staff were expected to notify the provider of weight gain per the orders. 3. Resident 11 was admitted to the facility on [DATE] with diagnoses including a stroke and alcoholic cirrhosis (liver disease). A review of admission orders revealed a 1/26/26 order for weekly basic metabolic panel labs (a blood test that measures eight different substances in your blood). A review of Resident 11's 2/2026 MAR revealed the weekly basic metabolic panel labs were charted as not being completed on 2/2/25, 2/9/26, and 2/16/26 by Staff 31 (LPN). On 2/25/26 at 1:43 PM Staff 22 (LPN Resident Care Manager) acknowledged Resident 11 was admitted with orders for a weekly basic metabolic panel lab and stated the labs were not completed as ordered. On 2/25/26 at 1:50 PM, Staff 31 stated Resident 11 did not have the weekly basic metabolic panel lab completed on 2/2/26, 2/9/26, or 2/16/26 because he had not been trained on obtaining blood samples for labs. On 3/2/26 at 11:55 AM, Staff 2 (DNS) stated labs are expected to be completed as ordered.

Based on interview and record review it was determined the facility failed to accurately assess a resident, thoroughly investigate and follow care plan interventions for elopement for 2 of 3 sampled residents (#s 99 and 102) reviewed for accidents. This placed residents at risk for elopement. Findings include:1. Resident 102 admitted to the facility on [DATE] with diagnoses including non-displaced type II dens fracture (stable fracture of the second cervical vertebra requiring neck immobilization), metabolic encephalopathy (brain dysfunction due to systemic metabolic disturbance), and delirium due to medical condition (acute, fluctuating confusion caused by illness). A 1/17/26 Elopement investigation revealed Staff 17 (CNA) was notified by a pedestrian that an elder person with a wheelchair was outside in the street crying and needed help. Staff 17 located Resident 102 standing behind her/his wheelchair holding onto it saying she/he was freezing and wanted to go home. Resident 102 was in the road about 20 feet from a busy intersection. Resident 102 was confused, resisted help but eventually sat in her/his wheelchair and allowed staff to bring her/him back to the facility. Staff 17 stated she was unsure how long Resident 102 was outside, but she/he was freezing cold and was not wearing a coat. On 2/25/26 at 6:24 PM, Staff 21 (LPN) reported she reviewed Resident 102's medical record prior to completing the admission Elopement Risk Evaluation. Staff 21 stated she was aware the resident had severe cognitive impairment, with fluctuating cognition, and the resident was not consistently aware of her/his surroundings. On 2/26/26 at 9:26 AM, Staff 18 (CNA) stated Resident 102 was frequently confused and agitated during her shifts and made multiple attempts to exit the facility. Staff 18 stated she reported Resident 102's behaviors to a nurse. Staff 18 further stated the resident's exit-seeking behavior was hard not to notice. Staff 18 reported on 1/17/26 at approximately 8:00 PM, she became aware Resident 102 was outside the facility unsupervised and assisted other staff to bring the resident back inside. Staff 18 estimated the resident had been outside for approximately 20 minutes before staff located her/him. Staff 18 further stated when Resident 102 was found, the resident was not wearing a jacket or shoes and appeared cold, wet, and confused. On 2/26/26 at 9:50 AM, Staff 15 (LPN) stated Resident 102 exhibited significant confusion and agitation. Staff 15 stated Resident 102 wandered throughout the facility in her/his wheelchair and attempted to exit through the front door on at least one occasion. On 2/26/26 at 2:54 PM, Staff 17 (CNA) stated Resident 102 exhibited exit-seeking behaviors shortly after admission and attempted to exit the facility multiple times. Staff 17 stated management was aware of the behavior. Staff 17 stated on 1/17/26, while on break, a pedestrian informed her that a resident was outside hysterical and cold. Staff 17 located Resident 102 near a busy intersection. Staff 17 stated the resident was cold, shaking, and was not wearing a jacket or shoes. On 2/26/26 at 4:26 PM, Staff 19 (RN) confirmed Resident 102's cognition fluctuated and stated the resident attempted to exit the facility on 1/17/26 earlier in the day. Staff 19 stated she did not believe the resident required a wander guard prior to the elopement. On 3/2/26 at 10:26 AM, Staff 2 (DNS) and Staff 3 (Regional Director of Clinical) acknowledged the facility did not reassess Resident 102's elopement risk after staff became aware of exit-seeking behaviors. 2. Resident 99 was admitted to the facility in 10/2025 with diagnoses including brain cancer and personality disorder. A 10/16/25 facility Elopement Risk Evaluation revealed Resident 99 was a moderate risk for elopement with no history of wandering or elopement. The instructions for the evaluation indicated it was to be completed with any significant change or as needed. A 10/20/25 revised care plan indicated Resident 99 was an elopement risk, staff were to provide frequent checks for the resident, she/he used a wheelchair for mobility, the resident was encouraged to attend activities to provide a distraction, and to evaluate her/his needs if the resident appeared to seek the exit. The 10/22/25 admission MDS revealed Resident 99 used a Wander Guard (electronic alarm system) daily and had a BIMS score of 6 (severely cognitively impaired). A 10/25/25 Elopement investigation revealed Staff 12 (CNA) went on break at 2:20 PM, returned at 2:50 PM, and was informed Resident 99 was taken to activities by Staff 13 (CNA). Staff 12 found the resident in the parking lot, and it was determined the resident entered the door security code to exit the building. On 2/26/26 at 9:19 AM, Staff 9 (RN) stated after she completed the initial elopement assessment for Resident 99, Staff 9 indicated she noticed increased agitation by the resident who wanted to smoke more often. Staff 9 stated she wrote nursing notes and acknowledged a revised elopement risk evaluation was warranted and was not completed. On 2/26/26 at 10:20 AM, Staff 12 stated Resident 99 required close supervision prior to her/his elopement. Staff 12 revealed the resident attempted to get out the door a lot but never exited without someone who was available to take the resident for a walk. Staff 14 stated there were multiple times she saw Resident 99 use the security code to get outside. On 2/26/26 at 12:40 PM and 2:50 PM, Staff 6 (Resident Care Manager-LPN) stated staff were required to have Resident 99 within their line of sight. Staff 6 stated additional interventions were implemented to address Resident 99's increased agitation and exit seeking behaviors and confirmed a new elopement assessment was not completed, needed supervision did not occur when staff went on break at the time of the resident's elopement, and Staff 6 did not verify the thoroughness of the investigation. On 2/26/26 at 1:08 PM, Staff 13 (CNA) stated Resident 99 became aggressive while Staff 14 was on break, so he traded the task to supervise the resident to another staff. On 2/26/26 at 3:09 PM, Staff 7 (activity assistant) stated Resident 99 often came and left from activities, and he was not informed Resident 99 was an elopement risk which required additional care for the resident. On 2/26/26 at 3:45 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged a thorough investigation was expected to understand who last saw the resident and what occurred prior to the elopement. On 3/2/26 at 9:11 AM, Staff 3 (Regional Director of Clinical) expected staff to follow Resident 99's plan of care.

Based on interview and record review it was determined the facility failed to provide care and services to prevent a UTI for 1 of 1 sampled resident (#8) reviewed for urinary tract infections. This placed resident at increased risk for recurrent UTIs. Findings include: Resident 8 admitted to the facility in 11/2025 with diagnoses including urinary retention (a condition related to the inability to completely empty the bladder when voiding). On 2/23/26 at 10:48 AM, Witness 2 (family member) indicated Resident 8 had four or more UTIs in the past year.A progress note dated 11/20/25 indicated Resident 8 required an appointment with a urologist specializing the treatment of urinary retention. Staff 16 (Social Services Director) scheduled Resident 8 for a urologist appointment on 12/2/25 and arranged transportation. Resident 8's clinical record contained no documented evidence she/he was seen by the urologist as planned on 12/2/25. Resident 8 was diagnosed with UTIs on 12/26/25, 2/17/26, and 2/24/26.On 3/2/26 at 11:15 AM, Staff 2 (DNS) stated Resident 8 was referred to the urologist to help manage her/his recurring UTIs. Staff 2 confirmed Resident 8 missed the 12/2/25 appointment and the facility did not reschedule the missed appointment.

Based on observation, interview, and record review it was determined the facility failed to address call lights in a timely manner for 2 of 6 sampled residents (#s 22 and 47) reviewed for staffing. This placed residents at risk for delayed care. Findings include: 1. Resident 47 was admitted to the facility in 7/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS is a disease that destroys the connection between the brain and muscles). A review of call light audits for Resident 47 revealed the following call lights on greater than 30 minutes: -11/2/2025 one hour and five minutes -11/7/2025 35 minutes -11/13/25 33 minutes -11/14/25 41 minutes -11/21/25 one hour and 12 minutes An 11/21/25 complaint alleged staff were ignoring Resident 47's call light. A 1/4/26 revised care plan indicated Resident 47 was to have cares in pairs. A 1/26/26 Grievance Communication Form indicated on 1/25/26 Resident 47 requested to use the restroom at 9:36 PM and did not receive assistance until 10:15 PM. The conclusion indicated Resident 47 did have a longer wait time because when she/he requested assistance staff were not available due to, a bunch of call lights in overtime two so Resident 47 waited in the front lobby and staff were not aware of her/his location. On 2/24/26 at 6:42 AM, Resident 47's call light was observed on. On 2/24/26 at 7:15 AM, Staff 10 (CNA) was observed to answer Resident 47's call light. Staff 10 acknowledged Resident 47's call light was on for more than 30 minutes and stated there were no staffing issues this shift but Resident 47 needed two staff members to provide assistance and everyone was busy. On 3/2/26 at 9:21 AM Staff 35 (CNA) stated the facility was continuously short CNA staff which makes the shift, hectic. On 3/2/26 at 9:33 AM Staff 36 (LPN) stated the facility was short CNA staff, quite a few nights. Staff 36 stated she assisted the CNAs with answering call lights, but it got busy and residents got frustrated. On 3/2/26 at 9:37 AM Staff 37 (CNA) stated the facility has been short CNA staff. Staff 37 stated when they were short CNAs, it would get busy, the nurses would try to help answer call lights, but they also had a job to complete. Staff 37 stated when they were short CNAs rounds took longer than two hours to complete. On 2/26/26 at 9:32 AM, Staff 2 (DNS) stated the call lights would go into overtime after being on for seven and a half minutes and would go into overtime two after being on for 15 minutes. 2. Resident 22 was admitted to the facility in 5/2025 with diagnoses including traumatic brain injury and chronic pain. The 2/10/26 Quarterly MDS indicated Resident 22 had a BIMS score of 15 (cognitively intact) and the resident's pain occasionally interfered with her/his daily activities. A 2/10/26 revised Care Plan indicated Resident 22 required one staff to assist her/him with all transfers. If staff were uncomfortable with transfers or the resident was unsafe, two staff were permitted to transfer the resident. Resident 22 was occasionally incontinent of bowel and bladder. A 2/13/26 Summary Call Data by Room/Bed report revealed, at 3:55 PM, Resident 22's call light was answered after 30 minutes. A 2/14/26 Grievance Communication Form revealed Resident 22 indicated her/his call light was not answered timely on 2/13/26 after the resident soaked her/his bed with water and required assistance. A 2/18/26 Grievance Communication Form revealed Resident 22 voiced concerns during a care conference of long call lights during resident smoke breaks. A 2/23/26 Summary Call Data by Room/Bed report revealed, at 6:33 PM, Resident 22's call light was answered after 25 minutes. On 2/23/26 at 1:41 PM, Resident 22 stated there were issues with long call lights when residents had smoke breaks. Resident 22 stated she/he often required toilet assistance when assistance was requested. A 2/24/26 Grievance Communication Form revealed Staff 4 (CNA) informed Resident 22 she was going on a break and told another CNA to address the resident's call light. On 2/24/26 at 2:36 PM, Staff 5 (CNA) stated a few weeks earlier Staff 28 (CNA) did not want to answer Resident 22's call light while Staff 5 took residents to smoke around 4:00 PM. Staff 5 stated Resident 22 and Staff 28 had a disagreement the previous day. Staff 5 confirmed Resident 22 waited 30 minutes for care which was provided when Staff 5 returned. On 2/27/26 at 1:35 PM, Staff 2 (DNS) stated Staff 28 removed himself from Resident 22's care without communicating to the charge nurse. Staff 2 expected staff to address call lights timely through improved communication. On 3/2/26 at 11:50 AM, Resident 22 stated Staff 4 went on break and left her/his call light on to alert another CNA that she/he required assistance. Resident 22 stated she/he was in pain by the time assistance was provided. On 3/2/26 at 11:57 AM, Staff 4 confirmed the CNA who did not answer Resident 22's call light timely on 2/23/26 was previously fired by Resident 22 from her/his care. Staff 4 stated communication between staff did not occur to answer Resident 22's call light timely. On 3/2/26 at 12:29 PM, Staff 2 stated she compared the multiple grievances filed for Resident 22 and acknowledged the root cause of long call lights for the resident was not addressed.

Based on interview and record review it was determined the facility failed to ensure residents did not receive unnecessary medications for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for side effects related to blood pressure medications. Findings include:Resident 4 was admitted to the facility in 12/2022 with diagnoses including heart failure and arterial fibrillation (an irregular heartbeat). A review of orders revealed a 6/11/24 order for metoprolol succinate (a medication used to treat high blood pressure), hold for a heart rate less than 60 beats per minute. A review of Resident 4's 1/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on:-1/10/26 heart rate was 59 per minute-1/22/26 heart rate was 59 per minute-1/24/26 heart rate was 52 per minute-1/29/26 heart rate was 52 per minute A review of Resident 4's 2/2026 MAR revealed Resident 4 was administered metoprolol succinate with a heart rate less than 60 beats per minute on:-2/10/26 heart rate was 56 per minute-2/12/26 heart rate was 58 per minute On 2/25/26 at 10:03 AM, Staff 32 (LPN) stated she administered Resident 4 the metoprolol succinate on 1/10/26,1/24/26, 1/29/26, 2/10/26 and 2/12/26 and acknowledged Resident 4's heart rate was less than 60 beats per minute on those dates, and the metoprolol succinate should have been held per orders.On 2/25/26 at 11:51 AM, Staff 9 (RN) stated on 1/22/26 Resident 4's HR was 59 and she administered the metoprolol succinate.On 2/27/26 at 11:38 AM, Staff 7 (LPN Resident Care Manager) stated staff were expected to hold the metoprolol succinate if Resident 4's heart rate was less than 60 beats per minute per orders.

Based on observation and interview it was determined the facility failed to ensure medications, were stored properly for 1 of 3 medication carts reviewed. This placed residents at risk for reduced medication effectiveness. Findings include:On 2/25/26 South Hall medication cart observations revealed Resident 15's insulin had been removed from the refrigerator and was not dated. Staff to 22 (LPN) confirmed the insulin should've been dated after staff removed the insulin from the refrigerator. Resident 6's insulin dated 2/18/26 was observed unopened on the medication cart. Staff 22 confirmed the insulin should've been kept refrigerated until used.On 2/25/26 at 4:01 PM, Staff 3 (Regional Director of Clinical) stated all nursing staff are expected to follow proper medication storage requirements, including refrigeration and dating of insulin.

Based on observation, interview, and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#57) reviewed for ADLs. This placed residents at risk for inaccurate medical records. Findings include:1. Resident 57 admitted to the facility in 6/2025 with diagnoses including type two diabetes mellitus with diabetic neuropathy. On 2/23/26 at 2:50 PM Resident 57 stated staff did not assist her/him with oral hygiene despite resident requests. On 2/24/26 at 11:34 AM, Resident 57 stated she/he required total assistance from staff to brush her/his teeth. When asked where the oral hygiene supplies were located, this resident indicated she/he did not know and had never seen a toothbrush in her/his room.On 2/27/26 at 9:11 AM Resident 57 reported she/he received assistance with brushing her/his teeth once that week on day shift on 2/25/26. Resident 57 stated she/he was not offered additional opportunities for oral hygiene.Resident 57's 2/24/26 Task: GG-Oral Hygiene report indicated oral hygiene was completed by Staff 25 (CNA) during the day shift (6:00 AM to 2:00 PM).On 2/25/26 at 4:17 PM Staff 25 stated she did not complete oral hygiene with Resident 57 on 2/24/26.Resident 57's 2/26/26 Task: GG-Oral Hygiene report indicated Staff 26 (CNA) assisted with oral hygiene during the evening shift (2:00 PM to 10:00 PM).On 2/27/26 at 10:13 AM Staff 26 stated he did not assist Resident 57 with brushing her/his teeth that week. On 3/2/26 at 11:22 AM Staff 2 (DNS) confirmed it was not acceptable for staff to document completion of care if it was not done.

