Every finding on record at Avamere Transitional Care at Sunnyside

Based on observation, interview, and record review, the facility failed to maintain evidence of grievance decisions for a period of no less than 3 years from the date of the grievance decision. This placed residents at risk for grievances not being resolved or documented. Findings include:On 8/17/26, an Entrance Conference letter request for grievances related to call lights, activities of daily living (ADLs), resident rights, and resident safety from 3/1/26 through 5/10/26 was submitted to Staff 1 (Administrator). On 8/17/26 at 11:15 AM, Staff 1 reported the 2026 grievance binder could not be located and was unavailable for review. On 8/21/26 at 10:00 AM, Staff 1 reported the grievance binder was last seen approximately two weeks earlier. The grievance binder remained unavailable for review. On 8/24/26 at 11:30 AM, Staff 4 (Social Services Director) reported she did not know when the grievance binder was last seen. On 8/24/26 at 2:15 PM, Staff 1 acknowledged the grievance binder should be maintained and available for review.

Based on interview and record review, it was determined the facility failed to ensure qualified staff administered medications for one of one facility reviewed for medication administration. This placed residents at risk for receiving medication errors. Findings included: The Oregon State Board of Nursing indicated the title abbreviation CMA is protected by Oregon law and means Certified Medication Aide, not Certified Medical Assistant. The abbreviation CMA could not be used by medical assistants in Oregon. Medical assistants are unregulated personnel and work in outpatient settings under the direction of a physician. The facility's Administering Medications policy, dated 4/2019, indicated only persons licensed or permitted by the state could prepare, administer, and document the administration of medications. A public complaint was received on 3/15/25, which alleged the facility failed to ensure staff were qualified to administer medications to residents. On 6/3/25 at 11:36 AM, Staff 20 (Staffing Coordinator) stated she posted on an agency website the facility needed CMAs to pass medications on day shift. Staff 19 (Agency Medical Assistant) signed up for the shift and passed medications on the first and second floors of the facility. It was not until the end of the day shift the facility realized Staff 19 was a Medical Assistant, not a CMA, and could not administer medications to residents in a nursing facility. On 6/4/25 at 11:51 AM, Staff 2 (DNS) stated Staff 19 told Staff 2 she was a medication aide. Staff 19 passed medications on 3/15/25, on day shift. Staff 2 stated Staff 19 did not pass the medications per established protocols and the nurses questioned her ability, so they looked up her license to find out she was a Medical Assistant not a CMA. On 6/5/25 at 11:06 AM, Staff 19 stated she was told she could administer medications at the nursing facility if she was working under a nurse or physician. Staff 19 stated she had worked eight hours in the facility on 3/15/25. On 6/6/25 at 1:15 PM, Staff 1 (Administrator), Staff 2, and Staff 3 (Regional Clinical Nurse) acknowledged Staff 19 administered medications to residents in the facility. Staff 2 stated the staffing agency was called, and the facility no longer used the staffing agency's services. Staff 2 stated her expectation was for nursing staff to be licensed or certified to work in the facility

Based on interview and record review, it was determined the facility failed to ensure narcotic drug records were in order, and an account of all controlled drugs was maintained for 4 of 4 medication carts reviewed for medication administration. This placed residents at risk for drug diversion. Findings included: On 6/4/25 at 11:14 AM, book four on the South hall's 5/2025 medication cart Narcotic log book revealed 57 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:30 AM, book four on the South hall's 4/2025 medication cart Narcotic log book revealed 45 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:45 AM, book seven on the North hall's 3/2025 medication cart Narcotic log book revealed 92 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:50 AM, book seven on the North hall's 4/2025 medication cart Narcotic log book revealed 82 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 11:55 AM, book seven on the North hall's 5/2025 medication cart Narcotic log book revealed 64 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:00 PM, book 14 on the South hall's 3/2025 medication cart Narcotic log book revealed 94 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:05 PM, book 14 on the North hall's 4/2025 medication cart Narcotic log book revealed 52 times out of 186 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:10 PM, book 14 on the North hall's 5/2025 medication cart Narcotic log book revealed 36 times out of 180 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 6/4/25 at 12:22 PM, Staff 2 (DNS) verified the missing signatures in the Narcotic books. Staff 2 acknowledged the Narcotic book always needed to be signed by two nurses or CMAs to verify the count was accurate.

Based on interview and record review it was determined the facility failed to ensure residents were able to be fully informed in language that she/he can understand of her/his health status and participate in health care decisions for 1 of 7 sampled residents (#39). This placed residents at risk for not being able to fully participate in their own health care. Findings include: Resident 39 was admitted to the facility in 8/2022 with diagnoses including hypertension (high blood pressure). A review of Resident 39's care plan initiated in 9/2022 revealed the resident was Spanish-speaking and stated translation services would be available to her/him. On 6/3/25 at 2:02 PM, Resident 39 stated some staff did not take the time to understand her/him and were impatient when she/he tried to communicate her/his needs. On 6/4/25 at 10:15 AM, Staff 5 (LPN) stated on the morning of 6/4/25 Staff 5 observed Staff 6 (CNA) tell Resident 39 to stop talking while he was attempting to take Resident 39's blood pressure. Staff 5 stated Resident 39 was trying to explain she/he wanted her/his blood pressure taken with the manual cuff rather than the tower. Staff 6 was not using the tablet translator. On 6/5/25 at 7:36 AM, Resident 39 stated she/he was not respected by staff when they did not bother to understand her/his needs or communicate with the resident when providing care. Resident 39 stated she/he was frustrated because Staff 6 did not understand Resident 39 did not like her/his blood pressure taken with the tower monitor and wanted it taken manually. On 6/6/25 at 8:57 AM, Staff 6 stated he was trying to take Resident 39's blood pressure and Resident 39 was getting very upset because the tower monitor was not reading correctly. Staff 6 stated he was blunt and straightforward with Resident 39 and did tell him to stop talking so he could take her/his blood pressure manually. Staff 6 stated he did not use the tablet translator. Staff 6 stated he thought it was unfair to residents that they could not easily communicate their needs when they didn't understand or speak English. On 6/6/25 at 1:04 PM, Staff 2 (DNS) stated staff were expected to use translator tablets. Staff 2 stated she did not provide any recent training on communicating with non-English speaking residents but assumed the training was part of their orientation. Staff 2 stated Staff 6 was placed on leave pending investigation for his interaction with Resident 39.

Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communication with a resident regarding the resolution of a resident's grievance for 1 of 1 sampled resident (#69) reviewed for dignity. This placed residents at risk for unaddressed concerns and grievances. Findings include: Resident 69 was admitted to the facility in 5/2025 with diagnoses including chronic pain and PTSD (Post Traumatic Stress Disorder). Resident 69's 5/24/25 admission MDS indicated the resident was cognitively intact. The facilities Grievance Policy dated 1/1/17 indicated concerns will be forwarded to the grievance official and appropriate department supervisor for action. The grievance official or department supervisor will contact the concerned resident or representative to inform them of the resolution of their concern. The grievance official and administrator will review the grievance and then forward a copy to the appropriate department manager for action within 72 hours of the receipt. The grievance official and appropriate department supervisor will take immediate action towards resolution of the concern upon receiving a copy of the grievance communication form and will record this action and resolution on the bottom section of the form. The grievance official, administrator or department manager will then contact the concerned party to inform them of the resolution to their concern. On 6/2/25 at 11:02 AM, Resident 69 reported that on 5/28/25 she/he spoke with Staff 2 (DNS) regarding staff not giving her/his pain medication in a timely manner. Resident 69 stated Staff 2 responded by expressing disapproval of residents entering her office to voice complaints about staff. Staff 2 stated she did not have time for this discussion and directed the resident to leave her office. Resident 69 described Staff 2's demeanor as rude and disrespectful. Resident 69 reported feeling she/he was not treated with dignity and respect. Resident 69 stated she/he told two staff members about her/his conversation with Staff 2 and they encouraged her/him to fill out a grievance form and provided one for that purpose. Resident 69 stated she/he completed the grievance communication form handed it to Staff 25 (RN) and she slid it under the administrators office door so they would not be noticed. On 6/4/25 at 9:14 AM, Resident 69 stated staff did not follow up with her/him regarding their grievance. The resident expressed concerns Staff 2 might confront her/him and become upset. Resident 69 also stated Staff 2 did not apologize and she/he felt disrespected. Resident 69 provided a copy of the 5/28/25 Grievance Communication Form which stated the following: The resident reported being prescribed oxycodone (narcotic pain medication) every four hours and alleged nursing staff were an hour late in administering her/his medication. The resident stated they informed a CNA of her/his upcoming physical therapy session and requested the nurse be notified to administer pain medications beforehand. After waiting 45 minutes, the resident reported speaking with Staff 2, who asked the resident to leave her office and expressed disapproval of complaints about the staff. The resident also reported Staff 2 was rude. The resident expressed dissatisfaction with the facilities pain management and rehabilitation services. On 6/5/25 at 8:44 AM, Staff 22 (CNA) stated last week Resident 69 requested pain medication but waited for an hour, as the nurse was attending to another resident and the medication aid was on lunch. Staff 22 noted Resident 69 was in more pain than usual and became upset, and she/he did not want to participate in physical therapy due to the pain. On 6/5/25 at 9:46 AM, Staff 21 (CNA) stated last week Resident 69 became upset because she/he waited over an hour for her/his pain medication. Resident 69 stated she/he talked to Staff 2 and felt like she lied to her/him. Staff 21 encouraged Resident 69 to fill out a grievance. On 6/6/25 at 8:02 AM, Staff 24 (Social Service Director) stated she was unaware Resident 69 filled out a grievance and she would follow up with the resident. On 6/6/25 at 8:18 AM, Staff 2 confirmed last week she had a discussion with Resident 69 regarding the resident's concerns about pain medication not being administered in a timely manner. Staff 2 reported she completed a risk management form related to the concern and provided staff education. She further stated the resident did not give her a grievance form and she believed the issue was resolved. On 6/6/25 at 1:08 PM, Staff 1 (Administrator) stated he was not aware Resident 69 submitted a grievance. Staff 1 reported his expectation was for all grievances to be brought to his attention as soon as possible and the resident to be contacted or provided with the investigative conclusion to the grievance. Staff 1 stated he would follow up with Resident 69. On 6/6/25 at 1:28 PM, Staff 25 confirmed around 6:00 PM on 5/28/25, Resident 69 approached her and stated she/he was very upset after a conversation with Staff 2. The resident reported she/he was never spoken to in that manner before and felt disrespected. Staff 25 stated Resident 69 completed a grievance form. Staff 25 stated she had a key to Staff 1's office and placed the grievance form in his mailbox. Staff 25 stated staff did not follow up with her regarding any additional information. On 6/6/25 at 3:00 PM, Staff 1 stated he found the missing grievance. Staff 1 confirmed the grievance process was not followed.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital for 1 of 1 sampled resident (#18) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include: A review of the facility's Bed Holds and Returns Policy dated 10/2022 stated residents, regardless of payer source, are provided written notice about these policies [.] at the time of transfer. Resident 18 was admitted to the facility in 11/2017 with diagnoses including congestive heart failure, COPD (chronic obstructive pulmonary disease), and respiratory failure. A review of Resident 18's clinical record revealed she/he was transferred to the hospital on 5/27/25. No evidence was found in Resident 18's clinical record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital. On 6/6/25 at 8:55 AM, Staff 2 (DNS) stated a written bed hold notification was not provided to Resident 18 or her/his representative at the time of transfer to the hospital because her/his payer source was Medicaid. On 6/6/25 at 10:33 AM, Staff 17 (Regional Nurse Consultant) confirmed a written bed hold policy, including reserved payment, needed to be provided to Resident 18 or her/his representative at the time she/he was transferred to the hospital.