Based on interview and record review, it was determined the facility failed to ensure resident care equipment was monitored as recommended for 1 of 3 sampled residents (#12) reviewed for accidents. Resident 12 experienced a fall from a broken shower chair, sustained rib fractures, and a closed head injury. Findings include: Resident 12 was admitted to the facility in 9/2024 with diagnoses including stroke. A 5/14/25 Fall investigation revealed Staff 12 (CNA) was providing Resident 12 with a shower. Resident 12's shower chair broke and Resident 12 fell onto the shower room floor, complaining of head and right rib pain. Resident 12 was sent to the hospital. A 5/14/25 hospital After Visit Summary revealed Resident 12 was diagnosed with a rib fracture, a closed head injury, and a bruise. A review of the undated shower chair owner's manual revealed the chair was to be checked at least monthly for glued fittings by attempting to pull the polyvinyl chloride (type of plastic) out of the fittings. The pipes on the shower chair needed to be checked for cracking, fractures, or other damage at least monthly. A Work History Report printed on 7/9/25 revealed no inspections of shower chairs were completed in 2024 or 2025. On 7/8/25 at 12:35 PM, Resident 12 stated on 5/11/25 the shower chair came apart and two CNAs put the chair back together. On 5/14/25 she/he received a shower and the chair collapsed causing fractured ribs. On 7/8/25 at 2:03 PM, Staff 11 (CNA) stated on 5/11/25 Resident 12 was in the shower chair and Staff 10 (CNA) noticed a piece was coming apart on the chair. Staff 11 stated they transferred Resident 12 to her/his wheelchair and Staff 10 took the shower chair to the maintenance room. Attempts to reach Staff 10 on 7/8/25 and 7/9/25 were unsuccessful. On 7/8/25 at 2:24 PM, Staff 8 (Maintenance Lead) stated on 5/12/25, there was a shower chair in the boiler room. Staff 8 stated there was no note on the chair and no work order was received for the chair. Staff 8 stated he did a visual inspection and figured a work order would come in. The shower chair was gone from the boiler room on 5/13/25. Staff 8 stated he did not do anything with the chair. On 7/9/25 at 10:37 AM, Staff 12 stated she obtained the shower chair from the shower room on 5/14/25 and placed Resident 12 in the shower chair. Staff 12 did not hear any cracking noises when setting Resident 12 into the chair or while taking her/him to the shower room. After the shower was completed, Staff 12 rolled the chair toward her so she could dry Resident 12's feet and the shower chair collapsed. On 7/9/25 at 11:09 AM, Staff 1 (Administrator) stated during the investigation they identified the process for broken equipment needed to be more streamlined. The deficient practice was identified as Past Noncompliance based on the following: On 5/16/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures of using the same equipment which previously was broken. The Plan of Correction included: -Broken shower chair was removed and discarded. -A facility wide audit and inspection of all shower chairs was completed. A new process was implemented for logging equipment inspections as well as a new tagging process for equipment requiring maintenance. -Facility wide education was provided to staff on equipment safety checks, the process for when equipment needed maintenance, and the new tagging process for equipment requiring maintenance. -Audits were completed for random staff knowledge on equipment not functioning properly and audits of shower chairs' functional status were completed on the following dates: 5/23/25, 5/30/25, 6/6/25, 6/7/25, 6/13/25, 6/20/25, 6/27/25, and 7/3/25.

2. Resident 16 was admitted to the facility in 7/2022 with diagnoses which included stroke. A 5/5/25 Bowel and Bladder Evaluation indicated Resident 16 was a candidate for scheduled toileting (timed voiding). A 5/5/25 quarterly MDS indicated Resident 16 was cognitively intact. A 6/3/25 care plan revealed Resident 16 was incontinent of bowel and bladder. Resident 16 had a history of urgency incontinence. Interventions included assisting with using the bathroom before breakfast and after lunch per preference to anticipate needs, resident used briefs, provide incontinentence care as needed, and provide peri care (cleaning of the genital area) after an incontinent episode. A public complaint was received on 6/23/25 alleging in 6/2025 Resident 16 was not cleaned properly after a bowel movement. The brief was clean, but Resident 16 had dried feces over groin area, buttocks and down her/his thighs. On 7/8/25 at 9:16 AM, Witness 1 (Complainant) stated twice in 6/2025 she found Resident 16 with dried feces on her/him. Witness 1 stated the first instance involved dried feces on her/his back, causing skin irritation. Witness 1 stated Staff 6 (CNA) came in, saw the dried feces on Resident 16, and cleaned her/him. The second instance involved dried feces on Resident 16's groin area. On 7/8/25 at 12:42 PM, Resident 16 stated staff would put her/him in a wheelchair and she/he would be in it all day with no incontinentence care unless she/he advocated for assistance. On 7/8/25 at 1:23 PM, Staff 6 (CNA) stated in 6/2025 he came on shift and assisted Resident 16 because she/he had dried feces on her/him and some dry skin flakes on her/his buttocks. Staff 6 stated Resident 16 was not fully cleaned following the previous incontinent episode. On 7/8/25 at 1:31 PM, Staff 5 (CNA) stated there was a day in 6/2025 when Resident 16 had explosive diarrhea and she was changing Resident 16's shirt and pants all day long. On 7/9/25 at 8:32 AM, Staff 7 (CNA) stated Resident 16 was difficult to clean after a bowel movement. Staff 7 stated she did not leave Resident 16 unclean after incontinentence care and there were times when she could only get 90 percent of Resident 16's feces off her/him because she/he would refuse additional cleaning. Staff 7 reported it to the nurse and let the next CNA know during the shift change. On 7/9/25 at 11:04 AM and 12:25 PM, Staff 1 (Administrator) stated she would expect staff to clean a resident thoroughly unless a resident refused. If a resident refused, CNA staff were expected to report the refusal to the nurse. Staff 2 (DNS) stated she expected the nurse to document if the resident refused incontinentence care in case there was a skin issue. Based on interview and record review it was determined the facility failed to provide adequate incontinentence and catheter care for 2 of 3 sampled residents (#s 14 and 16) reviewed for catheter care. This placed residents at risk for unmet care needs, skin breakdown and loss of dignity. Findings include: 1. Resident 14 was admitted to the facility in 12/2022 with diagnoses including chronic venous hypertension with ulcer and inflammation of bilateral lower extremity. A 12/2024 Annual MDS indicated Resident 14 was cognitively intact. A 12/16/24 signed order instructed staff to provide catheter care each shift. A 6/2025 TAR instructed staff to provide catheter care each shift. Catheter care was not completed during the night shift on 6/6/25. A FRI received on 6/9/25 alleged on 6/6/25 Resident 14 was not provided incontinentence care. On 7/8/25 at 9:05 AM, Resident 14 stated she/he notified staff she/he needed her/his brief changed on 6/6/25. Staff 14 (CNA) stated she could not provide care immediately and would return. On 7/8/25 at 4:10 PM, Staff 13 (CNA) stated during night shift on 6/6/25 he went to check on Resident 14 around 11:00 PM. Resident 14 was not changed for nine hours. Resident 14's catheter bag was full and was not checked on night shift. On 7/9/25 at 11:00 AM, Staff 10 (CNA) stated Resident 14 reported Staff 14 (CNA) answered her/his call light and stated she would return and never did on 6/6/25. Staff 10 and Staff 13 assisted Resident 14 with the brief change on the next shift. Staff 10 stated it was evident Resident 14 was not provided catheter or incontinentence care during the night shift on 6/6/25. Messages were left with Staff 14 (CNA) twice on 7/8/25 and twice on 7/9/25. Calls were not returned. On 7/9/25 at 11:32 AM, Staff 1 (Administrator) acknowledged Resident 14 was not provided incontinentence care and the expectation was to provide care each shift.

Based on observation, interview, and record review it was determined the facility failed to ensure professional standards were followed for 2 of 6 sampled residents (#s 39 and 442) for medication administration. Resident 442's medications were inappropriately administered resulting in a change of condition which required hospitalization . Findings include: Per [NAME] [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (A) Adhere to professional practice and performance standards; Per [NAME] [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: 1. Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). A public complaint was received on 5/30/24 which alleged on 5/29/24 at 7:30 AM Staff 28 (RN) administered Resident 442's morning medications, and within 30 minutes Witness 2 (Complainant) noticed the resident was not responding to staff when spoken to and became out of it. An 4/6/24 physician order indicated staff were to administer chlorpromazine (antipsychotic for mental disorder) PO, vitamin D3 PO, Protonix (treat reflux) PO, lithium ER (extended release for bipolar disorder) PO, and propranolol (for high blood pressure) PO. On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding. A 5/29/24 Hospital Summary note indicated Resident 442 arrived to the emergency room with altered mental status, and mildly elevated lithium levels. Normal lithium levels are 1.2 millequivents per liter and the resident's level was 2.5 millequivents per liter. Resident 442 was transferred to the ICU (Intensive Care Unit). On 10/7/24 at 2:13 PM Witness 2 stated Resident 442 was brought to the dining room for breakfast but did not eat. Witness 2 stated the resident was lethargic. Witness 2 stated Staff 28 was notified of the change of condition but the resident was not assessed. On 10/8/24 at 1:06 PM Staff 3 stated Staff 32 and Staff 34 requested she assess Resident 442. Staff 3 stated the resident was lethargic and sent out and admitted to the hospital. On 10/8/24 at 1:55 PM Staff 32 (CNA) stated on 5/29/24 Resident 442 was lethargic in the morning and was placed back in bed. Staff 32 stated Staff 28 was notified but the resident was not assessed. Staff 32 stated the resident was placed in her/his wheelchair for lunch but the resident was more lethargic and not responsive to stimuli. Staff 32 stated Staff 28 was again notified but the resident was not assessed. Staff 32 stated Staff 34 (CNA) was notified and requested Staff 3 (LPN-Resident Care Manager) to assess Resident 442. On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. 2. Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes. On 10/9/24 at 11:50 AM Staff 28 (RN) was observed to check Resident 39's CBG (blood sugar measurement) level in the dining room. Staff 28 placed the glucometer on the North medication cart and cleaned the glucometer with small alcohol prep wipes. On 10/9/24 at 12:10 PM Staff 28 stated she always used alcohol prep wipes to sanitize the glucometer, and she was not aware of another sanitizing wipe. On 10/9/24 12:15 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) stated the glucometer should be sanitized with the proper sanitizing wipes.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#442) reviewed for change of condition. Resident 442's medications were inappropriately administered resulting in a change of condition which required hospitalization . Findings include: Resident 442 admitted to the facility in 4/2024 with diagnoses including bipolar disorder (mental health disorder). An 4/6/24 physician order indicated staff were to administer lithium ER (extended release antipsychotic for bipolar disorder) PO. On 10/10/24 Drugs.com indicated lithium ER should not be crushed, chewed, or broken. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his medication in the morning, so Staff 28 (RN) crushed Resident 442's medication and administered the medication in pudding. A 5/29/24 Hospital Summary note indicated Resident 442 arrived to the emergency room with altered mental status, and mildly elevated lithium levels. Normal lithium levels are 1.2 millequivents per liter and the resident's level was 2.5 millequivents per liter. Resident 442 was transferred to the ICU (Intensive Care Unit). On 10/9/24 at 12:11 PM Staff 28 (RN) acknowledged she crushed Resident 442's lithium, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's lithium medication, which was not to be crushed, and no Medication Error documents were found in the resident's electronic record. Refer to F658

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#39) reviewed for medication administration. This placed residents at risk for lack of dignity. Findings include: Resident 39 admitted to the facility in 2/2024 with diagnoses including diabetes. On 10/10/24 at 11:50 AM Staff 28 (RN) performed a CBG (blood sugar measurement) check on Resident 39 in the dining room without permission from the resident with multiple residents in the dining room. Resident 39 required an insulin injection, Staff 28 raised the resident's shirt and administered the insulin into her/his abdomen. Resident 39 asked Staff 28 to administer the injection in her/his arm multiple times. Another resident in proximity to Resident 39 looked away during her/his insulin administration. On 10/10/24 at 12:05 PM Staff 3 (LPN-Resident Care Manager) and Staff 30 (LPN-Resident Care Manager) acknowledged Staff 28 failed to protect Resident 39's dignity by performing a CBG check in the dining room, and by lifting Resident 39's shirt in a populated common area to administer insulin.

Based on interview and record review it was determined the facility failed to ensure a resident's representative was included in the care planning process for 1 of 2 sampled residents (#77) reviewed for communication. This placed residents at risk for lack of input in the care planning process. Findings include: Resident 77 admitted to the facility in 12/2023 with diagnoses including stroke and aphasia (language disorder). An 4/18/24 Comprehensive Plan of Care Review indicated N/A (not applicable) related to the attendance of the responsible party. A 7/22/24 Annual MDS indicated Resident 77's BIMS assessment could not be completed, she/he was rarely understood and she/he used nonverbal communication to express her/his needs. A 7/23/24 Comprehensive Plan of Care Review indicated N/A related to the attendance of the responsible party. An 10/7/24 resident profile for Resident 77 indicated Witness 1 (Family Member) was her/his main contact. On 10/7/24 at 4:01 PM Witness 1 stated she did not receive invitations to Resident 77's care conferences and she was in the facility weekly. On 10/10/24 at 9:27 AM Staff 7 (Business Office Manager) stated invitations sent to Witness 1 for Resident 77's care conferences were completed through the mail, the invitations were returned to the facility due to an out of date address and the last attempt to contact Witness 1 was nine months earlier. Staff 9 stated Staff 6 (Social Services Coordinator) was not informed the invitations to Witness 1 were returned. On 10/10/24 at 9:39 AM Staff 6 stated family involvement at care conferences would benefit Resident 77. Staff 6 acknowledged there was no communication with Resident 77 or Witness 1 to ensure family contacts were included in the care planning process.

Based on interview and record review it was determined the facility failed to notify the physician regarding refusals and changes in condition for 3 of 9 sampled residents (#s 26, 42, and 442) reviewed for medications, and change of condition. This placed residents at risk for lack of physician involvement. Findings include: The facilities 2/2021 Requesting, Refusing, and/or Discontinuing Care or Treatment Policy indicated; -the healthcare practitioner must be notified of refusal of treatment. 1. Resident 26 admitted to the facility in 10/2017 with diagnoses including kidney failure. A 9/25/24 physician order indicated staff were to complete daily weights, and call the physician for a weight gain of two to three pounds per day over a two-day period or five pounds in one week. A review of the 9/2024 and 10/2024 TARs indicated Resident 26 refused daily weights from 9/25/24 through 10/9/24. A 9/25/24 physician order indicated staff were to check Resident 26's CBG (blood sugar measurement) level four times a day and to notify the physician for a CBG level less than 70 or greater than 400 before meals and at bedtime. No documentation was found in Resident 26's clinical record the physician was notified of the refusals of daily weights and CBG checks from 9/25/24 through 10/9/24. On 10/9/24 at 3:44 PM Staff 2 (DNS) confirmed the physician was not notified at any time of refusals for daily weights or CBG checks from 9/25/24 through 10/9/24. 2. Resident 442 admitted to the facility in 4/2024 with diagnoses including stroke. A 4/6/24 physician order indicated staff were to administer chlorpromazine (antipsychotic for mental disorder) PO, vitamin D3 PO, Protonix (treat reflux) PO, lithium ER (extended release for bipolar disorder) PO, and propranolol (for high blood pressure) PO. On 10/10/24 Drugs.com indicated the above medications should not be crushed or chewed. A public complaint was received on 5/30/24 which alleged on 5/29/24 at 7:30 AM Staff 28 (RN) administered Resident 442's morning medications, and within 30 minutes Witness 2 (Complainant) noticed the resident was not responding to staff when spoken to and became out of it. On 10/7/24 at 2:13 PM Witness 2 stated Resident 442 was brought to the dining room for breakfast but did not eat. Witness 2 stated the resident was lethargic. Witness 2 stated Staff 28 was notified of the change of condition but the resident was not assessed. On 10/8/24 at 1:55 PM Staff 32 (CNA) stated on 5/29/24 Resident 442 was lethargic in the morning and was placed back in bed. Staff 32 stated Staff 28 was notified but the resident was not assessed. Staff 32 stated the resident was placed in her/his wheelchair for lunch but the resident was more lethargic and not responsive to stimuli. Staff 32 stated Staff 28 was again notified but the resident was not assessed. Staff 32 stated Staff 34 (CNA) was notified and requested Staff 3 (LPN-Resident Care Manager) to assess Resident 442. On 10/8/24 at 1:06 PM Staff 3 stated Staff 32 and Staff 34 requested she assess Resident 442. Staff 3 stated the resident was lethargic and sent out and admitted to the hospital. A 5/29/24 Progress Note indicated Resident 442 had a difficult time swallowing her/his morning medications, so the medications were crushed and placed in pudding for administration. A 5/29/24 Hospital Summary Note indicated Resident 442 arrived to the emergency room with altered mental status, and mildly elevated lithium levels. Normal lithium levels were 1.2 millequivents per liter and the resident's level was 2.5 millequivents per liter. Resident 442 was transferred to the ICU (intensive care unit). No documentation was found in Resident 442's clinical record the physician was notified of the change of condition the morning of 5/29/24. On 10/9/24 at 12:11 PM Staff 28 stated Resident 442 took her/his medication whole in applesauce or pudding, but on the morning of 5/29/24 she/he could not swallow her/his medications and was lethargic. Staff 28 stated she crushed Resident 442's morning medications and placed them in pudding. Staff 28 acknowledged she crushed medications, which should not be crushed, and did not notify the physician of the resident's change of condition. On 10/9/24 at 3:03 PM Staff 2 (DNS) acknowledged Staff 28 crushed Resident 442's morning medications, which were not to be crushed, and did not notify the physician of the resident's change of condition timely. 41455 3. Resident 42 admitted to the facility in 6/2024 with diagnoses including cellulitus (deep infection of the skin) and heart failure. A 7/8/24 Alert Note indicated Resident 42 was observed with a reddened area above her/his left ankle and the resident requested to be sent to the emergency department. Resident 42 returned to the facility with a diagnoses of cellulitis and new orders for antibiotics. There was no indication Resident 42's physician was notified of the resident's change of condition. A 9/12/24 progress note indicated Resident 42 complained of uncontrolled pain and an inability to move her/his leg which had copious amounts of drainage. Resident 42 was transported to the emergency department. There was no indication Resident 42's physician was notified of the resident's change of condition. On 10/11/24 at 12:29 PM Staff 2 (DNS) acknowledged no physician was notified on 7/8/24 or 9/12/24 of the resident's change of condition.

Based on interview and record review it was determined the facility failed to assess and treat residents' pressure ulcers for 2 of 3 sampled residents (#s 16 and 79) reviewed for pressure ulcers. Resident 16 developed at Stage 3 pressure ulcer. This placed residents at risk for infections. Findings include: 1. Resident 79 was admitted to the facility 6/9/23 (Friday) with diagnoses including respiratory failure. Hospital Discharge Orders Report dated 6/9/23 revealed Resident 79 had a pressure ulcer to the tailbone region. Wound care was to be provided every Monday, Wednesday and Friday. A 6/9/23 Admission Nursing Database indicated the resident had a pressure ulcer to the tailbone. There were no measurements or descriptions of the ulcer on the form. A 6/2023 TAR revealed no wound care was provided until 6/13/23. This was four days after admission to the facility. Progress Notes revealed the following: -6/10/23 wound care was not provided because the resident started to fall asleep and refused -6/11/23 at 8:54 PM resident had pain to the tailbone region -6/11/23 at 9:08 PM tailbone region open with yellow green purulent (pus-indicative of infection) drainage, MD notified. -6/13/23 Wound nurse indicated she was asked to see the resident. The ulcer, which spanned from the tailbone to the anus, was 7.5 cm long and was full of slough (non-viable tissue). The resident verbalized pain to the buttock region. The wound nurse applied a dressing, but the resident immediately removed it. -6/14/23 the resident's physician assessed the resident and sent the resident to the hospital emergency department due to agitation and to rule out a stroke or sepsis from a wound infection. The resident returned with a diagnoses of wound infection. Skin and Wound Evaluation Forms revealed the following: -There was no form filled out when the resident was admitted on [DATE] -6/13/23 the ulcer was described as an unstageable pressure ulcer (unable to determine depth due to slough), the wound had 90% slough, signs of infection including increased drainage, redness and pain, moderate amount of purulent (pus) drainage. There was no length or width documented. -No form documented for 6/20/23 -6/27/23 the ulcer was noted to be improved. The ulcer was 7.9 cm long, was 100% covered with slough, did not have signs of infection and the note indicated the resident frequently removed the dressings. On 6/29/23 at 10:20 AM Staff 1 (LPN-Resident Care Manager) stated Resident 79 was admitted to the facility with a pressure ulcer to the tailbone region. Staff 1 stated staff were to assess all wounds, including pressure ulcers, and document in the clinical record on the skin assessment forms. Staff were to document treatment provided on the TAR. If a resident refused a treatment, staff were to attempt to provide the treatment on different shifts until the treatment was provided. Staff 1 also stated the pressure ulcers were to be monitored weekly. Staff 1 acknowledged the resident's pressure ulcer was not described in detail on the skin assessment sheet, treatments were not documented as provided for four days and skin assessments were not done on 6/20/23 when the wound nurse did not come into the facility. Staff 1 indicated the facility staff should have filled out the assessment if the wound nurse was not in the building. 41455 2. Resident 16 was admitted to the facility in 2021 with diagnoses including multiple sclerosis (a disease of the central nervous system), pressure ulcer and on hospice. A 12/15/22 Significant Change MDS indicated Resident 16 was on hospice and at risk for pressure ulcers due to decreased mobility and urinary incontinence. Staff were to provide skin treatments as ordered and monitor for any changes in Resident 16's skin condition. A 5/13/23 Wound Nursing Order indicated to cleanse Resident 16's genital area wound. Apply Iodosorb (iodine gel) to the wound bed and cover with an adhesive foam dressing. The dressing was to be changed as needed if soiled or loose. A 6/12/23 Wound Nursing Order indicated to monitor a blanchable (skin that turns white when pressed) redness located at the the base of Resident 16's genital area and notify the provider of any worsening. A 6/13/23 Progress Note at 6:59 AM revealed Resident 16 had a very loose bowel movement and Staff 13 (LPN) redressed her/his pressure ulcer with new dressing after Resident 16 was cleaned. No additional information about Resident 16's wounds were documented. On 6/13/23 at approximately 1:15 PM a hospice encounter note indicated the original wound to Resident 16's genital area continued to improve and a new Stage 1 pressure ulcer (wound which remained red when touched) was at the base of Resident 16's genital area according to a facility nurse since Resident 16 declined a wound assessment during the visit. A 6/14/23 at 1:04 PM Skin and Wound Evaluation revealed Resident 16's wound located at the the base of her/his genital area was a Stage 3 (full-thickness skin loss) pressure ulcer and measured 4.3 cm long and 1.7 cm wide. Evidence of infection included increased drainage, redness and warmth and the wound was bleeding and had a scab. The evaluation also revealed the loss of skin was due to urine or friction. A note revealed it was the first time a nurse assessed the pressure ulcer wound and nursing used the 5/16/23 order to treat the wound. On 6/29/23 at 5:06 PM Staff 13 stated on 6/13/23 at 6:59 AM she observed Resident 16 already had a scab on another pressure ulcer. On 6/28/23 at 10:12 AM Staff 2 (DNS) stated the facility neglected to complete a wound assessment for Resident 16's second pressure ulcer and no investigation related to the wound was started.

Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards of practice related to abuse and residents' changes in condition for 5 of 8 sampled residents (#s 305, 309, 312, 314 and 315) reviewed for abuse and change of condition. This failure resulted in Residents 305, 309 and 314 who experienced mental and verbal abuse and Residents 312 and 315 experienced a noted decline in condition without timely intervention prior to the residents' hospitalization . Findings include: [NAME] 8510450040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. [NAME] 8510450050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care. (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and (C) Selecting appropriate nursing interventions and strategies. [NAME] 8510450070 Conduct Derogatory to the Standards of Nursing Defined indicated the following: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (2) Conduct related to other federal or state statute/rule violations: 1. a.) Resident 305 was admitted to the facility in 2020 with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), major depression and epilepsy. Resident 305 was alert and oriented. A complaint intake dated 12/8/22 indicated Staff 5 (CNA) and Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 6 had also turned on all the lights in the resident's room, even though it was careplanned not to turn all the lights on, because it triggered the resident and set her/him off. Staff 7 attempted to stop Staff 6 from yelling at the resident and to leave the room to deescalate the situation but Staff 6 would not cooperate so she left to get help. The complaint indicated facility management was aware of Staff 6's behaviors but no corrective action was taken. On 3/21/23 at 9:45 AM Staff 14 (RCM/LPN) acknowledged she had not identified the incident as possible mental and verbal abuse by Staff 6 and she failed to investigate the incident. Staff 14 did notify Staff 1 (Administrator) and Staff 2 (DNS) of the incident but they also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. b.). Resident 309 was admitted to the facility in 2018 with diagnoses including stroke with hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) and respiratory failure. On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Staff 4 said she was aware that Resident 309 had also reported complaints about Staff 6. Social Services was aware of the resident's concerns and it was discussed at the resident's care conference. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. c.) Resident 314 was admitted to the facility in 2018 with diagnoses including neurocognitive disorder with Lewy bodies (progressive dementia that leads to a decline in thinking, reasoning and independent function). On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 6 would raise her voice to residents, throw temper tantrums and argue with residents. She had given verbal corrections to Staff 6. Resident 314 had verbalized complaints such as Staff 6 was belittling (made her/him feel stupid), not patient with her/him and Staff 6 demanded the resident take her/his pills and she/he had no right to refuse. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken. 2. a.) Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed that Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. She asked the resident's CNA Staff 9 if the nurse Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with a brain wound and infectious diseases). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done to correct the situation. The evening shift came on and finally sent the resident to the hospital. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not. Staff 6 just put the note in the medical record for the evening shift nurse. Staff 6 should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. b.) Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) said Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of a couple of residents that day (3/12/23) including Resident 315. They told her the resident was having difficulty breathing so Staff 6 told the CNA to give her/him a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. They told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse by Staff 13. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in the airway) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated she/he should have been sent out to the hospital without waiting. Staff 11 understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 directed the CNA to give the resident a shower to help his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. See F600 and F684

Based on interview and record review it was determined the facility failed to to identify, assess and select appropriate interventions for residents' change in condition for 2 of 2 sampled residents (#s 312 and 315) reviewed for a change of condition. This failure resulted in Resident 312 and Resident 315 experiencing a noted decline in condition without timely medical intervention prior to the residents' hospitalization s. Findings include: 1. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. A hospital History & Physical dated 3/12/23-3/16/23 indicated the resident had a hemicraniectomy on 6/20/22. The resident underwent a cranioplasty (neurosurgical procedure designed to repair or reshape irregularities or imperfections in the skull) on 1/12/23 it was noted the right brain hemisphere had necrosis and turned into a soupy yellow substance. Later the brain broth grew staph epidermidis (gram-positive bacteria). The resident was sent to the Emergency Department for swelling and drainage from the recent head injury site and was admitted to the hospital's neurosurgical service. An operative Note indicated the resident underwent: 1. Incision, irrigation and sharp debridement of the right posterior cranial wound. 2. Removal of underlying hardware. A Neurosurgery Progress Note dated 3/14/23 indicated the resident's primary admitting diagnoses included cellulitis (skin infection) of the scalp. The skull flap was not removed. It did not look infected, but there was a need to keep pressure on the head to prevent the fluid from reaccumulating. A broad spectrum antibiotic was ordered and staples needed to be removed in 2-3 weeks. On 3/21/23 at 12:01 PM Resident 312 stated she/he did not remember much about the day she/he went to the hospital but staff told her/him they would send her/him when they were ready. The resident remembered her/his head not feeling right and she/he wanted to go to the hospital for a couple of days prior. On 3/22/23 at 12:18 PM Staff 15 (CNA) stated she had been working on Sunday 3/12/23. She was in the dining room and noticed Resident 312 had fluid coming out of the back of her/his head, her/his hair was matted down with fluid and there was leaking onto the neck area. Due to the resident's background of brain surgery with a skull flap she was very concerned. She asked Staff 9 (CNA) if Staff 6 (LPN) knew about the drainage. Staff 6 said she would contact the doctor but then did nothing about it. Staff 15 felt Staff 6 would not respond so went to Staff 18 (LPN). Staff 18 looked at the resident and said the resident should go out to the hospital. Staff 18 spoke to Staff 6 and expressed concerns about the resident's condition. Staff 6 said the resident was fine and she was not sending the resident to the hospital and just wiped off the fluid with gauze without using gloves (on a resident with an surgical brain wound and infectious disease). Staff 9 came by later and told her Staff 6 was squeezing the resident's head like a pimple and they both knew that was wrong. Staff 18 had talked to the DNS but nothing was done during the entire day shift. On 3/23/23 at 10:48 Staff 9 indicated she got the resident up that morning and into her/his chair. She noticed the leakage from the back of the resident's head. She went and told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. She was very concerned so she spoke to Staff 15 (CNA) and Staff 17 (CNA). Staff 15 went and told another nurse Staff 18 because they felt it was serious and Staff 6 was not responding. Later Staff 9 said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Staff 18 was told again and Staff 9 asked if she should contact the DNS. Staff 18 contacted the DNS. Later that day Staff 9 reported to Staff 6 the wound was still swollen and draining and Staff 6 just told her to change the pillowcase. It felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital. This went on for all of day shift. When the evening shift nurse came on duty, she sent the resident out within the hour. The resident never said no to going out to the hospital. On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. Staff 6 told him she kept trying to get a hold of the physician. The resident was not sent out until the evening shift came on duty. Staff 2 did not indicate he had done anything else about the situation. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the possible change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything else about the situation. On 3/23/23 at 3:00 PM Staff 18 (LPN) said a CNA came to her and said Staff 6 was not listening to her about a problem with Resident 312. The resident (who had recent brain surgery) had an area on the head that was swollen and draining a significant amount of a clear but lightly bloody fluid from the surgical site. Staff 18 went and spoke with Staff 6 who said she would take care of it. Staff 18 told Staff 6 if there was significant drainage, she should send the resident to the hospital. Staff 18 knew an RCM/LPN had noticed a little drainage the day before and they had called the neurosurgeon and set an emergency appointment for Monday but were told if the area got worse (swollen and drainage) the resident should go to the hospital because the neurosurgeon was on call at the hospital that weekend. Staff 6 said it was just an abscess and blew her off. Staff 18 stated another staff member, Staff 17 (CNA) came to her and said she saw Staff 6 trying to drain the wound herself. Staff 6 had her two thumbs and was pushing on the wound area like you would squeeze a pimple. Staff 18 indicated you should never do that for a brain surgery patient. The RCM/LPN was notified and then the DNS but nothing happened. The resident did not get sent to the hospital until the evening shift nurse came to work and she sent the resident out. Staff 6 should have assessed the resident but she did not. The resident was admitted to the hospital and had a surgical procedure and also had cellulitis (a skin infection) of the scalp. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 312. The resident had fluid leaking from her/his surgical incision, the area was swollen and Staff 6 had been pressing on the area trying to drain it. They were all worried about the resident and felt Staff 6 was not addressing the issue. Staff 6 told her Resident 312 did not want to go to the hospital. Staff 13 went and saw the resident and thought she would have to convince the resident to go to the hospital but the resident told Staff 13 she/he had been asking to go to the hospital for three days so of course she/he would go. Then Staff 19 (CMA) told me Staff 6 kept telling her to give Resident 312 a pain pill, but you are not supposed to give pain medication if the resident may be going out to the hospital. Staff 6 first told Staff 13 to give the pain pill but Staff 13 would not because it should not be done under the circumstances and Staff 6 should know that was the case. Staff 13 said she had to assess the resident first. Staff 13 sent the resident out within the first hour she was on duty. Staff 6 put a note in the record which made it appear she had sent the resident out but she did not. Staff 13 indicated Staff 6 did not like to take recommendations from other staff and did not listen to them. Staff 13 was upset about the issue with Resident 312 because the resident wanted to go to the hospital. She tried to explain to Staff 6 as a nurse you should be able to assess a resident and determine that it would be more important to send the resident to the hospital if needed than to wait for a call back from a physician on a weekend. Staff 13 stated Staff 6 did not identify the change of condition, did not assess the resident and failed to intervene on the resident's behalf. On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) stated the Central Hall charge nurse had called her about Resident 312. Cognitively the resident was at baseline so she left it in the hands of the DNS. On Friday 3/10/23 the resident had complained about her/his head hurting. Staff 11 stated she expected the LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 11 thought Staff 6 had sent the resident out to the hospital but she did not, the evening shift nurse did. Staff 6 just put the note in the medical record. She should have been able to make the determination to send the resident out as needed without waiting for the physician to return a call. She knew it was a Sunday and reaching the physician would not be easy. 2. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/12/23 at 10:22 AM Staff 6 (LPN) wrote: Resident presented with complaints of cough and congestion and audible wheezing noted. Breathing treatment inhaler given with little relief. Resident had Duoneb (breathing treatment) prior to breakfast. The resident stated, It helped a little. On 3/23/23 at 10:11 AM Staff 21(CNA) said Resident 315 was breathing wrong. The resident's vitals were off and the resident said she/he needed to go to the hospital. Staff 21 said she had just started her evening shift when she noticed the resident was not breathing right. A CNA on the front hall called her into the room and the resident said she/he could not breath well so Staff 21 ran and grabbed the nurse. Another staff told her the resident was in bed all day and that was not normal behavior for the resident. She was very concerned about the resident. She knew the resident well and he did not look or sound good. On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concern to her about the condition of a couple of residents that day (3/12/22) including Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing but the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she did not send the resident out. She had done one breathing treatment earlier which did not help. Nothing else was done by Staff 6. The resident was finally sent out by the evening shift nurse Staff 13. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work CNAs came up to her and told her there was a problem with Resident 315. Multiple staff came to tell her to keep an eye on Resident 315 as the resident was not breathing well and did not look good. Within an hour she sent the resident out to the hospital. After shift change report she went in to see Resident 315. The resident's stats were down and she/he looked bad. The resident should have been sent out earlier. Staff 13 stated she had never sent two people out to the hospital in that short amount of time. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. Two CNAs changed the resident and said the resident could barely breathe. Staff 13 looked at the resident's history and the aides got her/ him ready. When she was on the phone with 911 for Resident 315 she requested Staff 6 to assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent both the residents out to the hospital but did not do so. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 at 5:50 PM Staff 11 (RCM/LPN) indicated she expected the LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if the resident's breathing was as bad as they said, she/he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said for Staff 6 to direct the CNA to give the resident a shower to help his breathing was not an appropriate medical treatment for a resident in respiratory distress.