Based on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services under physician orders for 1 of 2 sampled residents (#47) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include: Resident 47 was admitted to the facility in 8/2024 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease an airway disease which restricts breathing) and diabetes. The undated facility Oxygen Administration policy and procedures revealed: 1. Verify a physician's order for the procedure. Review the physicians' orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. The 12/24/24 care plan indicated Resident 47 experienced shortness of breath with decreased energy and fatigue. Interventions included learning signs of respiratory compromise, encouraging sustained deep breaths, and monitoring and documenting changes in orientation, increased restlessness, anxiety, and air hunger. Resident 47 was to have oxygen via nasal cannula PRN. O2 Sat Summary (Oxygen Saturation Summary) printed on 6/4/25 revealed from 5/1/25 through 6/3/25, Resident 47's oxygen vitals were checked 45 times, and the resident was documented as being on oxygen via nasal cannula 32 times. Resident 47's 5/16/25 Quarterly MDS indicated the resident was cognitively intact. On 6/2/25 at 12:50 PM, and 6/4/25 at 8:53 AM, Resident 47 was observed in bed with oxygen administered through a nasal cannula. On 6/3/25 at 8:08 AM, Resident 47 was observed in bed with oxygen administered through a nasal cannula. On 6/5/25 at 7:28 AM, Staff 3 (CNA) stated Resident 47 used oxygen while she/he was in bed but did not use it when she/he was up in her/his wheelchair. On 6/5/25 at 9:01 AM, Resident 47 was observed with oxygen administered through a nasal cannula. A review of the Resident 47's clinical record found no documentation of physician orders for oxygen administration, how often the oxygen filter was to be cleaned, checked, or how often the oxygen tubing was to be changed. On 6/5/25 at 10:28 AM, Staff 2 stated Resident 47 did not have any current orders for oxygen.

Based on interview and record review, the facility failed to provide appropriate pain management for 1 of 2 sampled residents (#55) reviewed for pain. This placed residents at risk for uncontrolled pain. Findings include: Resident 55 was admitted to the facility in 2/2025 with diagnoses including osteoarthritis of the hip and knee and chronic pain. A 4/16/25 Physician's Progress Note indicated Resident 55 experienced severe osteoarthritis. The recommendation was to continue pain management with PRN acetaminophen. A revised 4/17/25 care plan revealed Resident 55 experienced chronic pain due to gout, and bilateral severe osteoarthritis of the hip. Interventions included attempting non-pharmaceutical interventions before administering pain medications per physician orders and report to the nurse complaints of pain or requests for pain treatment. Resident 55's 5/21/25 Quarterly MDS indicated the resident was cognitively intact. Resident 55 received scheduled pain medication and no PRN pain medications. Resident 55 was in almost constant pain, which affected sleep, day-to-day activities, and therapy frequently. The resident reported a pain level of seven on a scale from 0-10. A 6/2025 MAR instructed staff to administer gabapentin 300 mg by mouth in the afternoon for pain and gabapentin 300 mg two capsules two times a day for pain at 8:00 AM and 8:00 PM. Resident 55 was also ordered to have acetaminophen 500 mg two tablets every 8 hours for pain. Both orders were administered as physician ordered. On 6/2/25 at 12:48 PM and 6/5/25 at 8:51 AM, Resident 55 stated she/he was asking for something to assist with breakthrough pain, but nothing had happened yet. Resident 55 stated there were days when she/he was very painful and needed additional medication. Resident 55 stated she/he took gabapentin and acetaminophen and did not take anything for breakthrough pain. Resident 55 stated she/he put in a request a couple of weeks ago and nothing was done. Resident 55 stated topical creams did not work. No documentation or communication with the provider about pain management was found in Resident 55's clinical record. On 6/5/25 at 11:21 AM, Staff 2 (DNS) stated she could not find any information to indicate the physician was contacted for clarification for the PRN acetaminophen. Staff 2 stated she expected staff to contact the physician to clarify the information in the physician's progress note.

Based on observation and interview it was determined the facility failed to ensure sufficient supplies were available to ensure a functional and comfortable environment for one of two floors reviewed for environment. This placed residents at risk for an uncomfortable living environment. Findings include: A public complaint received on 2/13/25 indicated the facility failed to provide enough supplies to meet resident care needs. On 6/5/25 at 9:24 AM, Staff 21 (CNA) reported since 2/2025 the facility experienced on-going shortages of bariatric sheets and towels for residents. As a result, residents often waited for clean linens before staff could change their beds. Staff 21 stated she reported these concerns to management however the issues continued to occur. On 6/5/25 at 9:25 AM, Staff 21 confirmed no bariatric sheets or towels were available for resident use in the North Hall linen closet. On 6/5/25 at 9:45 AM, Staff 29 (CNA) stated she looked for towels for a resident and was unable to find any in the North Hall linen closet. She further stated this was a common occurrence and she often searched other areas of the facility to locate linens for all residents. On 6/5/25 at 10:00 AM, Resident 43 stated the facility never had the right size sheets for her/his bariatric bed and the sheets frequently slipped off her/his mattress. Resident 43 also stated the facility frequently ran out of sheets, and she/he waited more than 20 minutes before staff could change her/his bedding. On 6/5/25 at 10:31 AM, Staff 22 (CNA) stated on weekends, the facility always ran out of bed pads and bariatric sheets. She informed the housekeeping management of the issue over the past few months however the facility still did not have enough linens for the residents. On 6/5/25 at 10:57 AM, Resident 31 stated for a period of time, the facility ran out of bariatric sheets several times a week. Resident 31 stated nine times out of 10 the CNA's were unable to make her/his bed until later in the day due to lack of bariatric sheets. On 6/5/25 at 11:16 AM, Staff 30 (CNA) stated the facility had multiple bedbound bariatric residents. Staff 30 reported the facility ran out of bariatric sheets daily, resulting in residents having to wait before their bedding could be changed. Staff 30 stated this made it difficult to provide care particularly on shower days when staff were expected to change resident sheets but often waited for supplies or searched throughout the facility to locate them. On 6/6/25 at 9:45 AM, Staff 27 (Maintenance Director) confirmed over the past several months both residents and staff expressed concerns about not having enough bariatric sheets and towels. On 6/6/25 at 1:19 PM, Staff 1 (Administrator) confirmed he was aware the facility had an ongoing issue with not having sufficient linens to meet the needs of all the residents.