Based on deficient practice in the areas of Freedom from Abuse, Neglect and Exploitation, Investigate/Prevent/Correct Alleged Violations and failure to adhere to Professional Standards of Practice of nursing to identify, assess and intervene for residents' Change of Condition it was determined the facility was not administered by the management team in an effective and efficient manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. As a result: Residents 305, 309 and 314 were mentally and verbally abused and Residents 312 and 315 experienced delays in treatment for significant changes of condition requiring hospitalization . Findings include: 1.The facility failed to ensure residents were free from mental and verbal abuse. a. On 12/8/22 Staff 5 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305 to take her/his medications. Staff 5 indicated facility management was aware of Staff 6's behaviors but had done nothing about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 7 said she felt Staff 6 deliberately antagonized residents and many of them did not care for her. Staff 7 said she knew some residents would refuse their medications so they would not have to interact with Staff 6. Staff 7 said she believed this was verbal abuse but no one at the facility ever interviewed her about this incident and Staff 6 continued to work with residents. On 3/23/23 Staff 14 (RCM/LPN) indicated Staff 6 had negative interactions with Resident 305 and with other residents also. Staff 6 would raise her voice to the residents and throw temper tantrums. Staff 14 said she told Staff 6 not to argue with residents and she had given verbal corrections. Staff 6 was also belittling, demeaning and disrespectful to residents and other staff. She reported her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but nothing was done. On 3/20/23 Staff 1 (Administrator) and Staff 2 (DNS) indicated Staff 4 (RCM/LPN) would have the information about this incident. No documentation was provided to indicate an investigation had been done by Staff 1 or Staff 2. On 3/21/23 Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. She told Staff 1 (Administrator) and Staff 2 (DNS) about the incident. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. She stated she did not complete an investigation and she should have. She did not interview or speak to the CNAs who were present during the incident or to other residents or staff. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. b. On 3/23/23 Resident 314 stated one of the nurses was very mean to her. The resident said the nurse was very rude to her/him, she was not patient or nice and made her/him feel bad. The resident's roommate was alert and oriented and identified the nurse in question as Staff 6. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 314. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but no corrective action was taken. On 3/23/23 Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. c. On 3/23/23 Resident 309 indicated there was a problem with Staff 6. Staff 6 was very belligerent and rude to her/him, her/his roommate, other residents and staff. Staff 6 snapped at everyone. Resident 309 also stated she did not like to come out of her/his room when Staff 6 worked because it was so unpleasant to be around her. On 3/22/23 Staff 14 (RCM/LPN) indicated she was aware Resident 309 had reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. On 3/23/23 at 3:45 PM Staff 1 (Administrator) and Staff 2 (DNS) provided no additional documentation related to this incident. Refer to F 600 2. The facility failed to ensure staff to resident incidents were investigated to rule out abuse. a. On 12/8/22 Staff 5 (CNA) said she heard Staff 6 (LPN) yelling and screaming at Resident 305. Staff 5 stated she felt it was verbal abuse but no one interviewed her about it and Staff 6 continued to work with residents. On 12/8/22 Staff 7 (CNA) indicated she heard Staff 6 yelling at Resident 305. She tried to get Staff 6 to stop yelling and leave the room but Staff 6 would not. Staff 7 felt it was abuse but no one interviewed her about it. On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. No documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. Refer to F 610 3. The facility failed to ensure residents were comprehensively evaluated and received timely treatment for serious changes of conditions which resulted in hospital admissions. a. Resident 312 was admitted to the facility in 2022 with diagnoses including hemicraniectomy (surgical procedure where a large flap of the skull is removed and the dura is opened; this gives space for the swollen brain to bulge and reduces the intracranial pressure), HIV disease and viral Hepatitis C. On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about the CNAs concerns. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation and no additional interventions were attempted. On 3/23/23 at 10:48 Staff 9 (TITLE) indicated noticed swelling and leakage from the back of Resident 312's head. She told Staff 6 who looked and touched it (with her hands not gloved for a resident with an open brain wound and infectious disease) but did not do anything else about it. Staff 9 also said she saw Staff 6 squeezing the area on the resident's head with her two thumbs like she was squeezing a pimple. Later Staff 9 reported to Staff 6 the resident's head was still swollen and draining and Staff 6 told her to change the pillowcase. Staff 9 felt that Staff 6 was not acting fast enough and the resident needed to go to the hospital On 3/23/23 at 3:30 PM Staff 2 (DNS) indicated the leaking had been identified by an RCM/LPN on 3/10/23 and an appointment had been made for Monday 3/13/23. He received a call from the day shift nurse indicating the wound was draining a lot and staff felt Staff 6 was not addressing the issue. He called Staff 6 who told him she was cleaning the drainage out of the resident's hair. Staff 6 said she called the physician's office and left a message and was waiting for a call back. She did not send the resident to the hospital although numerous staff had indicated she should. Staff 2 did not indicate he had done anything else about the situation. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. She was the nurse who send finally sent Resident 312 to the hospital. Staff 6 did not identify the resident's change of condition, did not assess the resident and failed to intervene on the resident's behalf. No documentation was found in the resident's medical record to indicate Staff 6 called or tried numerous times to contact the physician; no assessment of the resident was completed by Staff 6 related to the serious change of condition for Resident 312 and no interventions were noted. No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a possible change of condition for the resident. No documentation was found to indicate Staff 2 (DNS) had done anything about the situation or provide any intervention for the resident. b. Resident 315 was admitted to the facility in 2018 with diagnoses including spastic cerebral palsy, persistent asthma and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). On 3/24/23 at 8:58 AM Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. They told her the resident was having difficulty breathing and Staff 6 told the CNA to give the resident a shower to help the breathing. They felt the resident needed to go to a hospital not take a shower. The resident had trouble breathing since early morning and could not eat. The resident's respirations were 135. The CNAs stated they told Staff 6 but she would not send the resident to the hospital. Staff 6 did one breathing treatment earlier which did not help. Nothing else was done by Staff 6. On 3/24/23 at 9:28 AM Staff 13 (LPN) said she worked the evening shift on 3/12/23. When she came in to work multiple CNAs came to her and told her there was a problem with Resident 315. Resident 315 was not breathing well and did not look good. Staff 13 went in to see the resident. The resident's stats were down and she/he looked bad. The resident had a c-pap mask on and by the way she/he was breathing she could tell she/he must have had breathing issues for quite a while. She assessed the resident, checked the resident's history and sent him out with an hour of starting her shift. When she was on the phone with 911 for Resident 315, she requested Staff 6 assist with the call to the hospital on the conditions of the resident during the day but Staff 6 would not do so. Staff 13 said Staff 6 should have sent the resident out to the hospital in the morning when his breathing issues had worsened, but she did not. This was the second resident Staff 6 had failed to send out to the hospital that day. No documentation was found to indicate Staff 6 had assessed Resident 315 or provided appropriate interventions for a resident with respiratory distress. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The resident received nebulizer treatment, IV steroids, oxygen and IV magnesium. The resident remained with increased difficulty breathing and audible rhonchi (secretions in breathing) and therefore the hospitalist was consulted for admission. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). Refer to F600, F610, F658 and F684 4. The facility failed to ensure Professional Standards of Practice were adhered to related to Abuse and Changes of Condition. a.) On 3/21/23 at 9:45 AM Staff 4 (RCM/LPN) said CNAs came and told her there was a problem between Staff 6 and Resident 305. Staff 4 acknowledged she had not identified the incident as possible abuse and she failed to investigate the CNAs abuse allegations. Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incident but also failed to identify it as possible abuse. The incident was later determined to be mental and verbal abuse of Resident 305 by Staff 6. On 3/21/23 no documentation of an investigation was provided by Staff 1 (Administrator) or Staff 2 (DNS) when requested. b.) On 3/22/23 at 12:01 PM Staff 4 (RCM/LPN) indicated she was aware Staff 6 had multiple negative interactions with residents including Resident 309 and she was aware that Resident 309 had also reported complaints about Staff 6. The resident stated she did not feel safe around Staff 6. Staff 14 took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 309 by Staff 6. No documentation was found or provided related to Resident 309's reported complaints about Staff 6. c.) On 3/22/23 at 12:01 PM Staff 14 (RCM/LPN) indicated Staff 6 had multiple negative interactions with residents including Resident 314 who complained Staff 6 was mean to her/him. Staff 14 stated she took her concerns to Staff 1 (Administrator) and Staff 2 (DNS) but was not aware that any corrective action was taken and Staff 6 continued to work with residents. The incident was later determined to be mental and verbal abuse of Resident 314 by Staff 6. No documentation was found or provided related to Resident 314's reported complaints about Staff 6. d.) On 3/22/23 Staff 15 (CNA) stated she went to Staff 6 about Resident 312 having swelling and fluid draining from the site where she had brain surgery. Due to the resident's background of brain surgery with a skull flap (allows access to the brain) she was very concerned. Staff 6 said she would contact the doctor but did not and did nothing else about it. Staff 15 then notified another nurse Staff 18 (LPN) who recommended Staff 6 send the resident out to the hospital. Staff 6 did not. Staff 18 spoke to the DNS and he called Staff 6 but nothing was done to correct the situation. On 3/27/23 Staff 11 (RCM/LPN) stated she expected LPNs to know when they should send a resident to the hospital. They should do an assessment. She found no assessment for Resident 312. Staff 6 said she tried to reach the physician but there was no documentation to verify she had tried. Staff 6 failed to make the determination to send the resident out as needed. Staff 6 knew it was a Sunday and reaching the physician would not be easy. There were also instructions to send the resident to the hospital if her/his condition worsened because the neurosurgeon was on call that weekend. Staff 6 failed to identify, assess or intervene for the resident with a change of condition that required hospitalization . No documentation was found to indicate Staff 6 had followed nursing standards of practice to address a serious change of condition for Resident 312 or that Staff 2 (DNS) had done any follow up to ensure the resident received appropriate care. e.) On 3/24/23 Staff 17 (CNA) indicated Staff 15 (CNA) and Staff 9 (CNA) reported concerns to her about the condition of Resident 315. The resident had trouble breathing since early morning and she/he could not eat. The resident's respirations were 135. Staff 17 said they told Staff 6 this was not normal for the resident but she would not send the resident out. She did one breathing treatment for the resident which did not help. Nothing else was done by Staff 6. A hospital H&P dated 3/12/23 indicated the resident's chief complaint was shortness of breath for the last few days and much worse today. In the Emergency Department Resident 315 was noted to be in respiratory distress. The Hospital Course: resident was admitted with acute asthma exacerbation and human metapneumovirus infection (same virus family as RSV). On 3/27/23 Staff 11 (RCM/LPN) indicated she expected LPNs to know when they should send someone out to the hospital and when to do an assessment. There was no assessment or documentation by Staff 6. Staff 11 said if Resident 315's breathing was as bad as staff indicated he should have been sent out to the hospital without waiting. She understood Staff 6 did one nebulizer treatment for Resident 315 but it was not effective. Staff 11 also said Staff 6 had directed a CNA to give the resident a shower to help her/his breathing. That was not an appropriate medical treatment for a resident in respiratory distress. Refer to F600 and F658

Based on observation, interview and record review the facility failed to assess, monitor and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 37 had a worsening wound. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, [CONDITION(S)] and depression. Resident 37 required two-person assistance with bed mobility and repositioning. Resident 37 was at risk for impaired skin integrity and staff were to consult the wound nurse as appropriate. Resident 37 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/25/22 Admission Nursing Database revealed Resident 37's BIMS was 15 indicating she/he was cognitively intact. Resident 37 had a right heal blister. The length was 2.0 cm by a width of 1.5 cm. The blister was intact with brown edges. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were directed to keep the heel offloaded from the bed surface at all times and were to use a green offloading boot or pillow. -There was no clinical documented evidence of weekly wound assessments for Resident 37's and the care plan was did not direct staff to offload her/his right heel. On 5/2/22 at 10:20 AM and 5/5/22 at 11:06 AM Resident 37 stated she had a wound on her/his right heel and was not sure how she/he acquired it. Resident 37 stated she/he was to have a heel protector on her/his right foot when in bed but it was was not always done. Resident 37 stated she/he only had her/his right heel bandage changed one time that she/he could recall. Random observations on 5/4/22 from 12:43 PM through 3:00 PM revealed Resident 37 was in bed and her/his right foot was resting on the mattress without a boot protector or pillow underneath the right foot. On 5/5/22 at 11:14 AM Resident 37 was in bed with her/his right foot uncovered, her/his right foot was rolled outward as she/he tried to lift her/his foot, her/his heel stuck to the sheet. Resident 37's right heel was not bandaged the wound was nickel size, red in the center and white around the outside edges of the wound. On 5/5/22 at 3:11 PM Staff 26 (RCM/LPN) entered the room and acknowledged Resident 37's right heel was not offloaded. Staff 26 described the wound and indicated a circle at the base of her/his right heel, the wound was reddish/purple and the outer portion was white, not hot or warm, no drainage to the wound and Resident 37 indicated the wound was not painful. On 5/5/22 interviews were completed with Staff 27 (CNA) at 12:30 PM, Staff 32 (CNA) at 2:39 PM and Staff 31 (CNA) at 2:56 PM. All stated Resident 37 was dependent for bed mobility and repositioning in bed. Staff stated they were not aware of and wounds on Resident 37 except for her/his incision site from a previous fall. On 5/5/22 at 3:25 PM Staff 26 (RCM/LPN) acknowledged Resident 37's wound was not monitored appropriately. The right heel wound did not have a dressing on it, was not offloaded while the resident was in and Resident 37 was not placed on weekly wound rounds. A Skin and wound Evaluation on 5/6/22 revealed Resident 37 had a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) and was present upon admission. The wound area measured 2.1 cm squared by 1.7 cm in length by 1.8 cm in width. On 5/9/22 at 11:25 Staff 1 (Administrator) and Staff 2 (DNS) expected staff to complete thorough skin audits upon admission or re-admission, ensure weekly skin and wound rounds were initiated and completed, the care plan to be reflective of Resident 37's skin integrity and staff to follow the care plan.