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 4 of 7 sampled residents (#s 1, 2, 3, and 13) and 2 of 2 floors reviewed for call light wait times and staffing. This placed residents at risk for lack of ADL care needs. Findings include: 1. Resident 1 was admitted to the facility in 2015 with diagnoses including diabetes, and renal disease. A care plan dated 9/5/23, and revised on 12/5/24, revealed Resident 1 was incontinent of bowel and bladder. Resident 1 required one or two-person assistance for all ADL care needs and required a mechanical lift for transfers. On 12/27/24 at 1:30 PM, Witness 20 (Complainant) stated Resident 1 had concerns regarding long call light response times, which were 30 minutes or longer. Witness 20 stated the resident called him on multiple occasions when she/he was sitting in a wet and soiled brief. Witness 20 stated ongoing concerns with staffing and long call light response times dated back to July 2024. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and at 3:35 PM, Staff 13 (CNA) stated the resident was dependent on ADL care needs and had concerns with not enough staff to answer call lights. Staff 12 stated Resident 1 sat in wet and soiled briefs for 20 minutes or longer on more than one occasion. On 12/30/24 at 3:53 PM, Resident 1 was observed in bed. Resident 1 stated the facility did not have enough CNAs, which was a concern since the beginning of summer and continued to be an issue. Resident 1 stated call lights were long, at times up to 30 plus minutes. Resident 1 further stated she/he sat in a wet and soiled brief on multiple occasions. On 1/6/25 at 1:48 PM, Staff 11 (LPN-Resident Care Manager) stated Resident 1 had concerns of long call light wait times, since the summer months and was due to being short staffed. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 2. Resident 2 was admitted to the facility in 2024 with diagnoses including a stroke and depression. A care plan dated 6/28/24, and revised on 7/13/24, revealed Resident 2 was on a toileting program due to mixed bowel and bladder incontinence. Resident 2 required one-person assistance for all ADL care needs. On 12/27/24 at 12:30 PM, Resident 2 indicated she/he needed assistance with toileting due to her/his left sided weakness. Resident 2 stated there were concerns with long call light response times and she/he had sat in a wet and soiled brief for 20 plus minutes once when she/he was first admitted and another episode towards the beginning of December 2024. Resident 2 stated long call light wait times were 20 to 30 plus minutes and was an ongoing concern. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and on 12/31/24 at 2:13 PM, Staff 16 (CNA) stated Resident 2 required assistance with toileting but at times soiled herself/himself because of long call light response times. Staff 12 and Staff 16 stated long call light response times and being short staffed were an ongoing concern. On 12/31/24 at 9:45 AM, Staff 9 (LPN) stated Resident 2 concerns regarding long call light response times and had wet herself/himself on more than one occasion. Staff 9 stated the long call light response times were due to lack of staff which was an ongoing concern. On 1/6/25 at 5:22 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 3. Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and depression. A care plan dated 2/1/20, revealed Resident 3 was independent with transferring herself/himself in the room, utilized a bed side commode, and required one-person assistance with toileting hygiene. On 12/27/24 at 10:44 AM, and 1/2/25 at 11:20 AM, Resident 3 was observed sitting on the edge of her/his bed, well groomed. Resident 3 stated there were ongoing concerns with long call light wait times and the facility was short staffed from July 2024 to present. Resident 3 stated she/he could get onto the bedside commode herself/himself but needed assistance with wiping. Resident 3 stated she/he sat on the bedside commode for greater than 20 minutes to almost an hour without assistance, which occurred on more than one occasion and was very frustrating. On 12/30/24 from 11:00 AM, through 3:01 PM, Staff 22 (CNA), Staff 12 (CNA), and Staff 43 (CNA) were interviewed and stated Resident 3 needed assistance with wiping after she/he was on the bedside commode. Staff 22, Staff 12, and Staff 43 stated the resident sat on her/he bedside commode on multiple occasions for greater than 30 minutes. Staff 43 stated Resident 3 was frustrated and upset on those occasions because the bedside commode was uncomfortable. On 1/6/25 at 2:11 PM, Staff 11 (LPN-Resident Care Manager) stated he was aware Resident 3 had concerns with long call light wait times and sat on her/his bedside commode for extended periods of time due to being short staffed. Staff 11 stated call lights and staffing was an ongoing issue. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 4. Resident 13 was admitted to the facility in 2021 with diagnoses including a stroke and anxiety. A care plan dated 3/10/21, and revised on 12/5/24, revealed Resident 13 was frequently incontinent of urine. Staff were to assist Resident 13 with incontinent care after each episode. Resident 13 required substantial/maximum to dependent assistance with toileting hygiene. On 12/30/24 at 10:57 AM, and 1/2/25 at 12:30 PM, Resident 13 stated call light response times were terrible, CNAs passed by her/his room without answering the call lights, and took upwards of 40 minutes or longer. Resident 13 stated she/he sat in a wet brief on more than one occasion. Resident 13 stated every shift was terrible, but weekends were the worst. On 12/31/24 at 2:13 PM, Staff 16 (CNA) and on 1/3/25 at 2:13 PM, Staff 28 (CNA) were interviewed. Staff 16 and Staff 28 stated Resident 13 reported concerns with sitting in wet briefs on multiple occasions due to long call light response times of 20 to 30 minutes. Staff 16 and Staff 28 stated the resident was upset because it occurred on all shifts, but especially on the weekends. On 1/6/25 at 5:22 PM Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of call lights being a concern and it was an ongoing issue. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner. Staff 1 and Staff 2 acknowledged the facility struggled with appropriate CNA staffing ratios. 5. A review of the Direct Care Staff Daily Reports from 7/4/24 through 1/1/25 revealed state minimum bariatric CNA staffing requirements were not maintained for 74 of 90 days reviewed for staffing. On 12/27/24 the facility provided lists of residents who: -Required assistance with eating and were considered an aspiration risk: 13 -Required two-person assistance with transfers or mechanical lift: 35 -Required assistance with toileting: 41 -Residents who were incontinent: 52 -Residents who required behavioral healthcare needs: 9 -Residents who required bariatric healthcare needs: 10 Review of Resident Council Notes revealed the following concerns from 6/2024 through 12/2024: June 2024: Call lights were too long on evening shift. July 2024: Call lights response times were horrible especially on weekends. August 2024: Not enough staff on the weekends so terrible. Call light response times up to an hour wait. September 2024: Call light response time on swing shift were on average 30 to 45 minutes. October 2024: Call light response time on evening shift were 40 plus minutes. Resident 3 utilized call light for assistance off her/his bedside commode and just waits because no CNAs come to assist her/him. November 2024: Long call light response times on evening and swing shift. Residents called out for CNAs and they walked by the room and ignored the residents' call lights. December 2024: Long call lights on evening shift and a resident waited 80 minutes for assistance. CNAs made excuses as to why they were unable to answer call lights timely. Showers were not completed at the scheduled time. Interviews with staff revealed the following: On 12/27/24 at 9:41 AM, Staff 23 (CNA) and at 11:00 AM, Staff 22 (CNA) both stated staffing was terrible. The facility was short staffed all the time since 7/2024 and continued to be a struggle. Staff 22 and Staff 23 stated call lights could be 45 minutes or longer, and residents sat in wet and soiled briefs on multiple occasions. Staff 22 and Staff 23 further stated there was high acuity residents, including bariatric residents, which took more time. Staff 23 and Staff 22 stated wet wipe and briefs were difficult to access, because those supplies were no longer stored in the linen closets and had to be requested and turned into Staff 2 (DNS), which took time away from resident care. On 12/30/24 at 12:32 PM, Staff 12 (CNA) and at 2:20 PM, Staff 21 (CNA), and at 3:35 PM, Staff 48 (CNA) were interviewed. Staff stated they worked on both floors and staffing was not great. Staff 12, Staff 21 and Staff 48 stated the facility was short staffed constantly, as far back as 7/2024 and continued to be short staffed. Both floors had high acuity residents, as well as bariatric residents. Staff 12, Staff 21 and Staff 48 stated residents complained constantly regarding long call light response times, which ranged from 30 to 40 minutes, and residents sat in wet and soiled briefs due to lack of staffing. Staff 12, Staff 21 and Staff 48 stated the linen closets no longer had wet wipes or briefs and they had to request for additional wet wipes when running low or out and request more briefs, which at times made it difficult to provide timely care because CNAs had to turn in a form to Staff 2 (DNS) to receive the supplies, which resulted in longer call light wait times. Staff 12, Staff 21, and Staff 48 stated at times it was difficult to assist with getting residents up timely for meals and showers. Staff 12, Staff 21 and Staff 48 stated the facility was constantly short staffed, management was aware, and weekends were awful. On 12/31/24 at 9:45 AM Witness 23 (Complainant) stated the facility was constantly short staff dating back to 7/2024 and continued struggling to meet the acuity of residents in the building. Witness 23 stated call lights were greater than 25 to 30 minutes at times, depending on how short staffed the facility was. Witness 23 stated residents were very upset regarding lack of care and sitting in soiled briefs. Staff 23 further stated CNAs had to request wet wipes and brief supplies which slowed staff down because CNAs were to turn in a form to Staff 2 before acquiring more wet wipes or briefs. If Staff 2 was not available, the nursing staff had to access the supply room to retrieve more briefs for residents which took away from resident care. On 12/31/24 at 2:13 PM, Staff 16 (CNA) stated he worked on both floors and the lack of staffing went back to during the summer months, and was ongoing. Staff 16 stated the facility was constantly short staffed and call light response times were 15 minutes on a good day. Staff 16 stated residents complained of sitting in wet and soiled briefs and were very upset about lack of staff. Staff 16 stated the summer months were worse. On 1/2/25 at 10:00 AM, Staff 6 (RN) stated the facility struggled with staffing since 7/2024 and it was an ongoing concern. Staff 6 stated call light response times were long, and residents were very upset regarding call light response times. Staff 6 indicated it was difficult for her at times with CNAs not having access to wet wipes or briefs. If a CNA ran out of wet wipes and briefs, they completed a form and turned the form into Staff 2, to receive more supplies. If Staff 2 was not available, she would be responsible to retrieve more briefs from central supply for CNAs, which took time away from her resident care. Staff 6 stated she had never experienced anything like this. On 1/2/25 at 2:03 PM, Staff 19 (CNA) stated being short staffed and long call light response times were an ongoing issue as far back as 7/2024. Staff 19 stated residents sat in wet and soiled briefs for 30 minutes or longer due to being short staffed. Staff 19 stated many residents required two-person assistance or were dependent on ADL care. Staff 19 further stated residents were very upset regarding lack of care being provided. Staff 19 stated management was aware but it continued to be an issue. On 1/6/25 at 5:22 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware CNA staffing shortages dating back to 7/2024 and they continued to work on hiring more CNAs and meeting the appropriate ratios. Staff 1 and Staff 2 acknowledged there were concerns regarding call light response times. Staff 1 and Staff 2 stated all staff were responsible for answering call lights in a timely manner.

Based on observation, interview, and record review it was determined the facility failed to accommodate residents with the correct fit of incontinence briefs for 4 of 13 sampled residents (#s 1, 6, 13 and 15) reviewed for dignity and respect and accommodation of need. This placed residents at risk skin breakdown and discomfort. Findings include: 1. Resident 1 was admitted to the facility in 2015 with diagnoses including diabetes and renal disease. A care plan dated 9/5/23, and revised on 12/5/24, revealed Resident 1 was incontinent of bowel and bladder, and used a brief with tabs, size three extra-large. Staff were to ensure the brief tabs were secure, so they did not scratch the skin, and use barrier cream between skin if tab contact was anticipated. Resident 1 required two-person assistance for bed mobility and one or two-person assistance for a brief change. On 12/27/24 at 1:30 PM, Witness 20 (Complainant) stated Resident 1 was recently switched to a different brief size for incontinence care, and the brief was too small, was tight, and caused red marks on the resident's skin. Witness 20 stated the resident reported concerns to staff, but the resident was still in the smaller brief. Interviews were conducted on 12/30/24 from 12:32 PM through 3:35 PM, with Staff 12 (CNA), Staff 43 (CNA), and Staff 13 (CNA). Staff 12, Staff 43, and Staff 13 stated Resident 1 was incontinent of bowel and bladder and required one or two persons to provide incontinence care. Staff 12, Staff 43, and Staff 13 stated residents were changed over to new brief sizes and Resident 1 complained the new brief was too small, cut into her/his skin, and rubbed uncomfortably. Staff 13 stated Resident 1's previous brief went over the top of the resident's pannus area, but the new sized brief went under the pannus, causing the tabs to rub, and resulting in red skin around the area. Staff 12 stated the new briefs were decided based on height and weight only, and nothing else about Resident 1 was considered. On 12/30/24 at 3:53 PM, Resident 1 was observed in bed. Resident 1 stated she/he was provided a new brief size, and the brief was way too small. The resident pulled down her/his blankets, and lifted her/his pannus, and the brief was visible along with where the tabs attached to the brief. Resident 1 stated the brief was too tight around her/his legs, rubbed on her/him, and was very uncomfortable. Resident 1 further stated she/he spoke with Staff 2 (DNS) and Staff 11 (LPN/Resident Care Manager), but both staff indicated the brief was the correct size based off her/his height and weight and did not allow her/him a different size. On 1/6/25 at 1:48 PM, Staff 11 stated Resident 1 was sized for a new brief based off the resident's height and weight. The brief she/he was fitted for did not recommend a larger brief size, according to the chart. Staff 11 stated he was aware Resident 1 was not comfortable in the new brief and the resident preferred a brief that went over the top of her/his pannus. On 1/6/25 at 3:13 PM, Staff 2 stated all residents were sized for new briefs and she was not sure what size Resident 1 wore prior to the brief change, but the old brief was place over the resident's pannus area. The new sized brief was based on height and weight, and staff were trained on the new brief sizes. Staff 2 stated she was unaware there were concerns regarding Resident 1's new brief size. 2. Resident 13 was admitted to the facility in 2021 with diagnoses including a stroke and anxiety. A care plan dated 3/10/21, and revised on 12/5/24, revealed Resident 13 was frequently incontinent of urine, and used a brief with tabs, size three extra-large. Staff were to assist Resident 13 with incontinent care after each episode. Resident 13 required substantial/maximum to dependent assistance with toileting hygiene. On 12/30/24 at 10:57 AM, Resident 13 stated she/he was very upset due to being placed in a new brief size. Resident 13 stated the brief she/he was fitted for was too small, and was tight around the thighs, and crotch area. Resident 13 stated CNAs could not supply her/him with a bigger brief size because of what her/his care plan indicated. Resident 13 stated, This is just not right. On 12/31/24 at 9:35 AM Witness 23 (Complainant) stated Resident 13 was recently switched to a different brief size for incontinence care and the brief was too small, tight, and uncomfortable for Resident 13. Witness 23 stated the resident was very upset regarding the new brief and asked for a different size brief but was told the brief fit her/him appropriately and was based off her/his height and weight. Witness 23 stated upper management did not consider Resident 13's waist size or lower body size. Witness 23 further stated upper management told residents they needed to buy their own briefs if the residents were unhappy with the size of brief provided. On 12/31/24 at 2:13 PM, Staff 16 (CNA), and on 1/3/25 at 2:13 PM, Staff 28 (CNA) stated Resident 13 was frequently incontinent of bladder, and required one staff person to assist with her/his incontinent care needs. Staff 16 and Staff 28 stated Resident 13 was extremely upset about the new brief sizes because the new brief was tight around her thighs, and crotch area. Staff 16 and Staff 28 stated to their knowledge, Resident 13 did not have redness or skin breakdown. On 1/2/25 at 2:35 PM, Staff 7 (LPN) stated Resident 13 was very upset regarding her/his brief size change and felt the brief was too small. Staff 7 stated a brief specialist was in the building and assisted with determining the correct brief size for each resident, which was based off height and weight. On 1/6/25 at 3:57 PM Staff 2 (DNS) stated she was aware Resident 13 was upset about the new brief sizing and was focused on the color of the brief. Staff 2 stated the new briefs were determined by height and weight for each resident. Staff 2 stated she was unaware Resident 13 had concerns regarding the brief being too small and uncomfortable. 3. Resident 15 was admitted to the facility in 2024 with diagnoses including morbid obesity and anxiety. A care plan dated 8/15/24, and revised on 12/4/24, revealed Resident 15 required one-person assistance with toileting, and used size two extra large briefs without tabs. Staff were to ensure the brief was securely fastened. On 12/31/24 at 9:35 AM Witness 23 (Complainant) stated Resident 15 was recently switched to a different brief size for incontinence care and the brief was too small, tight, and uncomfortable for Resident 15. Witness 23 stated the resident was very upset regarding the new brief and asked for a different size brief but was told the brief fit her/him appropriately and was based off her/his height and weight. Witness 23 stated upper management did not consider Resident 15's waist size or lower body size. Witness 23 further stated upper management told residents they needed to buy their own briefs if the residents were unhappy with the size of brief provided. On 1/3/25 at 10:50 AM, Resident 15 was observed sitting in her/his wheelchair, well groomed with no odors. Resident 15 stated she/he required one staff person to assist with toileting and pulling up her/his clothing. Resident 15 stated she/he was switched to a smaller brief than her/his prior size and the new brief was way too small. Resident 15 stated it was tight and rubbed on her/his thighs. Resident 15 stated she/he reported concerns to upper management, and was told to buy her/his own briefs and would not be supplied with a larger brief size. Resident 15 stated it was very upsetting. On 1/3/25 at 11:30 AM, Staff 16 (CNA) and at 11:57 AM, Staff 29 (CNA) stated Resident 15 was a one- person assist with toileting but was known to self-transfer. Staff 16 and Staff 29 stated the resident complained of the new brief size change and indicated the briefs were too tight, pinching her/him and the tabs that attach to the brief do not stay adhered. Staff 16 and Staff 29 stated the resident was informed to buy her/his own supplies from upper management because Staff 2 (DNS) would not supply the resident with a larger brief. On 1/6/25 at 4:13 PM, Staff 2 and at 5:37 PM, Staff 1 (Administrator) stated all residents were sized for new briefs and was not sure what size Resident 15 wore prior to the brief change. Staff 1 and Staff 2 stated the new sized brief was based on height and weight, and staff were trained on the new brief sizes. Staff 1 and Staff 2 stated they were unaware Resident 15 was uncomfortable in her/his brief and did not know the resident was buying her/his own supply. 42270 4. Resident 6 admitted to the facility in 5/2019 with diagnoses including Guillain-Barre Syndrome (a neurological disorder which causes muscle weakness, tingling, and paralysis). A 7/23/24 Wound Evaluation revealed Resident 6 had a Stage 4 pressure wound (a wound that extends completely through all layers of the skin, exposing muscle, tendon, or bone) on her/his coccyx (tailbone). An 8/2/24 Progress Note revealed Resident 6 complained to staff about facility staff using face towels to do wound care and the Resident Care Manager requested an order for wet wipes due to Resident 6's skin breakdown. A review of Resident 6's orders revealed no orders for staff to use wet wipes instead of washcloths for incontinence care and wound care on the coccyx. On 12/31/24 at 1:50 PM and on 1/2/25 at 12:58 PM Resident 6 stated the facility staff used washcloths to clean the area around her/his coccyx wound. Resident 6 stated Staff 2 (DNS) had the facility staff use washcloths instead of wet wipes. Resident 6 stated the facility staff used the washcloths for incontinence care currently when the facility ran out of wet wipes and it was painful due to the wound on her/his coccyx area. On 1/2/25 at 2:12 PM Staff 46 (CNA) stated the staff did not have access to enough wet wipes for all the personal care provided daily and the staff were to fill out a slip to request wipes to be delivered by Staff 2 once a day. Staff 46 stated the staff were to use washcloths to do incontinence care for Resident 6 and she/he complained about it being very rough because her/his skin was delicate. On 1/2/25 at 3:49 PM Staff 37 (CNA) stated the facility staff were required to use washcloths for incontinence care and on resident wounds. Staff 37 stated Resident 6 complained about the washcloths being uncomfortable. On 1/6/25 at 12:54 PM Staff 2 stated the facility moved to using washcloths for residents rather than wet wipes for all residents except those with skin breakdown; and those with skin breakdown were added to a list and approved for use of wet wipes. On 1/6/25 at 2:30 PM Staff 2 provided an undated Resident Approved for Wet Wipes List of residents who were approved for wet wipes for incontinence care and stated the facility moved to washcloths on 7/16/24. The Resident Approved for Wet Wipes List revealed Resident 6 was not approved to receive incontinence care with wet wipes until 8/2/24. Staff 2 confirmed Resident 6 should have always been on the list of residents to use wet wipes instead of wash cloths but there was a time staff used wash cloths for incontinence care. Staff 2 reviewed the orders for residents with approval for wet wipes and confirmed Resident 6 did not have an order for the staff to use wet wipes instead of wash cloths.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rights to a dignified existence for 2 of 5 sampled residents (#s 3 and 15) reviewed for dignity and respect. This placed residents at risk for diminished quality of life. Findings include: 1. Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and depression. A care plan dated 2/1/20, revealed Resident 3 was independent with transferring herself/himself in the room, utilized a bed side commode, and required one-person assistance with toileting hygiene. A Grievance Communication Form Dated 9/30/24, revealed the following: - Resident 3 turned on the call light for help at 12:15 PM. At 12:30 PM, Resident 3 placed herself/himself on the beside commode. At 1:15 PM, her/his roommate went out and asked staff for help. At 1:20 PM, almost one hour after the resident turned on the call light, a CNA entered the room and helped Resident 3 off the bedside commode. -Staff 41 (Former CNA) stated Resident 3 indicated her/his call light was on for 45 minutes and Staff 41 told Resident 3 she was the only one answering call lights because the other CNA was providing another resident a shower after lunch. Staff 41 apologized. -Staff 2 (DNS) indicated Resident 3 was independent in her/his room for the most part and Staff 41 intended to assist Resident 3, but another resident was crying in the hall and was distraught. Staff 41 made a judgement call. -Staff 41 apologized to Resident 3 post incident. Resident 3 was upset and crying and stated, It wasn't fair. -Staff 2 indicated the long call light did occur. Staff were not ignoring the call light, or Resident 3's needs, because the CNAs were working the best they could. On 1/2/25 and 1/3/25 attempts to contact Staff 41 were unsuccessful. On 1/2/25 at 11:20 AM, Resident 3 was observed sitting on the edge of her/his bed. The resident's bedside commode was adjacent to the bed. A call light was attached to the wall next to the bedside commode. Resident 3 stated she/he completed a grievance form regarding the 9/30/24 incident. Resident 3 stated she/he could get onto the bedside commode herself/himself but needed assistance with wiping. Resident 3 stated she/he sat on the bedside commode for almost an hour without assistance and was in tears because her/his bottom hurt from the hard plastic. Resident 3 stated this occurred on more than one occasion and was very frustrating. On 1/6/25 at 2:11 PM, Staff 11 (LPN-Resident Care Manager) stated he spoke with Resident 3 after the incident on 9/30/24, and she/he was upset regarding the incident. On 1/6/25 at 3:39 PM, Staff 2 stated she was aware of the incident on 9/30/24, and Resident 3 was upset from sitting on the bedside commode for an extended period. Staff 2 stated she encouraged the resident to turn her/his call light on sooner when Resident 3 knew when she/he was going to use the commode. 2. Resident 15 was admitted to the facility in 2024 with diagnoses including morbid obesity and anxiety. A care plan dated 8/15/24, and revised on 12/24/24, revealed Resident 15 needed to be supervised when smoking. Resident 15 obtained her/his smoking materials from staff, and returned them when she/he was done smoking. A review of progress notes from 8/30/24 through 9/7/24 revealed Resident 15 was found to have smoking paraphernalia on her/him and was caught smoking while unsupervised. The resident handed over her/his smoking paraphernalia to staff when asked. A Progress Noted dated 9/13/24 at 10:43 AM, revealed the following: -Staff 30 (Former Nursing Student) went into Resident 15's room to provide wound care after the resident returned from visiting with a friend. Therapy was working with the resident. -Staff 30 completed the resident's wound treatment and asked if it was ok if she checked the resident's makeup bag. Staff 30 requested to check due to patient's friend having history of bringing patient paraphernalia. -Resident 15 agreed to have her/his bag searched, and the therapist was present. Staff 30 found a white oval pill with M367 scripted on one side and a lighter. Staff 30 confiscated the pill, took the lighter, and reported the information to Staff 9 (LPN), who then contacted Staff 2 (DNS). The items were given to Staff 2. -Staff 30 spoke with Staff 31 (Former LPN-Resident Care Manager), who requested staff to do a room search immediately and to check Resident 15 when she/he came back downstairs. -Staff 30 indicated two additional nurses went and searched Resident 15's room and belongings, but no smoking paraphernalia was found. -Resident 15 returned to her/his room and was upset, and yelled at the staff for being in her/his room, saying, You guys need to get the fuck out of my room. You have no right to be in my fucking room. Get the hell out of here. This isn't right, you can't do this, you need to tell [Resident 15] before you search [Resident 15's] room. -Staff 31 informed Resident 15 staff were doing this per administration's direction and needed to complete a full body check on Resident 15. Staff communicated with the resident about which body part needed to be checked prior to touching the resident. The search was completed, and nothing was found on the resident. -Staff 31 let the resident know she/he did not need to yell and indicated to talk nicely to staff. Staff 31 tried to let the resident know staff already searched the room and the resident did not need to leave her/his room. -Resident 15 proceeded to go downstairs and felt she/he was being targeted by staff due to her/his room being searched without permission. On 1/6/25 at 12:10 PM, Resident 15 was observed in her/his room seated in her/his wheelchair. Resident 15 stated she recalled the 9/13/24 incident and stated a staff person sniffed her/his hair upon returning from outside. When the resident returned to her/his room, a staff person approached the resident and asked if she could look into Resident 15's bag, to which the resident agreed. Resident 15 stated they found a Vicodin (pain pill) and a lighter, which the staff member confiscated. Resident 15 stated she/he and the staff person left the room. Resident 15 stated when she/he returned there were multiple staff in her/his room conducting a search. Resident 15 stated W.T.F., you searched [Resident 15's] room without [Resident 15's] permission. Resident 15 stated she/he was flustered, and staff indicated they needed to complete a body search. Resident 15 stated she felt coerced and let Staff 31 complete the body search. Resident 15 stated Staff 31 indicated she was told by Staff 1 (Administrator) and Staff 2 the search needed to be completed. Resident 15 stated the staff found nothing on her/him or in the room. Resident 15 stated she/he felt humiliated, targeted, and angry. On 1/6/25 at 12:54 PM, Staff 9 stated she was aware of the incident on 9/13/24 and was directed by Staff 31 to search Resident 15's room and assist with a body search. Staff 9 stated she could not recall if the resident was in the room during the search or if the staff asked the resident's permission to search the room. Staff 9 stated she was not comfortable with the search but did what was asked of her. Staff 9 stated Resident 15 was extremely upset and angry about what happened and felt her/his rights were violated. On 1/6/25 at 3:05 PM, Staff 31 stated she was not involved with the incident but only heard about Resident 15's room search and body search. Staff 31 stated Staff 1 and Staff 2 were aware and followed up regarding the 9/13/24 incident. On 1/6/25 at 4:37 PM, Staff 30 stated Resident 15 had a history of being non-compliant with smoking paraphernalia and had items confiscated from her/him before the 9/13/24 incident. Staff 30 stated Staff 1 and Staff 2 told her to an keep an eye on the resident due to non-compliance with smoking. Staff 30 stated she was in Resident 15's room to provide treatment, and the resident had a purse which was unzipped, in which she saw a lighter. Staff 30 stated she asked the resident if she could search her/his purse and the resident agreed. Staff 30 stated she found a pill and lighter in the resident's purse, confiscated them, and informed Staff 31. Staff 30 indicated she and a couple other staff members were told to search the resident's room and had done so without permission. Resident 15 was out of the room during the search, and no one asked permission to search her/his room. Staff 30 stated upon Resident 15's return, she was extremely upset, stating, You should not be going through my stuff without my permission. Staff 30 stated Staff 31 informed the resident a body search needed to be completed and Staff 31 conducted the body search. Staff 30 stated Resident 15 was very upset, cursed, and nothing was found in the resident's room or on her/his body. Staff 30 stated the incident made her very uncomfortable and she never experienced anything else like it. On 1/6/25 at 4:13 PM and 5:37 PM, Staff 1 and Staff 2 were present for an interview. Staff 1 and Staff 2 stated Resident 15 was non-compliant with smoking paraphernalia, and both were aware of the incident that occurred on 9/13/24. However, both staff stated they were unaware Resident 15's room was searched, or a body search was completed without the resident's permission. Staff 1 stated she expected staff to ask permission prior to searching the resident's room or when conducting a body search.