Based on interview and record review the facility failed to ensure a resident was transferred safely for 1 of 2 sampled residents (#37) reviewed for accidents. Resident 37 sustained a fracture to her/his left femur. Findings include: Resident 37 was admitted to the facility in 8/2020 with diagnoses including diabetes and stroke. A revised care plan dated 10/25/21 indicated Resident 37 had an ADL self-care performance deficit and limited mobility related to stroke, [CONDITION(S)] and depression. Resident 37 required two-person assistance with bed mobility, repositioning and required a mechanical lift for transfers. A Fall Incident Report dated 3/27/22 revealed the following: -Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. -Staff 28 indicated while transferring Resident 37, the mechanical lift legs were partially open to allow her/his wheelchair to fit as close to her/him as possible and Resident 37 was sideways in the mechanical lift directly above her/his wheelchair which was also sideways. When Staff 28 and Staff 29 pulled up the straps on the back of the mechanical lift to get her/him positioned correctly the entire mechanical lift tipped over sideways. -Staff 29 indicated while transferring Resident 37 she/he was hooked up to the mechanical lift and the mechanical lift legs were partially opened to get her/him as close to her/his wheelchair as possible. Resident 37 was sideways directly above the wheelchair when Staff 28 and Staff 29 pulled her/him back her/his weight shifted towards the bathroom and the mechanical lift just fell on top of her/him towards the bathroom and Staff 29 tried to push the mechanical lift out of the way but could not catch the lift in time. -The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. -Resident 37 was on the floor and her/his head was against the bathroom door and the mechanical lift was pressed on top of her/him. -Staff 17 (LPN) assessed Resident 37 for injuries once the mechanical lift was removed off her/him. Resident 37 was yelling and screaming throughout the assessment and her/his pain level was 10 out 10. Resident 37 bumped her/his head during the fall, complained of pain to her/his left knee and left hip and her/his right great toenail was partially off and bleeding. -Resident 37 was sent to the hospital which revealed she/he had fractured her/his left leg. A 5/1/22 Plan of Correction revealed the following: -A facility incident report was completed regarding the 3/27/22 incident which revealed Resident 37 was being transferred from her/his bed to her/his wheelchair by Staff 28 (CNA) and Staff 29 (CNA) and the mechanical lift tipped over during the transfer. The mechanical lift legs were not in a locked position and were not fully open when the mechanical lift tipped over onto Resident 37. The mechanical lift was rated for Resident 37's weight. Resident 37 fractured her/his leg due to the fall. -All staff were educated and completed competencies regarding safe transfers. -Continued education occurred at the all staff meetings, CNA meetings and the Hoyer lift manufacturer training video was viewed at the meetings. -The results of the weekly audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed. On 5/2/22 at 10:27 AM Resident 37 stated she/he had fractured her/his left leg due to a transfer in the mechanical lift. Resident 37 stated two CNAs were transferring her/him from her/his bed to her/his wheelchair and the whole lift tipped over and she/he was still in the sling when she/he hit the floor. Resident 37 stated staff got her/him unattached from the sling and moved the mechanical lift off her/him and her/his entire left side was very painful. Resident 37 stated she/he was sent to the hospital and x-rays confirmed she/he broke her/his left femur as a result from the mechanical lift fall. On 5/6/22 at 11:28 AM Staff 28 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 28 stated she was behind the mechanical lift and had the control in her hand. Staff 29 was the other CNA in the room and Staff 29 was repositioning Resident 37 while in the sling to get her/him in the wheelchair. When Staff 29 pulled on the sling, the mechanical lift fell over on top of Resident 37. Staff 28 stated she remembered the legs of the mechanical lift being partially opened and one of them she thought was in a locked position. Staff 28 stated Resident 37 was still attached in the sling when the mechanical lift fell on top of her/him. Staff 28 stated Resident 37 was crying in pain and yelling her/his leg hurt and she/he did not want to be on the floor. Staff 28 stated Staff 17 entered the room, assessed her/him and the mechanical lift was pulled off Resident 37. On 5/9/22 at 9:36 AM Staff 29 stated she assisted with the transfer on 3/27/22 for Resident 37. Staff 29 stated Resident 37 was in the mechanical lift moving her/him from the bed to the wheelchair when Staff 28 (her CNA partner) pulled Resident 37 towards her, the mechanical lift tipped over on the floor and was on top of Resident 37. Staff 29 did not recall if the mechanical lift legs were locked or open because it happened so fast. Staff 29 stated Resident 37 had some blood to her/his toe and landed on her/his left side. On 5/9/22 at 10:01 AM Staff 17 stated she was in the building working at the nurses' station on 3/27/22 when she heard a loud crash and entered Resident 37's room, and found her/him on the floor with the mechanical lift on top of her/him. Staff 17 stated the mechanical lift legs were not fully opened and they were not in a locked position causing the mechanical lift to tip over. Staff 17 stated Resident 37 was hysterical, talking fast and swearing. On 5/9/22 at 11:25 AM Staff 39 (Regional Nurse Consultant) stated he was in the building when Resident 37 had her/his fall on 3/27/22. Staff 39 stated he entered the room and Resident 37 was up against the bathroom door and complained of pain to her/his left side. Staff did move her/him away from the bathroom door and she/he was having increased pain to her/his left leg. Staff 39 stated Staff 28 and Staff 29 were doing a side transfer with Resident 37 and should not have attempted the transfer. Staff 39 further stated the mechanical legs were not fully open or in a locked position when attempting to place Resident 37 in her/his wheelchair.

Based on observation, interview and record review it was determined the facility failed to provide adequate foot care for 1 of 3 sampled residents (#61) reviewed for pain management. This resulted in Resident 61 having unmanaged pain. Findings include: Resident 61 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. On 4/30/19 at 3:15 PM Resident 61 moaned loudly during an interview. When questioned the resident indicated she/he was having very bad pain in the left foot and toe area. The resident expressed signs of pain with loud moaning, grimacing and eyes watering. Staff 14 (LPN) assessed the resident's painful left foot. Staff 14 indicated his assessment revealed the resident had two painful toe areas, the toenails were overgrown and possibly ingrown. Staff 14 indicated he would notify hospice of the resident's painful left foot. An observation of Resident 61 on 4/30/19 at 3:25 PM revealed the resident had pain in the left foot when the foot was touched. The skin on her/his left foot was in poor condition; dry, flaky and cracking. There were reddened areas around the middle and small toenail bases, the second toe was permanently twisted over the big toe and the nails were overgrown and thick. On 5/6/19 at 3:02 PM Witness 7 (Hospice RN) indicated their agency was not notified of the poor foot condition and painful toes on Resident 61's left foot. They received no communication about the issue from the facility. On 5/8/19 at 1:38 PM no documentation was found in the medical record to indicate anyone addressed the resident's painful left foot. Staff 14 indicated he faxed the hospice agency regarding the resident's foot issue but did not document the communication in nursing progress notes and he was not sure what happened with the fax. On 5/8/19 at 2:12 PM Staff 2 (DNS) located a copy of the fax Staff 14 sent on 4/30/19. The fax reported the resident was painful on the left third and fifth toenails, the nails were thick and staff were unable to trim them. Staff 14 requested hospice staff take care of nails. Staff 2 (DNS) explained the fax was not followed up on to determine what happened. The fax was re-sent on 5/8/19, or nine days after surveyors brought the issue to the facility's attention. On 5/9/19 at 9:45 AM Witness 8 (Home Heath Physical Therapist) was with Resident 61 in her/his room assessing the resident for use of a walker. Witness 8 stated he worked for the home health and hospice agency and could assess the resident's feet. With the resident's consent he removed her/his shoe and when he removed the sock Resident 61 moaned loudly in pain. He gently continued and verified the resident's toenails were grossly overgrown and the third and fifth toe were painful. The resident then stated the right foot hurt also. Witness 8 removed the other shoe and sock and assessed the resident's right foot and identified a painful middle toe. The skin of the right foot was also dry and flaky and the toenails were overgrown enough that they were turning at a 90-degree angle to the nail base. Witness 8 confirmed the resident's feet were in poor condition and were painful. On 5/9/19 at 10:11 AM Staff 5 (RNCM) acknowledged the resident's toenails were overgrown, might be ingrown and may have had a fungus. The resident's feet were painful. The left foot middle toe and small toe nail bases were red and the middle toe on the right foot was also painful. Staff 5 indicated staff determined a podiatrist would need to address the toes because they were so overgrown and thick and because the resident was so painful. Staff 5 acknowledged the follow up to the 4/30/19 fax was not timely.

Based on observation, interview and record review it was determined the facility failed to ensure residents remained free of safety hazards related to smoking and falls for 3 of 8 sampled residents (#s 7, 21 and 88) reviewed for accidents. Resident 21 had a fall and experienced a head injury which required evaluation at the emergency department (ED). Findings include: 1. Resident 21 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 21's care plan focus area for falls dated 3/5/19 indicated the resident was a high fall risk due to a history of falls, deconditioning (reduced functional capacity) and weakness. Fall interventions included changes to the wheelchair cushion, use of anti-slide items, reminders to use the call light, monitor after administration of suppositories, keeping the bed in a low position when the resident was in bed and fall mats. A Physical Therapy Evaluation dated 11/6/18 revealed Resident 21 had an extensive history of unwitnessed falls without signs of injury. An incident report dated 12/14/18 revealed Resident 21 was found in the dining room sitting on the foot rests of the wheelchair. The resident stated I slid out of my chair and I did not hit my head when asked by staff. The incident report indicated there was no sign the resident was injured and a contoured cushion and an anti-slip cover was added to the wheelchair seat. A 3/5/19 progress note indicated Resident 21 was not sitting properly in wheelchair and had difficulty remaining in the wheelchair, so staff assisted her/him to the floor. The 3/5/19 incident report revealed the contoured cushion, the anti-slip cover and the foot pedals were on Resident 21's wheelchair when she/he slid out. A follow-up note in the report on 3/11/19 indicated the current fall interventions were not effective. A PT evaluation on 3/6/19 recommended a tilt-in-space wheelchair (specialized wheelchair to facilitate effective positioning) for Resident 21. The wheelchair was scheduled for delivery on 3/13/19. Progress notes dated 3/15/19 revealed Resident 21 was found on the floor by housekeeping staff with her/his head under the bed resting on the metal frame. The note indicated the resident hit her/his head and complained of eight out of 10 pain level and nausea. The resident declined to go to the ED for evaluation. Resident 21 was later noted to have a small hematoma (collection of blood outside of a blood vessel) to the backside of the head. The 3/15/19 incident report revealed Resident 21 stated she/he did not remember to use the call light and felt like getting up. The report indicated the resident had a rectal suppository administered prior to the incident and may have felt the urge to have a bowel movement. The report concluded the resident required frequent checks by all staff to ensure she/he was safely positioned in her/his bed or wheelchair. On 3/27/19 a purchase order was submitted for Resident 21's tilt-in-space wheelchair. Progress notes dated 4/3/19 indicated Resident 21 was found on the floor of her/his room in front of the wheelchair. The resident complained of head pain and her/his blood pressure was 178/90 (high) approximately two hours after the fall. According to the notes Resident 21 stated she/he slipped out of the wheelchair because her/his socks were slippery. The 4/3/19 incident report included follow-up documentation which revealed Resident 21's blood pressure continued to rise after the fall and her/his head pain was nine out of 10. The resident requested to be transferred to the ED for evaluation. The report revealed Resident 21 returned from the ED with a [DIAGNOSES REDACTED]. The report indicated an anti-slip sheet would be added to the top of the wheelchair cushion and the tilt-in-space wheelchair was still not delivered. There was no determination of the effectiveness of current fall interventions. The 4/3/19 ED information revealed Resident 21 experienced a closed traumatic injury of the head and was discharged back to the facility after several hours with monitoring precautions. An invoice for the new wheelchair was dated 4/3/19. Resident 21's care plan did not indicate the tilt-in-space wheelchair was included as an intervention to minimize falls. Intermittent observations on 4/29/19, 4/30/19, 5/2/19, 5/6/19 and 5/7/19 revealed the bed was not in a low position while Resident 21 was in bed and no fall mats were in place. On 4/30/19 at 1:11 PM Resident 21 was observed seated in the wheelchair in the dining room and when asked about falls the resident stated she/he was the (queen/king) of falls. The resident indicated she/he was not sure what caused the falls but she/he was unable to stand and it was hard to stay in the wheelchair sometimes. On 5/2/19 at 8:38 AM Resident 21 was observed sitting up in bed eating breakfast with the bed in a high position and no fall mats on either side of the bed. When asked about where the foot rests were on her/his wheelchair, the resident stated it was new and the foot rests were around here somewhere. On 5/7/19 at 4:15 PM Staff 28 (CNA) stated Resident 21 did not try to get out of bed on her/his own very often. Staff 28 indicated the main fall intervention for the resident was the new wheelchair and they kept the contoured cushion for the seat. On 5/8/19 at 10:13 AM Staff 29 (CNA) stated Resident 71 occasionally tried to get out of bed and there were fall mats by the bed. During an interview on 5/9/19 at 10:04 AM Staff 15 (LPN-Resident Care Manager) stated the new wheelchair was the key to preventing Resident 71's falls and altering the other wheelchair was not successful. Staff 15 acknowledged the tilt-in-space wheelchair was not acquired timely and Resident 71 experienced a head injury before it was delivered. Staff 15 further acknowledged care planned fall interventions including a low bed and fall mats were not followed by staff. 2. Resident 88 was admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. The facility's Smoking Guidelines (revised 2/11/10) included the following information: - Residents who smoke will be evaluated by a Licensed Nurse (LN) for smoking safety using the Smoking Safety Evaluation prior to being able to smoke at the facility. - The LN will determine if the resident is independent or to be supervised. - The LN will initiate a smoking care plan that identifies dependence status, risks, safety devices needed and other interventions. - Educate visitors not to provide residents with smoking material prior to notifying the LN and identify if the visitor is safe to supervise the resident during smoking. Resident 88's 4/15/19 Admission MDS indicated the resident did not use tobacco. During interviews on 4/30/19 at 9:38 AM and 5/2/19 at 2:47 PM Resident 88 indicated she/he smoked once a week at the facility when her/his caregiver came to visit. The resident stated her/his smoking supplies were kept in the closet of her/his room and she/he was aware of the location of the facility smoking area and where the ash trays were located. On 5/2/19 at 3:02 PM during observations of the resident smoking area Staff 55 (Nursing Assistant) stated the smoke lock boxes were used to store and secure resident smoking materials. On 5/2/19 at 3:07 PM Staff 11 (LPN-Resident Care Manager) was asked for a smoking assessment for Resident 88. Staff 11 stated the resident was not a smoker and he was not aware of her/him smoking since admission to the facility. Staff 11 acknowledged he was not aware of whether the resident had any smoking materials in her/his room. On 5/2/19 at 3:12 PM the surveyor and Staff 11 talked with Resident 88 who acknowledged smoking every week when her/his caregiver visited at the facility. The resident stated her/his smoking supplies were stored in the drawer or closet in her/his room. Staff 11 located a package of cigarettes in a bag of Resident 88's toiletries and there was no lighter. Staff 11 stated he was not sure an assessment was required since the resident's caregiver was always present and supervised the resident. On 5/3/19 at 9:15 AM Staff 53 (CNA) stated she was not aware Resident 88 smoked. Staff 53 indicated if a resident smoked it had to be determined whether she/he was independent or needed supervision. During interviews on 5/7/19 at 9:58 AM and 5/8/19 at 3:42 PM Staff 11 acknowledged Resident 88's smoking assessment was not completed. 3. Resident 7 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A fall investigation dated 2/14/19 cited equipment failure and furniture as predisposing factors of a fall on 2/14/19. The updated care plan on 2/15/19 indicated the need for a non-skid fabric between the bed frame and mattress to prevent the mattress from sliding. On 5/3/19 at 8:40 AM Resident 7 was observed in her/his bed with the urinal approximately three feet away from the edge of the bed. The mattress was hanging approximately five inches over the bed frame on the same side as the urinal. There was no non-skid fabric under the mattress. On 5/3/19 at 10:24 AM Staff 47 (Maintenance Assistant) stated he secured the mattress for a second time to the resident's bed on 3/9/19 using new metal bars, wedge cushions and non-skid fabric. He went to check his work the day after his repair and the non-skid fabric was no longer there. A second fall investigation dated 3/14/19 stated Resident 7 at 6:10 AM dropped her/his urinal and slid off the bed trying to get it. The fall investigation indicated predisposing factors including: equipment failure, weakness, gait imbalance, wet floor and improper footwear. The investigation did not include information about the use of the non-skid fabric. On 5/7/19 at 12:01 PM Staff 2 (DNS) confirmed the care plan indicated the use of non-skid fabric for the resident's mattress and should be in place.