Based on interview and record review it was determined the facility failed to notify the physician regarding a change in condition for 1 of 4 sampled residents (#5) reviewed for change of condition. This placed residents at risk for lack of physician involvement. Findings include: The facility's Change in a Resident's Condition or Status Policy Statement dated 2/2021 directed the nurse to notify the resident's attending physician or the on-call physician of a significant change in the resident's physical condition. Resident 5 was admitted to the facility in 10/2023 with diagnoses including Congestive Heart Failure (a chronic condition in which the heart does not pump blood as well as it should) and a below the knee amputation. Review of Resident 5's clinical record revealed the following: - On 10/27/24 Resident 5 had a 4.9 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. - On 10/29/24 Resident 5 had a 10.2 pound weight gain in the past seven days. No evidence was found to indicate the physician was notified. - On 11/1 Resident 5 had a 4 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. - On 11/3 Resident 5's had a 3.2 pound weight gain in 24 hours. No evidence was found to indicate the physician was notified. A Nursing Care Note dated 11/10/24 revealed the provider was notified of Resident 5's weight gain - to188.2 pounds [8.4-pound gain in one week]. Resident 5 was sent to the hospital and admitted for evaluation of lower extremity swelling. On 1/2/25 at 2:50 PM Staff 32 (LPN-Resident Care Manager) stated when daily weights were ordered for patients with CHF the nurse was expected to report a weight gain of two pounds in 24 hours or five pounds in a week. Staff 32 stated she did not notify the provider of any weight changes. On 1/2/25 at 3:56 PM Staff 34 (LPN) stated she recalled Resident 5 being upset about her/his weight gain but could not recall the exact date. Staff 34 stated she did not notify the provider of any weight gains. On 1/6/25 at 11:18 AM Staff 2 (DNS) confirmed the physician was not notified for dates identified. Staff 2 stated she expected nursing staff to notify the physician when a resident had weight gain of two or three pounds within a 24-hour period, or if a resident had a five-pound increase within a week. On 1/6/25 at 3:10 PM Staff 42 (Medical Director) stated staff should follow the American Heart Association recommendations and notify the provider regarding a resident who had weight gain of two or three pounds within a 24-hour period, or if a resident had a five-pound increase within a week, which could be a potential sign of worsening heart failure.