Based on observation, interview and record review it was determined the facility failed to provide appropriate pain management for 1 of 3 sampled residents (#61) reviewed for pain. This resulted in Resident 61 having unmanaged pain. Findings include: Resident 61 was admitted to the facility in 2019 with diabetes and heart failure. On 4/30/19 at 3:15 PM Resident 61 moaned loudly multiple times during an interview. When questioned the resident indicated she/he was having very bad pain in the left foot and toe area. The resident expressed signs of pain with loud moaning, grimacing and eyes watering. Staff 14 (LPN) assessed the resident's painful left foot. Staff 14 indicated his assessment revealed the resident had two painful toe areas, the toenails were overgrown and possibly ingrown. Staff 14 indicated he would notify hospice of the resident's painful left foot. An observation of Resident 61 on 4/30/19 at 3:25 PM revealed the resident had pain in the left foot when the foot was touched or the sock removed. On 5/6/19 at 3:02 PM Witness 7 (Hospice RN) indicated their agency was not notified of the painful toes on Resident 61's left foot. They received no communication about the issue from the facility. On 5/8/19 at 1:38 PM no documentation was found in the medical record to indicate anyone addressed the resident's painful left foot. Staff 14 indicated he faxed the hospice agency regarding the resident's foot issue but did not document the communication in nursing progress notes and he was not sure what happened with the fax. On 5/8/19 at 2:12 PM Staff 2 (DNS) was able to locate the fax Staff 14 sent on 4/30/19. The fax reported the resident was painful on the left third and fifth toenails, the nails were thick and staff were unable to trim them. Staff 14 requested hospice take care of nails. Upon investigation, Staff 2 (DNS) explained the fax was not followed up on to determine what happened. The fax was re-sent on 5/8/19, or nine days after surveyors brought the issue to the facility's attention. On 5/9/19 at 9:45 AM Witness 8 (Home Heath Physical Therapist) was with Resident 61 in her/his room assessing the resident for use of a walker. Witness 8 stated he worked for the home health and hospice agency and could assess the resident's feet. With the resident's consent he removed her/his shoe and when he removed the sock Resident 61 moaned loudly in pain. He gently continued and verified the resident's toenails were grossly overgrown and the third and fifth toe were painful. The resident then stated the right foot hurt also. Witness 8 removed the other shoe and sock and assessed the resident's right foot and identified a painful middle toe. The skin of the right foot was also dry and flaky and the toenails were overgrown enough that they were turning at a 90-degree angle to the nail base. Witness 8 confirmed the resident's feet were in poor condition and were painful. On 5/9/19 at 10:11 AM Staff 5 (RNCM) acknowledged the resident's toenails were overgrown, might be ingrown and may have a fungus. The resident's feet were painful. The left foot middle toe and small toenail bases were red and the middle toe on the right foot was also painful. Staff 5 indicated a podiatrist would need to address the toes because they were overgrown, thick and the resident was so painful. Staff 5 acknowledged the follow up to the 4/30/19 fax was not timely for a resident with pain issues.

Based on interview and record review the facility failed to ensure facility staff adhered to professional standards regarding physician order [REDACTED].#s 3, 4, 10, 11, 14, 15, 19, 47 and 48). Facility staff failed to timely process or verify physician orders. The facility population included residents with [DIAGNOSES REDACTED]. These residents received high risk medications including [MEDICATION NAME] (a blood thinning medication), insulin (a life essential hormone which regulates many processes in the body), [MEDICATION NAME] (a [MEDICAL CONDITION] medication) and [MEDICATION NAME] (a medication to reduce fluid retention) that, if not administered timely and in accordance with the physician orders, would likely result in significant medication errors placing residents at risk of serious harm or death. Findings include: State of Oregon OAR [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (3) Conduct related to the client's safety and integrity: (c) Failing to develop, implement or modify the plan of care; (4) Conduct related to communication: (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (C) Failing to document information pertinent to a client's care; A 1/6/19 physician order [REDACTED]. A 1/16/19 Medication Error investigation indicated a physician order [REDACTED]. The investigation revealed Staff 3 (RN) was too busy during her shift and did not process the orders. A 1/25/19 physician order [REDACTED]. A 1/28/19 Medication Error investigation indicated a physician order [REDACTED]. The investigation revealed Staff 19 (LPN) and Staff 15 (LPN) both reported they did not see the order. Staff 3 (RN) indicated she processed as many orders as she could before she had to complete treatments and the 1/25/19 order for Resident 7 was not processed. A 1/28/19 Medication Error investigation indicated a 1/25/19 physician order [REDACTED]. Staff 15 (LPN) performed the order verification and did not detect the error. A 1/29/19 physician order [REDACTED]. The order was entered into the electronic health record to skip 1/29/19 and begin the new dose on 1/20/19. Staff 47 (RN) and Staff 4 signed to indicate they performed the order verification. The order entry was not corrected. A 1/29/19 physician laboratory order for Resident 26 indicating the next INR lab (a lab test used to monitor patients who receive blood thinning medication) was to be completed on 2/1/19 was not entered into the TAR by Staff 47 who processed the order. There was no documentation to indicate an order verification occurred to correct the error. A 2/1/19 physician order [REDACTED]. An order verification was not performed until 2/4/19. Staffing Assignment sheets revealed Staff 11, 14 (LPN), 47, and 48 (LPN) worked the shifts in between the time the order was inaccurately processed until the order verification was performed. On the evening of 2/8/19 a physician order [REDACTED]. The order was not processed until the evening of 2/10/19. On 1/24/19 at 11:31 AM Staff 3 (RNCM) stated when new physician orders [REDACTED]. Staff 3 further stated the order verifications should be performed by the next shift. On 2/7/19 at 12:19 PM Staff 3 (RNCM) stated it was extremely busy on the North hall unit with more treatments than in the past. He reported when he worked the floor as a charge nurse he was scrambling to get things done. On 2/14/19 at 4:15 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the Immediate Jeopardy related to professional standards, and at 4:30 PM at a subsequent meeting with Staff 1, Staff 2 and additionally Staff 38 (Regional RN) Surveyors requested a plan of correction to immediately protect residents from harm be developed and implemented. The facility submitted an acceptable immediate plan of correction to remove the immediate risk to resident health and welfare on 2/14/19 at 7:02 PM. The plan included: - admission hold for new admissions effective immediately until appropriate staffing levels are met - analysis of resident acuity related to available staff - implementing hospitality aides to assist with daily tasks - explore the use of agency staff - all licensed staff inservice prior to the start of shift on the timely processing of all physician orders - immediate audits of all current potential medication and lab errors that contributed to the deficient practice - consultation with the pharmacy to evaluate the facility medication system - all physician orders [REDACTED]. - nurse managers complete daily rounds to ensure all physician orders [REDACTED]. The facility's Immediate Jeopardy Plan of Correction was accepted on 2/14/19 at 7:30 PM and verified as implemented on 2/14/19 at 8:00 PM. Refer to F725, F755 and F770

Based on interview and record review the facility failed to provide sufficient staffing to ensure physician orders [REDACTED].#s 7, 9, 23, 25, 26, 27, 31 and 32) reviewed for medications. The resulted in multiple medication errors and delay in lab services and treatments. Findings revealed insufficient staffing as a root cause to the physician order [REDACTED]. These residents received high risk medications including [MEDICATION NAME] (a blood thinning medication), insulin (a life essential hormone which regulates many processes in the body), [MEDICATION NAME] (a [MEDICAL CONDITION] medication) and [MEDICATION NAME] (a medication to reduce fluid retention) that if not administered timely and in accordance with the physician orders, would likely result in significant medication errors placing residents at risk of serious harm or death. Findings include: 1. The facility's Direct Care Staff Daily Report and Nursing Schedules revealed from 9/1/18 to 2/13/19 there were 23 out of 167 days without eight consecutive hours of RN coverage between the start of day shift and the end of evening shift as required by state rule, and 6 out of 167 days without eight consecutive hours of RN coverage in a 24-hour period. 2. Review of Resident Council notes revealed concerns regarding call light response times at the October, (MONTH) and (MONTH) (YEAR) meetings. 3. The Direct Care Staff Daily Reports, Staffing Sheets and Payroll from 1/22/19 through 2/18/19 reflected 9 out of 27 days the facility failed to meet state minimum CNA to resident staffing ratios. Interviews conducted with staff, residents and family members from all three halls revealed the following: - 1/22/19 at 2:15 PM Staff 24 (LPN) stated there were frequent evening call light wait time complaints and they were short CNA staffing in the evenings. - 1/22/19 at 1:39 PM Staff 17 (CNA) stated there were never enough CNAs, especially during the evenings. She stated CNAs were often asked to work more than eight hour shifts. - 1/22/19 at 3:21 PM Witness 1 (Complainant) stated during the last year there were not enough nurses which made it difficult to get all the work completed during a shift and also resulted in the next shift trying to catch up. For example, there was a physician order [REDACTED]. - 1/23/19 10:00 AM Resident 3 stated the call light wait times were often 20-30 minutes and CNAs have said they are short-handed. - 1/23/19 at 4:01 PM Staff 8 (RCM LPN) stated the facility needed more CNAs. - 1/23/19 at 4:34 PM Witness 3 (Family) stated more CNAs were needed and stated her family member waited close to 45 minutes for the call light to be answered. - 1/23/19 at 5:00 PM Staff 4 (RNCM) stated there was a need for more CNAs due to the acuity level of the residents in the facility. - 2/1/19 at 2:45 PM Staff 20 (CNA) stated there were not enough CNAs to meet the acuity level of the residents and CNAs were asked to work four more hours after an eight hour shift so often the CNAs were burning out. Staff 20 stated the worst time was between 6:00 AM and 8:00 AM related to residents' needs and the facility was short of CNAs often during that time frame. - 2/5/19 11:22 AM Staff 11 (LPN) stated she worked at least 50 hours a week and there were daily CNA shortages in all units of the building. Staff 11 stated charge nurses often had to work as CNAs. - 2/6/19 at 3:46 PM Resident 34 stated call light wait times were up to one and a half hours and mostly after the dinner meal. - 2/6/19 at 11:12 PM Staff 45 (LPN) and Staff 28 LPN) stated as charge nurses they spent hours of their shifts trying to get CNAs to cover shifts. - 2/6/19 at 11:20 PM Staff 32 (LPN) reported when a new order was received it was transcribed into the electronic chart and a copy of the MAR indicated [REDACTED]. Staff 32 stated it was a regular occurrence for verification checks to not be completed timely. Staff 32 stated the facility's system for physician order [REDACTED]. - 2/6/19 at 11:38 PM Staff 15 (LPN) stated the system to process physician orders [REDACTED]. Staff 15 stated it could take days for the verification checks to be completed and often there were transcription errors due to the lag in timing of the verification check. Staff 15 stated the facility was frequently short staffed and nurses helped on the floor and spent time calling staff to come in to work. - 2/7/19 at 12:19 PM Staff 3 (RNCM) stated the North Hall unit was extremely busy due to increased resident treatments. Staff 3 stated when he worked the floor as a charge nurse there was not enough time to get all the tasks completed. He stated a bridge nurse was on staff to assist with processing orders for all the units but that staff member also worked the floor as a charge nurse often and did not have time to process all physician orders. - 2/14/19 at 9:37 AM Staff 35 (LPN) stated physician orders [REDACTED]. Staff 35 stated the North Hall's acuity level for resident care was high and there were frequently CNA shortages. - 2/14/19 at 6:28 PM Staff 27 (LPN) stated his position was to assist with processing physician orders [REDACTED]. Staff 27 stated the North Hall had the most delay with physician order [REDACTED]. - 2/21/19 at 3:25 PM Staff 3 (RN) stated the acuity level on the North Hall was high and it was difficult to process physician orders [REDACTED]. On 2/14/19 at 4:15 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the Immediate Jeopardy related to staffing and it's effect on the timeliness and accuracy of processing physician orders, and at 4:30 PM at a subsequent meeting with Staff 1, Staff 2 and additionally Staff 38 (Regional RN) Surveyors requested a plan of correction to immediately protect residents from harm be developed and implemented. The facility submitted an acceptable immediate plan of correction to remove the immediate risk to resident health and welfare on 2/14/19 at 7:02 PM. The plan included: - admission hold for new admissions effective immediately until appropriate staffing levels are met - analysis of resident acuity related to available staff - implementing hospitality aides to assist with daily tasks - explore the use of agency staff - all licensed staff inservice prior to the start of shift on the timely processing of all physician orders - immediate audits of all current potential medication and lab errors that contributed to the deficient practice - consultation with the pharmacy to evaluate the facility medication system - all physician orders [REDACTED]. - nurse managers complete daily rounds to ensure all physician orders [REDACTED]. The facility's Immediate Jeopardy Plan of Correction was accepted on 2/14/19 at 7:30 PM and verified as implemented on 2/14/19 at 8:00 PM. Refer to F658, F755 and F770

1. Based on interview and record review it was determined the facility failed to process physician orders [REDACTED].#s 7, 9, 23, 25, 26, 27, 31 and 32) reviewed for medications. The facility population included residents with [DIAGNOSES REDACTED]. or death. Findings include: On [DATE] at 11:38 PM Staff 15 (LPN) stated the process for handling new physician orders [REDACTED]. She reported the nurse on the next shift was supposed to perform an order verification to determine if the order was entered correctly. Staff 15 stated Staff 4 (RNCM) performed the final verification. When asked if the process worked as described, she reported it could take days for the order verification to occur. Staff 15 further stated there were instances when the order was entered incorrectly the first time resulting in medication errors. She reported if the order verification was done on time, the errors could be prevented. In an interview on [DATE] at 12:19 PM Staff 4 (RNCM) acknowledged there was an issue with timely and accurate order processing on North hall. He stated the problem occurred for the past six months. a. Resident 31 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician order [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The [DATE] dose was documented as held by nurse and the [DATE] dose was held by the system. A review of the clinical record revealed the hold order was entered incorrectly causing the [DATE] dose of [MEDICATION NAME] to appear as held instead of the [DATE] dose. Documentation on the bottom of the order indicated the order was initially processed on [DATE]; the order verification did not occur until [DATE]. On [DATE] at 3:20 PM Staff 3 (RNCM) confirmed Resident 31's [MEDICATION NAME] was held for two days and it should have been held for one day. b. Resident 23 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician's orders [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. Resident 23's electronic clinical record revealed the new dose of [MEDICATION NAME] was not entered to begin until [DATE]. On [DATE] at 10:30 AM Staff 2 confirmed Resident 23 did not receive [MEDICATION NAME] on [DATE] but should have. c. Resident 26 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. (i) A [DATE] physician's orders [REDACTED]. A timestamp on the top of the physician's orders [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. Documentation made by staff on the bottom of the physician's orders [REDACTED]. On [DATE] at 10:51 AM Staff 2 (DNS) confirmed Resident 26 received the wrong dose of [MEDICATION NAME] on [DATE]. (ii) A [DATE] physician's orders [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. A Medication Error investigation revealed the [DATE] physician's orders [REDACTED]. On [DATE] at 12:19 PM Staff 4 (RNCM) confirmed Resident 26 received the wrong dose of [MEDICATION NAME] on [DATE]. d. Resident 32 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician's orders [REDACTED]. The timestamp on the top of the physician order [REDACTED]. Staff documentation on the physician order [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. On [DATE] at 3:20 PM Staff 4 (RNCM) confirmed the order for [MEDICATION NAME] was received on [DATE] but was not processed until [DATE]. He further stated Resident 32 did not receive the medication until [DATE]. e. Resident 27 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician's orders [REDACTED]. Resident 27's ,[DATE] TAR indicated she/he received [MEDICAL TREATMENT] on Monday, Wednesday and Friday. A review of the ,[DATE] MAR indicated [REDACTED]. Resident 27 received the medication seven times on [MEDICAL TREATMENT] days when she/he should not have. On [DATE] at 12:19 PM Staff 4 (RNCM) reported the order for hydrochlorithiazide was entered incorrectly into the electronic MAR. He further stated the error should have been caught by the order verification checks and was not. Staff 4 confirmed Resident 27 received the medication on [MEDICAL TREATMENT] days when she/he should not have. f. Resident 25 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician order [REDACTED]. A review of the ,[DATE] MAR indicated [REDACTED]. A Medication Error investigation dated [DATE] indicated the [MEDICATION NAME] order was entered into the electronic MAR indicated [REDACTED]. On [DATE] at 12:19 PM Staff 4 (RNCM) reported the [MEDICATION NAME] order was entered incorrectly into the electronic MAR indicated [REDACTED]. Staff 4 confirmed Resident 25 only received one dose of [MEDICATION NAME]. g. Resident 7 admitted to the facility in ,[DATE] in a persistent vegetative state (a chronic state of [MEDICAL CONDITION] in which a person shows no signs of awareness). (i) A [DATE] physician order [REDACTED]. A review of the ,[DATE] TAR revealed the resident continued to receive the tablet Tylenol through [DATE]. Beginning on [DATE], Resident 7 did not receive scheduled Tylenol. A Medication Error investigation related to the Tylenol order revealed the tablet order was discontinued on [DATE], two days after the order was received. The new order for the liquid Tylenol was not entered onto the TAR. According to the Medication Error investigation, Staff 3 (RN) stated she must have made a mistake while entering the orders into the electronic TAR. On [DATE] at 11:31 AM Staff 4 (RNCM) confirmed Resident 7 did not receive the liquid Tylenol as ordered on [DATE]. (ii). A [DATE] physician order [REDACTED]. -Change [MEDICATION NAME] [MEDICATION]) back to 400mg every 8am via [DEVICE] (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) -Stop am feeding at 6am and restart at 10am -All morning meds at 8am -Change free water to 100mg every 4 hours -Start Tylenol liquid via [DEVICE] at am -Change feedings back to 60ml/hr, feeding to run 20 hours per day -[MEDICATION NAME] level in one month A review of Resident 7's ,[DATE] TAR revealed the new orders did not start until [DATE]. A Medication Error investigation revealed the [DATE] physician orders [REDACTED]. The investigation further indicated multiple nurses through several shifts missed processing these orders. On [DATE] at 12:19 PM Staff 4 (RNCM) confirmed the [DATE] physician orders [REDACTED]. (iii) A [DATE] physician order [REDACTED]. A review of the ,[DATE] TAR revealed the morning dose of the liquid [MEDICATION NAME] was not administered on [DATE] because the medication was not available in the facility. The TAR further revealed the order for liquid [MEDICATION NAME] was discontinued on [DATE]. A Medication Error investigation indicated after Resident 7 missed the morning dose of the medication, a new order was obtained to use the tablet version of [MEDICATION NAME] which was available in the cart. The investigation revealed the new order was not entered onto the TAR which resulted in Resident 7 missing the evening dose of the [MEDICATION NAME]. On [DATE] at 12:19 PM Staff 4 (RNCM) confirmed Resident 7 missed her/his scheduled dose of [MEDICATION NAME]. h. Resident 9 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician order [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. On [DATE] at 4:41 PM Staff 4 reported the order to discontinue the atorvastatin was received the afternoon of [DATE] prior to the scheduled dose but the order did not get processed that day. He confirmed Resident 9 received a dose of atorvastatin and she/he should not have. On [DATE] at 4:15 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the Immediate Jeopardy related to pharmacy services, and at 4:30 PM at a subsequent meeting with Staff 1, Staff 2 and additionally Staff 38 (Regional RN) Surveyors requested a plan of correction to immediately protect residents from harm be developed and implemented. The facility submitted an acceptable immediate plan of correction to remove the immediate risk to resident health and welfare on [DATE] at 7:02 PM. The plan included: - admission hold for new admissions effective immediately until appropriate staffing levels are met - analysis of resident acuity related to available staff - implementing hospitality aides to assist with daily tasks - explore the use of agency staff - all licensed staff inservice prior to the start of shift on the timely processing of all physician orders - immediate audits of all current potential medication and lab errors that contributed to the deficient practice - consultation with the pharmacy to evaluate the facility medication system - all physician orders [REDACTED]. - nurse managers complete daily rounds to ensure all physician orders [REDACTED]. The facility's Immediate Jeopardy Plan of Correction was accepted on [DATE] at 7:30 PM and verified as implemented on [DATE] at 8:00 PM. Refer to F658, F725 and F770 2. Based on interview and record review it was determined the facility failed to provide prescribed medications for 5 of 13 sampled residents (#s 5, 9, 24, 25 and 30) reviewed for medications. This placed residents at risk for adverse side effects from not receiving ordered medications. Findings include: a. Resident 9 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. The resident began hospice services on [DATE]. A [DATE] physician order [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. A progress note dated [DATE] at 11:30 PM indicated the medication would be delivered by pharmacy in the morning. A progress note dated [DATE] at 11:21 AM indicated the facility was still waiting for the [MEDICATION NAME] to be delivered. Resident 9 died on [DATE] before the [MEDICATION NAME] was received. On [DATE] at 11:31 AM Staff 4 (RNCM) confirmed Resident 9 did not receive the [MEDICATION NAME] due to not having the medication available in the facility. He further stated the nurse who was in contact with the pharmacy should have requested this medication be delivered STAT (sent immediately). b. Resident 30 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A review of Resident 30's ,[DATE] MAR indicated [REDACTED]. On [DATE] at 10:35 AM Staff 2 (DNS) confirmed Resident 30 did not receive [MEDICATION NAME] or [MEDICATION NAME] because they were not available in the facility and should have been. c. Resident 5 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician's orders [REDACTED]. A review of the ,[DATE] MAR indicated [REDACTED]. On [DATE] at 11:20 AM Staff 2 (DNS) confirmed Resident 5 did not receive the ordered [MEDICATION NAME] on [DATE] because it was not received from the pharmacy and Staff 11 (LPN) did not pull it from the emergency supply. d. Resident 25 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A review of the ,[DATE] MAR indicated [REDACTED]. The morning dose of [MEDICATION NAME] was not administered on [DATE] because the medication was not available in the facility. On [DATE] at 10:56 AM Staff 2 (DNS) reported when an over-the-counter medication such as [MEDICATION NAME] was out of stock, staff purchase the medication at the store. She stated she was not aware the [MEDICATION NAME] was out of stock on [DATE]. Staff 2 confirmed Resident 25 did not receive the ordered [MEDICATION NAME] on [DATE]. On [DATE] at 11:01 AM Staff 49 (Interim Administrator) reported he identified medication ordering as an issue in the facility. e. Resident 24 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] physician's orders [REDACTED]. A review of the ,[DATE] MAR indicated [REDACTED]. On [DATE] at 10:56 AM Staff 2 (DNS) reported when an over-the-counter medication such as [MEDICATION NAME] was out of stock, staff purchase the medication at the store. She stated she was not aware the [MEDICATION NAME] was out of stock on [DATE]. Staff 2 confirmed Resident 25 did not receive the ordered [MEDICATION NAME] on [DATE]. On [DATE] at 11:01 AM Staff 49 (Interim Administrator) reported he identified medication ordering as an issue in the facility.

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely and accurately for 4 of 13 sampled residents (#s 16, 23, 26 and 31) reviewed for medications. The facility population included residents with [DIAGNOSES REDACTED]. or death. Findings include: On 2/12/19 at 9:09 AM Staff 37 (LPN) stated all INR (a lab test used to monitor patients who receive blood thinning medication) labs were completed in the morning to provide enough time for the results to be sent to the physician to receive new [MEDICATION NAME] orders before the evening administration. She reported the process for INR labs and order processing was the nurse filled out the INR form following the lab draw and sent it to the physician. She further stated the physician wrote the new orders on the form, including the new [MEDICATION NAME] dose, the next INR lab due date and the orders were then processed as a new order. 1. Resident 16 admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. According to the (MONTH) 2019 TAR, Resident 16 had her/his INR lab completed on 1/31/19. A 2/1/19 Nurse Practitioner (NP) Note indicated the NP reviewed the 1/31/19 INR lab results, made no changes to the current dose and wanted the INR rechecked next week. A review of the (MONTH) 2019 TAR on 2/7/19 did not reveal an INR lab was due. On 2/7/19 at 12:19 PM Staff 4 (RNCM) verified there was no entry in the (MONTH) TAR to indicate when Resident 16's next INR lab was due to be drawn and it should have been done. 2. Resident 31 admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. A 1/29/19 [MEDICATION NAME] form indicated the next INR lab was due on 2/5/19. A review of the 2/2019 TAR revealed the 2/5/19 INR lab was not completed and documented as held per nurse. A 2/5/19 Progress Note indicated input incorrectly, will administer on swing. No documentation was found in the clinical record to indicate the INR was completed on 2/5/19. On 2/22/19 at 1:45 PM Staff 2 (DNS) confirmed the INR lab was not done on 2/5/19 as ordered. 3. Resident 23 admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. A 1/29/19 [MEDICATION NAME] form indicated the next INR lab was due on 2/5/19. A review of the 2/2019 TAR revealed the 2/5/19 INR lab was not completed and documented as held by nurse. A 2/5/19 Progress Note indicated input incorrectly, will administer on swing. No documentation was found in the clinical record to indicate the INR was completed on 2/5/19. On 2/21/19 at 10:30 AM Staff 2 (DNS) confirmed the INR lab was not done on 2/5/19 as ordered. The lab was drawn two days later when the physician noted the lab was not completed. 4. Resident 26 admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. A 1/29/19 [MEDICATION NAME] form indicated the next INR lab was due on 2/1/19. A review of the 2/2019 TAR did not indicate an entry for an INR lab on 2/1/19. No documentation was found in the clinical record to indicate an INR lab was completed on 2/1/19. On 2/21/2019 at 10:51 AM Staff 2 (DNS) confirmed the order for the 2/1/19 INR lab did not get processed and entered on the TAR and was not completed. She further stated the missed INR lab was not noticed until 2/6/19. On 2/14/19 at 4:15 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the Immediate Jeopardy related to laboratory services, and at 4:30 PM at a subsequent meeting with Staff 1, Staff 2 and additionally Staff 38 (Regional RN) Surveyors requested a plan of correction to immediately protect residents from harm be developed and implemented. The facility submitted an acceptable immediate plan of correction to remove the immediate risk to resident health and welfare on 2/14/19 at 7:02 PM. The plan included: - admission hold for new admissions effective immediately until appropriate staffing levels are met - analysis of resident acuity related to available staff - implementing hospitality aides to assist with daily tasks - explore the use of agency staff - all licensed staff inservice prior to the start of shift on the timely processing of all physician orders - immediate audits of all current potential medication and lab errors that contributed to the deficient practice - consultation with the pharmacy to evaluate the facility medication system - all physician orders [REDACTED]. - nurse managers complete daily rounds to ensure all physician orders [REDACTED]. The facility's Immediate Jeopardy Plan of Correction was accepted on 2/14/19 at 7:30 PM and verified as implemented on 2/14/19 at 8:00 PM. Refer to F658, F725 and F755

Based on interview and record review it was determined the facility failed to implement or revise care planned interventions for 1 of 3 sampled residents (#2) who were reviewed for pressure ulcers. Resident 2 developed a Stage 2 pressure ulcer and it worsened. Findings include: Resident 2 was admitted to the facility in January 2016 with [DIAGNOSES REDACTED]. The Admission Nursing data Base dated 1/21/16 documented Resident 2 did not have a pressure ulcer. The Comprehensive Care Plan dated 1/21/16 identified the resident's risk for a pressure ulcer. Interventions included notification of the physician, resident and/or family of any new skin areas. The Incident Report dated 1/26/16 documented Staff 4 (LPN) saw there was open area on the resident's left heel, it was bleeding and its size was 6 x 5.5 cm. The Wound/Vascular Log dated 1/26/16 identified the resident's left heel had a Stage 2 pressure ulcer (partial-thickness loss of skin). The January 2016 TAR revealed the left heel wound treatment began on 1/27/16 and the wound care included a normal saline cleanse and a [MEDICATION NAME] dressing every other day. The Investigative Report dated 1/28/16 written by Staff 3 (Resident Care Manager, LPN) indicated the resident used her/his heels for bed mobility and when transferring in and out of bed. The report revealed the resident used a diabetic foot slipper at home and her/his family was going to bring in the slipper. The Admission MDS dated [DATE] indicated the resident had a facility-acquired pressure ulcer and was having OT and PT. The CAA revealed the resident's family was to bring in the resident's diabetic slipper from home. The Care Plan dated 1/28/16 included a new intervention of floating the resident's heels and the resident was to wear her/his diabetic slipper when it was available. The Wound Progress Note dated 2/5/16 revealed the size of the black eschar (devitalized tissue) which covered the resident's left heel wound was 7 x 7 cm and it was an unstageable pressure ulcer. The wound note indicated the resident continued to push on her/his heels for bed and wheelchair repositioning and the family was to bring in the resident's diabetic slipper. The resident's January and February 2016 Progress Notes included floating heels but no other type of heel protection was documented. On 7/26/16 at 11:15 am Resident 2 stated they put her/his feet on slippery plastic-covered pillows and my feet kept slipping off the pillows. Resident 2 indicated the facility did not follow through with getting a diabetic slipper or booties. On 7/26/16 at 12:30 pm Staff 8 (CNA) stated the resident's heels were floated on a pillow and the resident used a mobility bar for self-repositioning in bed. Staff 8 indicated she was not aware of a bootie or any other type of foot protection the resident might have worn. On 7/26/16 at 12:40 pm Staff 4 (LPN) indicated she told the resident not to lean on her/his heels when scooting up in bed. She stated [MEDICATION NAME] dressings were applied and she did not recall whether the resident wore a diabetic sock or a bootie for protection. On 8/1/16 at 11:00 am Witness 4 (Family) stated no one asked the family to bring in a diabetic slipper. On 8/1/16 2:05 pm Staff 3 (Resident Care Manager, LPN) stated the resident's family was supposed to bring a diabetic slipper which the resident reportedly used at home and the resident's care plan included the use of a diabetic slipper. Staff 3 indicated the diabetic slipper never arrived and the resident did not wear a protective foot covering. On 8/2/16 at 10:30 am Staff 2 (DNS) acknowledged Resident 2 was often transferred in and out of bed and there was no evidence the resident wore a slipper or bootie for skin protection.