Based on observation, interview, and record review it was determined the facility failed to ensure residents food preferences were honored for 1 of 3 sampled resident (#3) reviewed for food. This placed residents at risk for food lessened quality of life. Findings include: Resident 3 was admitted to the facility in 2020 with diagnoses including morbid obesity and diabetes. A 12/27/24 meal ticket revealed Resident 3 ordered barbecue country ribs, scalloped potatoes, mixed vegetables, fruit salad, two strawberry kiwi juices and two diet lemon sodas. On 12/27/24 at 12:21 PM, Resident 3 was observed eating lunch in her/his room and the meal consisted of barbecue country ribs, scalloped potatoes, and mixed vegetables. The resident received one strawberry kiwi juice and one diet lemon lime soda. There was only one beverage each and no fruit salad delivered with the meal. On 12/27/24 at 12:25 PM, Resident 3 stated she/he did not receive what she/he requested which occurred often. Staff 12 (CNA) was present and acknowledged the resident did not receive what she/he requested, and which was a common occurrence. On 12/31/24 at 8:14 AM, Staff 12 (CNA) delivered Resident 3's breakfast which included a Belgian waffle with syrup, oatmeal, Canadian bacon, scrambled eggs, coffee and one milk. Nothing on the meal ticket was circled and Resident 3 stated she/he did not order any of the breakfast items because the resident was never given the menu on 12/30/24 to be completed. Staff 12 confirmed this happened often because residents were not always given menus the day before. On 12/31/24 at 8:25 AM, Staff 12 stated Resident 3's preferences were often not honored. The resident liked to receive two bowls of Cheerios, a yogurt, and a cup of hot chocolate. On 12/21/24 at 1:26 PM, Staff 25 (Dietary Manager) stated CNAs were responsible to ensure residents completed menus for the next day's meal and turn the menu selection in the day before to ensure residents' preferences were honored. Staff 25 stated she was not aware Resident 3 did not receive what she/he ordered on 12/27/24. Staff 25 stated when a menu selection was not submitted, residents received whatever printed out on the meal ticket. Staff 25 acknowledged she was unaware of Resident 3's preference because she was new to the position and was learning the dietary meal ticket system on the computer.

Based on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include: 1. On 1/22/24 at 9:23 AM during the initial tour of the main kitchen, the following was observed regarding refrigerator two: -One plastic carton of moldy strawberries. -One container with a lid of sliced lemon wedges with no date. -One bag of sliced bread with a date, but not sealed. On 1/22/24 at 9:27 AM Staff 13 (Dietary Manager) confirmed the identified items were not appropriately stored. 2. On 1/24/24 at 11:31 AM Staff 24 (Cook/Dietary Aide) was observed to pick up a hamburger bun with ungloved hands and place it on the plate. She was observed to place a hamburger patty on the bun with tongs and then proceeded to move aside the hamburger bun with ungloved hands. The surveyor stopped Staff 24 and questioned why she was not wearing gloves. Staff 24 stated she forgot to put a pair on. Staff 13 (Dietary Manager) was present during this observation and interview. On 1/24/24 at 2:25 PM Staff 13 acknowledged Staff 24 was not wearing gloves while handling food during the lunch service on 1/24/24. She stated it was her expectation for staff to wear gloves when directly handling food items.

Based on interview and record review it was determined the facility failed to promptly respond to grievances and recommendations from the resident council for 4 of 4 months reviewed and ensure clothing and missing personal property were addressed timely for 2 of 3 sampled residents (#s 53 and 56) reviewed for personal property. This placed residents at risk for unresolved quality of life and care issues. Findings include: 1. The 6/2004 Grievance Policy indicated the Activities Director or designee was to complete a grievance form when a global issue was raised at a resident council meeting. The form was to be given to the appropriate department head for follow up and departments were to respond within five days. During a resident group meeting on 1/24/24 at 1:30 PM residents stated facility staff did not consistently respond to suggestions timely or concerns offered by the resident council. Residents indicated they did not feel staff communicated with them effectively and did not feel fully informed of the actions taken in response to their concerns. Resident Council Minutes from 9/2023, 10/2023, 11/2023 and 12/2023 revealed the following resident issues: 9/2023: -Residents felt the return of missing clothing was improved, but there was still a long delay for items to be returned. Laundry services responded a new staff person would start in 10/2023 to assist with laundry services. -Residents reported call light wait times were too long, and CNAs ignored call lights if not assigned to them. The staffing coordinator indicated call light audits would be completed, and CNAs were re-educated regarding call light response times and the responsibility of all CNAs to answer call lights. -Residents requested more board games and physical games, such as ping pong. The activities department did not respond regarding the suggestion. 10/2023: -Residents reported call light response times were sometimes 45 minutes and CNAs told residents they did not have enough staff in the building. The staffing coordinator indicated they were actively recruiting to help with appropriate coverage. They also sent out alerts in staff meetings and staff huddles to remind CNAs about call light response times. 11/2023: -Residents reported clothing items were missing for a few residents. Laundry services indicated they would be on the lookout for the clothing items. -Residents felt like call light wait times were still too long. CNAs stated they are not your CNA and can't help. The staffing coordinator indicated CNAs would be re-educated regarding answering call lights timely, and all CNAs were to answer call lights even if not assigned to the resident/section. 12/2023: -Residents reported ongoing concerns about not getting clothing items back and their clothing items not being labeled. Laundry services indicated they were short-staffed and doing their best to get clothing items returned as quickly as possible. On 1/24/24 at 1:54 PM Staff 15 (Social Services Director) stated a grievance was to be completed for missing clothing items and she then attempted to locate the missing items. If a missing clothing item was not found it was replaced, and grievances were addressed within five days. Staff 15 stated residents complained about delays in getting their clothes back timely and Staff 12 (Account Manager) handled laundry services. On 1/24/24 at 2:20 PM Staff 12 stated she was in charge of laundry services and was short-staffed for a couple of months. Staff 12 stated she had trouble with laundry services, including residents' clothing items. Staff 12 stated clothes should be sorted, washed and returned to residents in two or three days, but clothes took more than seven days to return to residents. Staff 12 further stated she had some racks of unidentified clothes in laundry services, but did not have time to sort them. On 1/25/24 at 10:26 AM Staff 11 (Activities Director/Central Supply) stated she took notes during resident council and placed the completed forms with identified concerns in each department heads' mail box to address, and each department had three to five days to respond to the concern. Staff 11 stated once a response was completed from each department, the forms were given to Staff 1 (Administrator) to review. On 1/25/24 at 12:32 PM Staff 1 and Staff 2 (Interim DNS) stated they were aware of concerns with laundry services. Staff 1 stated they were collaborating with laundry services to resolve the staffing concern and the delays in returning clothes to residents. Staff 1 stated he expected grievances, including resident council concerns, to be followed up on as soon as possible, but typically it took five business days to complete. Staff 1 and Staff 2 stated they were aware of staffing issues and were actively working on ensuring call light response times were addressed and all staff were responsible for answering call lights, not just CNAs. 2. Resident 56 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease. On 1/22/24/24 at 10:30 AM and 1/24/24 at 9:09 AM Resident 56 stated laundry services was short staffed and she/he had missing clothing items for approximately three weeks including shirts, pants and bras. Resident 56 stated she completed paperwork regarding the missing items but no one followed up with her/him and the clothing items had not been returned. On 1/24/24 at 9:33 AM Staff 9 (CNA) stated Resident 56 reported she/he was missing shirts, pants and bras. Staff 9 stated laundry services were slow and there were concerns with clothing items not being returned timely for Resident 56. On 1/24/24 at 1:54 PM Staff 15 (Social Director) stated she was unaware of Resident 56's missing clothing items and a grievance was to be completed for the missing items. Staff 15 stated residents complained about delays in getting their clothes back timely and Staff 12 (Account Manager) handled laundry services. On 1/24/24 at 2:20 PM Staff 12 stated she was in charge of laundry services and was short staffed. Staff 12 stated she had trouble with laundry services, including residents' clothing items. Staff 12 stated clothes should be sorted, washed and returned to residents in two or three days, but clothes took more than seven days to return for residents. Staff 12 further stated she had some racks of unidentified clothes in laundry services, but did not have time to sort them. On 1/25/24 at 12:32 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated they were aware of concerns with laundry services. Staff 1 stated they were collaborating with laundry services to resolve the staffing concern and the delays in returning clothes to residents. 3. Resident 53 admitted to the facility in 4/2023 with diagnoses including malnutrition. On 1/22/24 at 11:23 AM Resident 53 stated three to four months ago her/his property was placed in the hallway while the flooring was replaced. During that time she/he saw two residents going through her/his property. Resident 53 stated she/he was missing a cell phone when the property was returned to her/his room. Resident 53 stated a grievance form was completed and she/he did not receive a response from facility staff regarding the missing cell phone. Resident 53's 4/16/23 Inventory of Personal Property indicated the resident had a cell phone. On 1/25/24 at 1:52 PM Staff 15 (Social Services Director) stated when she received a grievance form from a resident who was missing a personal property item she delegated the grievance to the appropriate facility staff, such as Staff 12 (Account Manager) or Staff 1 (Administrator). Staff 15 stated she received a grievance form from Resident 53 about a missing cell phone. Staff 15 stated she delegated the grievance form regarding Resident 53's missing cell phone to Staff 1. Staff 15 stated she was unable to locate the grievance form related to Resident 53's missing cell phone. On 1/25/24 at 1:57 PM Staff 1 (Administrator) stated he was unaware of Resident 53's missing cell phone, had not received a grievance form, and therefore the resident's missing item was not investigated.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 4 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 1/25/24 the facility provided lists of residents who: -Required assistance with eating: 5 -Required assistance with dressing: 49 -Required assistance with bathing: 58 -Required assistance with toileting: 52 -Required two-person assistance with transfers: 10 -Required mechanical lift transfers: 21 -Required incontinence care: 32 -Had wandering behaviors: 4 -Had behavioral healthcare needs: 18 Resident Council Notes were reviewed and indicated the following: 9/2023: call light response times were up to one hour and there were not enough staff to give showers. A lot of CNAs turned off call lights and stated they would be back, but never returned. 10/2023: Call light response times were still too long, staff indicated they would be back in a minute and never came back. 11/2023: Call light response was still an issue. 12/2023: Call light response still took too long and there were CNAs who did not help. A review of the facility Direct Care Staff Daily Reports from 12/23/23 through 1/21/24 revealed the facility had insufficient CNA staff for one or more shifts to meet the state minimum staffing requirement on the following dates: -12/23/23 -12/28/23 -1/5/24 -1/6/24 -1/8/24 -1/12/24 -1/17/24 Interviews with residents revealed the following concerns: -On 1/22/24 at 1:05 PM Resident 56 stated the facility was short-staffed on evenings and weekends. She/he stated it took 30-45 minutes to get assistance and sometimes it's too late, I go in my briefs and I have to get changed. -On 1/22/24 at 10:22 AM Resident 6 stated she/he got up to the wheelchair by her/himself because she/he waited too long for assistance. Resident 6 stated it took up to one hour to get help. Interviews with staff revealed the following concerns: -On 1/23/24 at 2:16 PM Staff 19 (RN) stated she did not have time to administer Resident 16's ordered bowel medications on 1/1/24 and 1/2/24 because there was not enough staff and she had to prioritize the other residents' needs. Staff 19 further stated if a resident was critically ill or if there were new admissions it was difficult to get everything done. -On 1/24/24 at 10:07 AM Staff 21 (CNA) stated several residents required mechanical lifts which made it difficult to complete showers because it took up to 40 minutes to complete a shower for those residents. Staff 21 further stated she was not always able take a lunch because she was too busy. -On 1/24/24 at 10:14 AM Staff 14 (LPN) stated morning medication pass was heavy. Staff 14 further stated there were some treatments including dressing changes which she was not able to complete during her shift and often passed treatments to the next shift. -On 1/24/24 at 12:43 PM Staff 22 (RN) stated medication pass was difficult for one person to complete and she often had to do both medication pass and treatments. Staff 22 stated medications were given up to an hour late due to the heavy workload. Staff 22 further stated the 100 hall had residents that required a lot of care, CNAs often reported they were not able to get everything done, and she often had to help the CNAs with resident care. -On 1/25/24 at 10:00 AM Staff 23 (CNA) stated prior to 1/2024 staff were not able to complete showers. Staff 23 stated residents were often given a bed bath instead of a shower due to time constraints. Staff 23 stated meals were given late and the food was served cold due to being short staffed. On 1/25/24 at 10:46 AM and 1/26/24 at 11:27 AM Staff 1 (Administrator) acknowledged staffing concerns included nursing staff not being able to administer ordered medications due to not having enough time. Staff 1 acknowledged the facility had a lot of residents with high acuity needs and the facility continued to work on staffing issues. Refer to F684.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 2 of 2 medication storage refrigerators reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 1/24/24 at 12:48 PM the medication refrigerator on the 200 hall was observed with Staff 27 (RN). Review of the refrigerator temperature log indicated temperatures were to be maintained between 36 to 46 degrees. The Logs from 1/1/24 through 1/24/24 revealed 20 instances with no temperatures logged. The medication refrigerator contained tuburculin (used for testing and diagnoses of Tuburculosis) and influenza vaccines (vaccines which require refrigeration). On 1/24/24 at 1:20 PM Staff 2 (Interim DNS) stated the medication refrigerator was to be checked twice a day (AM/PM). Staff 2 further stated there was not to be any holes in the temperature logs especially with vaccines in the medication refrigerators. 2. On 1/24/24 at 1:16 PM the medication refrigerator on the 100 hall was observed with Staff 27 (RN). Review of the refrigerator temperature log indicated temperatures were to be maintained between 36 to 46 degrees. The logs from 1/1/24 through 1/24/24 revealed 12 instances with no temperatures logged. The medication refrigerator contained Tuburculin (used for testing and diagnoses of Tuburculosis) and influenza vaccines (vaccines which require refrigeration). On 1/24/24 at 1:20 PM Staff 2 stated the refrigerator was to be checked twice a day (AM/PM). Staff 2 further stated there was not to be any holes in the temperature logs especially with vaccines in the medication refrigerators.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' rights to a dignified existence and self-determination for 1 of 1 sampled resident (#56) reviewed for dialysis. This placed residents at risk for a diminished quality of life. Findings include: Resident 56 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease. On 1/24/24 at 11:50 AM Resident 56 was observed in her/his wheelchair in the hallway talking to Resident 11. Both residents decided to eat lunch together and Resident 56 moved her/his bedside table next to Resident 11's door. Resident 11 received her/his lunch at 11:53 AM and started eating, but Resident 56's meal did not arrive. Resident 56 stated I never get my meals with the other residents. At 12:00 PM Resident 56 asked Staff 9 (CNA) and Staff 14 (LPN) about her/his lunch and stated I did not get my breakfast this morning either. Staff 9 told Resident 56 the kitchen lost her/his meal slip and asked Resident 56 what she/he wanted for lunch. Resident 56 requested a burger and tater tots. Resident 11 stated I want some tater tots too. Staff 9 brought tater tots for Resident 11 at 12:05 PM, but Resident 56 still had no lunch. Resident 56 stated she/he was hungry and frustrated because she/he wanted to eat her/his lunch with Resident 11. Resident 56 received her/his burger and tater tots At 12:15 PM after Resident 11 was almost finished with her/his lunch. On 1/24/24 at 12:15 PM Staff 9 and Staff 14 stated Resident 56's meal slip was misplaced in the kitchen, which caused her/his breakfast and lunch delivery to be delayed. Staff 9 stated Resident 56 was upset about missing her/his meals and not eating lunch with Resident 11. On 1/24/24 at 2:05 PM Staff 13 (Dietary Manager) stated Resident 56's meal slip was misplaced and thought it was on her desk. Staff 13 stated the meal trays and meal slips were supposed to be arranged by room numbers for the hall carts. Staff 13 stated she expected meals to be served timely.

Based on interview and record review it was determined the facility failed to report results of abuse investigations to the State Survey Agency within the required time frame for 2 of 4 sampled residents (#s 34 and 49) reviewed for abuse. This placed residents at risk for abuse. Findings include: A 9/18/23 FRI for abuse involving a verbal abuse altercation when Resident 13 yelled at Resident 34 and Resident 49. The investigation was completed and submitted to the State Agency on 9/26/23 (three days late). On 1/25/24 at 1:59 PM Staff 2 (Interim DNS) acknowledged the facility investigation was not reported to the State Survey Agency within five working days.