Based on interview and record review it was determined the facility failed to provide supervision for 1 of 3 sampled residents (# 2) reviewed for falls. Resident 2 fell and required stitches. Findings include: Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. 1. The resident's September 2014 Significant Change MDS/CAAs indicated the resident was at risk for falls. The resident was identified to have a history of "multiple" falls. The resident's risk factors also included impaired cognition and deconditioning. The goal was for the resident to not sustain injury from falls. Identified interventions included to not leave the resident in the bathroom unassisted. The resident's Care Plan initiated on 3/14/14 indicated the resident was to go to bed after meals. The Care Plan also included the resident was to be toileted before and after meals, at bed time and as needed. The care plan was revised on 11/18/14 to indicate the resident was to be kept in line of sight when the resident was awake. Written statements from Staff 7 (CNA), Staff 11 (CNA), Staff 20 (LPN), Staff 21 (CNA) and Staff 22 (LPN) provided on 4/3/15 from Staff 10 (Administrator) indicated the staff were familiar with Resident 2. Staff 7, 11, 20, 21 and 22 indicated Resident 2 was able to propel in the wheelchair and was able to move quickly from one location to another location. Staff 21 indicated staff intervened when they saw the resident propel toward the resident's room to assist with toileting or to transfer to bed. Staff 22 indicated the night shift was "vigilant" to ensure the resident did not self transfer. Staff 22 also indicated the resident did not ask for assistance for transfers. Staff 21 indicated the resident propelled to her/his room and did not ask for assistance. The staff intervened when the resident propelled from the dining room toward the resident's room. Staff 21 indicated "the majority of the time" the resident needed assistance with toileting or to go back to bed. The resident's 11/22/14 Incident Report initiated at 2:48 pm and revised on 11/25/14 indicated the resident fell on [DATE]. Resident 2 reported she/he tried to walk from the wheel chair to the toilet, lost her/his balance, fell and hit her/his head. The resident was sent to the local emergency room for evaluation. The report included a statement from Staff 9 (CNA). Staff 9 reported she was by the nurses' station and heard a loud noise. Staff 9 entered the resident's room and found the resident on the floor with the resident's head under the sink. There were no other interviews to indicate if the resident was within site of staff prior to the fall. The note also did not include the following information: actual time of the resident's fall, if the resident was offered to go to bed after lunch, if the resident was up early for dinner and if the resident was toileted. The 11/22/14 at 9:15 pm note indicated the resident returned from the hospital and had stitches to the left ear. At 11:31 pm the note indicated the resident was provided Morphine (narcotic pain medication) for reports of right arm pain. Resident 2's 11/22/14 at 1:03 pm Follow-Up Question Report by Staff 18 (CNA) recorded the resident was assisted for toileting one time on the day shift of 11/22/14. The report included Witness 6 (Former CNA) worked the evening shift. On 3/31/15 at 7:54 am Staff 18 (CNA) stated she usually charted the number of times a resident was assisted with toileting when she had time and not at the time the assistance was provided. Staff 18 indicated she usually charted at the end of the shift. Staff 18 stated the day shift ended at 2:00 pm. On 4/1/15 at 11:10 am Witness 6 (Former CNA) stated she recalled when Resident 2 fell , hit her/his ear and was sent to the hospital. Witness 6 did not see the fall and did not remember anything else regarding the event. A written statement dated 3/23/15 by Staff 19 (CNA) indicated he saw Resident 2 in the dining room at approximately 2:00 pm. This was about 20 minutes prior to the approximate time of the fall. The Time Card detail for Staff 19 (CNA) indicated on 11/22/14 Staff 19 clocked off from duty at 2:12 pm. On 3/9/15 at 11:30 am and 4/3/15 at 11:10 am Staff 1 (LPN) stated he recalled Resident 2's fall on 11/22/14. Staff 1 stated the resident's room was adjacent to the nurses' station. Staff 1 indicated the time of the fall was the change of shift. He was at the nurses station prepping the tasks needed to be done on the evening shift. Staff 1 stated he was not sure how the resident ended up in the bathroom and did not recall where the resident was prior to the fall. Staff 1 indicated he likely heard the resident fall since the resident's room was close to the nurses' station. Upon entering the room, the resident was observed to be on the floor of the bathroom, and he did a quick but thorough assessment. Staff 1 did not recall if he activated the emergency medical system (EMS) or if he delegated the phone call to another staff. Staff 1 indicated from the time the resident fell until the EMS was activated was between two and five minutes. After the EMS arrived Staff 1 provided a report of the resident's history and the events of the incident to EMS staff. The EMS staff assessed the resident, obtained paperwork from the facility and then transported the resident to the hospital. Staff 1 did not initiate the incident report until after the EMS staff left. The incident report indicated it was initiated at 2:48 pm. Staff 1 stated he did not put in the time of the fall. The resident's 11/22/14 Final Patient Care Form from the emergency medical system indicated emergency services were activated on 11/22/14 at 2:34 pm. This was approximately 20 minutes after the resident was seen in the dining room by staff . On 3/17/15 at 10:37 am Staff 9 (CNA) stated she was at the nurses station on 11/22/14. Resident 2 fell at the change of the shift. Staff 9 indicated she was not assigned to work with the resident on 11/22/14. Staff 9 heard a noise from the resident's room and went into the room and found the resident on the bathroom floor as described in the incident report. Staff 9 stated there were no other staff with the resident and she was the first staff in the resident's room after the resident fell . On 4/2/15 at 8:03 am Staff 20 (LPN) stated she worked the day shift on 11/22/14. She recalled Resident 2 was in the dining room at the change of shift. Change of shift was at 2:00 pm. The dining room and the resident's room were within sight of the nurses station. Staff 20 stated she provided the change of shift report and was documenting on the computer when the resident fell . Staff 1 assisted the resident. The resident had an injury and Staff 20 knew the resident needed stitches. Staff 20 prepared the resident's documentation to send to the hospital. Staff 20 stated during report she was not able to keep an eye on the resident because she was focused on providing information to the oncoming nurse. The resident was able to propel in a wheelchair and moved quickly. Staff 20 indicated if she saw the resident entering her/his room without assistance she assisted the resident. Staff 20 stated she did not see Resident 2 enter her/his room. On 3/9/15 at 11:45 am and 3/17/15 at 11:37 am Staff 8 (Assistant DNS) reviewed the resident's 11/22/14 Incident Report and Care Plan and acknowledged the resident was to be kept in line of site. Staff 8 indicated there were no other interviews completed to indicate if the resident was within line of sight of staff prior to the fall and if the resident was assisted back to her/his room and to the bathroom after lunch, or if the resident was assisted with toileting prior to the fall. Staff 8 indicated lunch was from approximately 12:00 pm to 1:30 pm and the resident was noted to fall at approximately 2:48 pm. 2. The resident's 11/20/14 at 8:39 pm Progress note indicated the resident was sitting in her/his wheelchair next to the nurses station. Witness 3 (Former Charge Nurse) left the nurses station to assist another resident. The note indicated Witness 3 exited an unsampled resident's room and Witness 3 heard a noise from Resident 2's room. The resident was found on the floor next to the resident's bed. The resident reported back pain and reported she/he was trying to get into bed. No other injuries were noted. The resident was assisted to bed. The resident's Incident Report initiated on 11/20/14 at 7:45 pm indicated the resident was found on the floor next to the bed. The resident reported back pain, but no other injuries were noted. The incident report indicated Staff 7 (CNA) was in another resident's room when the resident fell . There was no indication the resident was within line of site of other staff. On 3/10/15 at 1:25 pm a call was placed to Witness 3 (Former Charge Nurse). A return call was not received. On 3/10/15 at 1:45 pm Staff 7 (CNA) indicated she did not recall the events of 1/20/15. On 3/9/15 at 11:45 am and 3/17/15 at 11:37 pm Staff 8 (Assistant DNS) reviewed the resident's 11/20/14 Incident Report and Care Plan and acknowledged the resident was to be kept in line of site. Staff 8 indicated the evening meal was completed at approximately 6:00 pm to 7:30 pm. There were no additional interviews included on the incident report to indicate the resident was within line of sight of staff prior to the fall and the reason the resident was not assisted to bed after the evening meal.

Based on interviews and record review it was determined the facility failed to follow the care plan to not leave the resident unattended in the bathroom for 1 of 4 sampled residents (#1) reviewed for accidents. The resident sustained [REDACTED]. The resident was evaluated at the local hospital emergency department. The abrasion on her/his right arm resulted in the resident being treated for [REDACTED]. Resident 1 was admitted to the facility in 3/2013 with [DIAGNOSES REDACTED]. The 3/15/13 Fall Risk Evaluation indicated the resident had a history of [REDACTED]. The 4/18/13 CNA pocket care plan directed the CNAs to "STAY WITH (Resident 1) IN BR (bathroom) ...." The 4/20/13 progress note indicated Resident 1 fell in the bathroom. The resident sustained [REDACTED]. The resident was examined at the local hospital emergency department. The 4/20/13 fall investigation completed by Staff 1 (Assistant DNS) indicated Resident 1 fell in the bathroom when Staff 4 (CNA) left the resident unattended in the bathroom. The resident's care plan stated the resident was not to be left unattended in the bathroom. Staff 4 (CNA) was assisting Resident 1's room-mate in the room when Resident 1 fell in the bathroom. Staff 1 (Assistant DNS) indicated Staff 4 was assigned to care for Resident 1 on 4/19/13. The 4/20/13 witness statement completed by Staff 4 (CNA) indicated Staff 4 assisted the resident to the bathroom. Resident 1's room-mate asked for assistance with the menu. Staff 4 asked Resident 1 to call for Staff 4 or to put the call light on. Staff 4 assisted Resident 1's room-mate with the menu. Staff 4 went into the bathroom and found Resident 1 on the floor. Staff 4 stated she was not assigned to care for Resident 1 though she had the pocket care plan with her. The 4/24/13 physician's visit notes indicated on 4/22/13 the resident had right wrist pain secondary to the 4/20/13 fall. The physician indicated the resident did not complain of right wrist pain when she/he was at the local hospital emergency department so there was no x-ray taken of the right wrist. The resident's right wrist was x-rayed on 4/23/13 and was negative for a fracture. The resident continued to complain of right wrist pain and was having a difficult time transferring and regressed in therapy. The physician assessed the resident's right upper arm had [DIAGNOSES REDACTED] and edema and was tender to palpation. The resident was placed on an antibiotic for cellulitis. The 4/26/13 physician's visit notes indicated on 4/26/13 the resident fell causing an abrasion to her/his right elbow. The abrasion developed into cellulitis in her/his right upper extremity, mainly concentrated around the hand, wrist and lower forearm. The physician assessed there was a reduction in the swelling and pain of the resident's right wrist and hand. An interview on 6/3/13 at 9:30 am with Staff 1 (Assistant DNS) revealed Resident 1's care plan assessed the resident not to be left alone in the bathroom. Staff 1 stated Staff 4 (CNA) had been assigned to care for Resident 1 on 4/19/13. Staff 1 stated on 4/20/13, Staff 4 (CNA) left the resident alone in the bathroom and the resident fell . Staff 1 stated the x-ray was negative for a fracture though the resident was treated for [REDACTED]. An interview on 6/3/13 at 1:00 pm Staff 3 (LPN) revealed Staff 3 was informed by Staff 4 (CNA) of Resident 1's fall in the bathroom. Staff 3 verified Staff 4 left the resident unattended in the bathroom.

Based on interview and record review it was determined that the facility failed to follow professional standards for 1 of 1 sampled residents (#2). Resident 2 sustained a laceration on her/his right leg requiring sutures. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] (6) (d) Follow the care plan as directed by the licensed nurse; (f) Tasks associated with safety. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/14/11 chart care plan indicated the resident had impaired physical mobility with a risk for falls and needed the assistance of two CNAs for transfers. The 7/30/11 Interdisciplinary Progress Notes (IPN) indicated at 9:50 pm the resident was transferred from wheelchair (w/c) to bed and said her/his leg hurt. The resident had a 13 cm laceration on her/his right leg and the wound was bleeding copiously. The resident was transported to the local hospital emergency room and the laceration required sutures. The 7/30/11 Occurrence Report written by Staff 2 (RNCM) indicated the resident had been assessed and care planned for two person transfers. Staff 7 (CNA) stated she transferred the resident by herself because the resident was an easy transfer. Staff 2 interviewed other CNAs and they indicated the resident needed the assistance of two CNAs for safe transfers. Staff 2's interviews revealed the resident was inconsistent with transfers and required the most assistance when she/he had to stand for a few moments. The conclusion of the investigation was the Arco rail (bed cane) was the cause of the skin tear and the rail was to be removed. Staff 2 determined if the resident had been assisted by two CNAs the resident's skin tear would probably still have occurred. Staff 2 indicated Staff 7 (CNA) did not follow the resident's care plan regarding the use of two CNAs for transfer assistance. Staff 7 was suspended from employment until the investigation was concluded. The 8/2/11 Plan of Correction written by Staff 1 (DNS) indicated the resident's skin tear occurred due to the use of the Arco rail as the resident's posterior calf impacted the rail which was in a down position causing a skin tear. Staff 1 identified Resident 2 as a high risk for skin integrity compromise as she/he had multiple skin tears and bruises, dependent [MEDICAL CONDITION] which caused third spacing (shifting of fluid) to her/his lower extremities and her/his skin lacked any elasticity and would tear very easily. Staff 1 indicated the skin tear occurred as a result of the impact of the side rail, though Staff 7 (CNA) failed to follow the resident's care plan for a two person transfer. Staff 1(DNS) indicated it was her professional opinion the injury occurred and the injury would have likely occurred if two CNAs were involved with the transfer. Staff 1 indicated the skin tear was not a result of the transfer itself and was related to the impact of the rail. Staff 7 (CNA) was suspended from employment pending an ongoing investigation with disciplinary action to follow. An interview on 8/8/11 at 1:15 pm with Staff 3 (LPN) revealed the resident required the assistance of two CNAs because the resident's abilities were unpredictable. An interview on 8/8/11 at 2:00 pm with Staff 5 (CNA) and Staff 6 (CNA) revealed Resident 2 was always transferred with the assistance of two CNAs and never one CNA because the resident was not steady on her/his feet. An interview on 8/8/11 at 3:55 pm with Staff 7 (CNA) revealed she was the CNA who cared for Resident 2 on 7/30/11. Staff 7 stated the resident asked her to assist the resident to bed. Staff 7 stated she knew the resident's care plan indicated the transfer assistance of two CNAs. Staff 7 stated she wanted to help the resident into bed and thought she could manage the transfer by herself. Staff 7 stated thought the resident's bed caused the skin tear. Refer to F-323.

Based on observation, interview and record review it was determined the facility failed implement a resident's fall safety devices for 1 of 4 sampled residents (# 1) who had experienced falls. Findings include: Resident 1 was admitted to the facility in September 2009 with [DIAGNOSES REDACTED]. The comprehensive care plan dated 1/28/11 indicated the resident was at risk for injury due to history of falls, dementia and weakness. Interventions to prevent fall related injuries included; low bed, fall mattress on each side of the bed, bolster mattress on the bed, wheelchair and bed pressure pad alarm, motion alarm at entrance of the room and not to leave resident alone in room when up in the wheelchair. The alarms were to be checked for function and placement at least each shift. The April 2011 MDS indicated the resident had short and long term memory deficits, required extensive assistance from staff for all ADLs. Resident 1 was dependent for transfers and was incontinent. According to the facility's investigative report dated 5/24/11, Resident 1 was found on the floor of her/his room yelling out for help at 9:50 am. The resident's bed alarm had not sounded and was noted to be in the off position. The fall mattress was not in place beside the resident's bed. The resident had sustained two skin tears on her/his left forearm. According to the Fall Details Report the resident was toileted at 7:00 am and last visually observed and repositioned at 9:40 am. The Interdisciplinary Progress Notes dated 5/24/11 indicated Staff 4 (LPN) and Staff 6 (CNA) entered Resident 1's room and found the resident on the floor. Staff 4 assessed the resident who sustained skin tears on the left arm, Staff 4 determined the resident had no other injuries. The resident was placed on 72 hour neuro checks and vital signs for precaution. Staff 4 treated the resident's skin tears. The family and the physician were notified. On 6/7/11 at 2:05 pm, Staff 1 (DNS) stated during her investigation into the circumstances surrounding the resident's fall "information just didn't add up." Staff 1 stated, Staff 7 (CNA) initially reported she turned on the resident's alarm, put the pad down on the floor and left for her break. Staff 1 stated the time frames were validated to within 10 minutes and the relief CNA had not been to the resident's room. Staff 1 stated she received written statements from the two CNAs that had cared for Resident 1 on 5/24/11. Staff 1 stated Staff 7 was the last person who cared for Resident 1 at 9:40 am. Staff 1 stated the written statement provided by Staff 7 indicated "...I took (her/him) to bed and turned on the bed alarm, connected (her/him) to the personal alarm... asked the aid to check the personal alarm and went on my break." Staff 1 stated the resident did not use a personal alarm attached to her/him, the resident had a pressure pad alarm and motion alarm. Staff 1 stated Staff 7 was suspended pending the investigation but had since been terminated for not following the resident's care plan. On 6/7/11 at 2:50 pm, Staff 4 (LPN) stated she was the nurse on duty and found the resident on the floor. Staff 4 stated she happened to be walking by the resident's room and saw the resident on the floor between the wheelchair and the bathroom door. Staff 4 stated she knew the resident had alarms but no alarms were going off. Staff 4 stated the resident had previously been in bed. Staff 4 stated, "when I entered the room I noticed the fall mattress propped up against the end of the bed not on the floor like it was suppose to be and the pressure pad alarm was turned off." On 6/8/11 at 9:30 am, Resident 1 was observed out of bed and in a wheelchair by the nurse's station. The resident had a pressure pad alarm that was connected and in the on position. On 6/8/11 at 9:50 am, Staff 5 (CNA) stated if the resident was in her/his wheelchair, in the room, she/he would attempt to get into bed. Staff 5 stated, "we have a motion alarm in the doorway of the room, if the resident tries to go in there it will sound." On 6/8/11 at 10:15 am, the resident was observed being wheeled out of her/his room by a CNA after being toileted. Staff 4 (LPN) was observed going over to the resident's doorway and looked at the motion alarm that was mounted on the door jam. Staff 4 stated she checked the alarm and reported the CNA had turned the alarm back to the on position. On 6/8/11 at 10:45 am, Resident 1 was observed to be resting in bed with all safety measures that were care planned in place.