Based on interview and record review it was determined the facility failed to ensure a resident who was continent was not checked by CNA staff for incontinence for 1 of 3 sampled residents (#1) reviewed for dignity. This caused Resident 1 to have increased anxiety, persistent anger and tearfulness. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/26/22 Admission Nursing Database indicated Resident 1 was alert, oriented but was agitated. The resident was assessed to be continent of bowel and bladder and independent with transfers, toileting and bed mobility. The resident usually went to bed at 9:00 PM and woke up at 8:00 AM. A note indicated the resident did not want to be disturbed at night because she/he startled easily. A Progress Note dated 4/28/22 at 4:19 AM indicated the resident stated she/he needed to leave the facility. The note indicated the resident signed papers acknowledging she/he left against medical advice, the physician was notified and a message was left with the local state agency to report a concern with the resident's sudden facility departure. The resident later returned. A 4/28/22 Progress Note by Staff 1 (Corporate RN) revealed the resident's friend reported Resident 1 had anxiety and the resident preferred to have space and could be overwhelmed with staff when the resident experienced anxiety. The friend also reported the resident could become disoriented at night when staff checked her/his vital signs resulting in increased anxiety. The resident's preference was to not be woken up on night shift for vital signs. The care plan was updated. A Care Plan updated on 4/28/22 revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to be careful not to invade the resident's personal space. The Care Plan did not include the resident was incontinent and wore incontinent briefs. A 4/29/22 Progress Note written at 5:51 AM by Staff 2 (LPN) revealed a CNA did morning rounds and went into Resident 1's room. The resident started to cry. The nurse attempted to speak to the resident but the resident refused to talk. At 5:00 AM the resident went outside for 45 minutes and then returned to the facility. On 6/6/22 at 4:57 PM Staff 4 (LPN) stated he worked the evening shift. Staff 4 stated as he left his shift he directed Staff 5 (Night Shift CNA) to not enter Resident 1's room unless the resident activated the call light. On 6/5/22 at 10:55 PM Staff 5 stated Staff 4 informed her Resident 1 was admitted to the facility and staff were not to go into her/his room at night unless the resident activated the call light. Staff 5 stated all night she did not hear from the resident and at about 4:00 AM she wanted to check on Resident 1 to see if she/he was incontinent. Staff 5 asked Staff 6 (CNA) to assist her. They knocked on the resident's door before entering the resident's room and before touching the resident's covers she spoke to the resident and stated she needed to check the resident's incontinent brief. The resident covered her/his face with the blanket. Staff 5 tried to pull the blanket down from the top but the resident would not let go of the blanket so Staff 5 lifted the blanket from the bottom and reached under the blanket to feel if the bedding was wet. The resident did not wear an incontinence brief and did not have an incontinence pad under her/his hips. The resident was not wet so they left. The resident did not say anything to them. After they left the room she heard crying from Resident 1's room and Staff 7 (LPN) went into the resident's room but the resident screamed at Staff 7. On 6/6/22 at 4:29 PM Staff 6 stated she was not assigned to Resident 1 but went into Resident 1's room with Staff 5 to check to see if the resident was incontinent. Staff 5 put her hand under the blanket to check if the bedding was wet. The resident said no and would not let go of the blanket so they left the resident's room. Staff 2 tried to speak to the resident but the resident screamed more. The resident cried, went outside, sat in her/his van and then called a friend. On 6/8/22 at 10:54 AM Staff 2 stated the CNAs reported Resident 1 was not happy and was crying. He went to the resident room but the resident would not talk to him and looked very scared. A 4/29/22 Progress Note written at 4:27 PM by Staff 1 revealed the resident was upset with staff when they attempted to provide care when the resident was sleeping. The resident became disoriented and the resident requested staff place signs on the door to not interact with he resident between the hours of 9:00 PM and 8:00 AM. A 5/7/22 email from Resident 1 to Witness 1 (Director of State Department of Human Services) indicated when staff checked her/him in the middle of the night for incontinency with no warning, being woke up out of sleep, brought back flash points of the past. The resident indicated she/he didn't feel safe any more. On 6/8/22 at 4:29 PM Staff 1 stated she spoke with the resident a few hours after the incident and the resident was still very angry.

1. Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 5 of 22 residents (#s 20, 25, 26, 27 and 28) identified at risk for aspiration and who were to be supervised while eating. All identified residents were observed to be left unattended with meals and/or fluids during continuous observations. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 8/2017 Dysphagia Diets and Aspiration Precautions policy statement indicated residents with observed indicators of dysphagia or required altered textures and/or thick liquids would have general aspiration precautions taken. a. Resident 20 readmitted to the facility in 2/2020 with diagnoses including [CONDITION(S)]. The 10/26/21 Physician Order indicated Resident 20 was to receive a regular diet with an easy chew texture and thin consistency. The 10/1/21 Care Plan indicated Resident 20 required 1:1 assistance with eating. The 10/9/21 Aspiration Precaution sign indicated Resident 20 was to receive 1:1 assistance, encourage intake and check to check for pocketing. On 10/28/21 at 5:55 PM Staff 41 (CNA) was observed to leave Resident 20's room. The resident had her/his meal at the bedside within reach and was observed chewing food. The surveyor asked Resident 20 if she/he was chewing food and she/he stated yes. On 10/28/21 at 6:03 PM Staff 41 acknowledged Resident 20 was left in the room unattended with the meal and acknowledged the resident should not have been left alone. b. Resident 25 admitted to the facility in 2015 with diagnoses including stroke. Resident 25 was diagnosed with Alzheimer's disease and dementia in 2019. The 10/20/21 Physician Order indicated Resident 25 was to receive a regular diet with pureed texture and thin consistency. The 7/20/17 Care Plan indicated Resident 25 was on aspiration precautions and required to sit up for meals, distant supervision and feed assist PRN. The 8/31/21 and 9/26/21 Aspiration Precaution signs located in an Aspiration Risk Book and/or in the resident room indicated Resident 25 was to receive close supervision with meals and to have supervision with meals in the dining room. Resident 25's medical record indicated the resident required distant supervision in the dining room. Resident 25 had a history of aspiration and aspirated at the facility in 3/2021. On 10/26/21 at 5:47 PM Resident 25 was observed eating independently in the hallway and drinking thin liquids with no staff present. c. Resident 26 admitted to the facility in 9/2020 with diagnoses including [CONDITION(S)] disease and dysphagia (difficulty swallowing). The 10/11/21 Physician Order indicated Resident 26 was to receive a regular diet with soft and bite sized texture, thin consistency and swallow precautions. The 10/27/21 Kardex (staff care plan) indicated Resident 26 required 1:1 staff participation to eat and after the meal search mouth for food residue, and keep upright. The 1/20/21 Aspiration Precaution Sign indicated Resident 26 required 1:1 assistance with meals and to limit distractions. On 10/28/21 at 5:15 PM Resident 26 sat across from the nurses station with a mug of fluid on the bedside table in front of her/him and within reach. At 5:47 PM a staff member walked up to Resident 26, moved the mug of fluid so it was directly in front of her/him and then walked away. At 5:48 PM Resident 26 began to take sips out of the mug; no staff supervision or assistance was provided. At 5:54 PM the dinner tray was placed in front of Resident 26, the food was set-up and the bedside table was lowered. The staff member then walked away which left Resident 26 alone and unsupervised with her/his meal tray. Resident 26 attempted to clean her/his hands and start the meal without staff assistance or supervision. At 5:58 PM a staff member sat next to Resident 26 and began to assist her/him with the meal. At 6:28 PM Resident 26 sat with two cups of fluid on the bedside table in front of her/him with no assistance or supervision from staff. On 10/28/21 at 6:46 PM Staff 39 (CNA) stated she placed the food tray in front of Resident 26 and left without providing eating assistance or supervision. On 10/28/21 at 6:43 PM Staff 14 (CNA) stated Resident 26's assistance with meals fluctuated daily and acknowledged she was not aware Resident 26 required 1:1 supervision or assistance. Staff 14 acknowledged Resident 26 sat across the nurses station with two cups of fluid in front of her/him without supervision. On 10/28/21 at 6:50 PM Staff 26 (Regional RN) stated 1:1 assistance and supervision meant there should be a staff member with the resident when the resident had food or fluids. Staff 26 verified any resident who required 1:1 assistance or supervision with meals should never be left alone with fluids. d. Resident 27 admitted to the facility in 2019 with diagnoses including [CONDITION(S)], stroke and [CONDITION(S)]. The 10/20/21 Physician Order indicated Resident 27 was to receive a regular diet pureed texture and mildly thick consistency. The 4/13/19 Care Plan indicated Resident 27 required 1:1 close supervision for meals in the dining room for swallow precautions. The 4/19/21 Aspiration Precaution Sign indicated Resident 27 was to receive 1:1 assistance as needed and assist with small bites. On 10/28/21 at 5:35 PM Resident 27 was observed sitting outside of her/his room. The resident was given her/his food tray and utensils. Resident 27 was observed to eat independently. At 5:42 PM the resident was observed to be cough and drool while eating independently in the hall. No staff were present. At 5:44 PM staff were observed to move the residents tray out reach for a brief moment and placed the tray back within the resident's reach and walked away. At 5:48 PM staff were observed telling Resident 2 that they would be right back and walked away. e. Resident 28 admitted to the facility in 10/2021 with diagnoses including stroke and dysphagia (difficulty swallowing). The 10/20/21 Physician Order indicated Resident 28 was to receive a regular diet with soft and bite sized texture and thin consistency. The 10/27/21 Care Plan indicated Resident 28 was to receive supervision with eating and PRN assistance. The 10/19/21 Aspiration Precautions Sign indicated Resident 28 required 1:1 supervision with meals and to check for pocketing. On 10/28/2021 at 5:17 PM a visitor was observed at the front door stating she wanted staff to give Resident 28 food as they were doing a window visit downstairs. Staff 1 took the food from the visitor. On 10/28/21 at 6:05 PM Resident 28 was observed to have nachos on a table next to her/him within reach in the dining room. Staff 48 (RN) entered the dining room and removed the nachos and stated the resident was on aspiration precautions and was not supposed to have nachos. On 10/28/21 at 7:04 PM Staff 1 stated she provided the nachos to Resident 28. On 10/28/21 at 9:28 PM Staff 1 (Administrator), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised during meals. An immediate plan of correction (POC) was requested. On 10/28/21 at 10:41 PM the facility submitted a final POC was approved. The IJ Immediacy Removal Plan included: -All residents currently in the facility with aspiration precautions would be reviewed to ensure care plan and aspiration precautions reflect the same information. Residents that are not to have fluids at bedside have been checked to ensure fluids currently not at bedside. -All nursing staff will be in-serviced on the policy of aspiration precautions, how to read and understand the pink precautions signs and definitions of supervisions as outlined in the policy. All nursing staff in the building currently would receive the in-service prior to leaving [10/28/21] and day shift would be in-serviced prior to staring their shift [10/29/21]. All other nursing staff would be in-serviced no later than 11:59 PM on 10/29/21 unless staff were unreachable, ie: on leave, vacation or paid time off (PTO). Any staff who were not reachable would receive the in-service prior to starting their next shift. -By end of day on 10/29/21 the dining room would be open to residents requiring assistance for eating and residents that required assistance that stayed in bed would receive the 1:1 assistance as outlined in the care plan and aspiration sheet. -Any current residents on aspiration precautions that had not been assessed by speech therapy in the past 12 months or who had a change in cognition would be reevaluated by speech therapy. This would be completed by 11/5/21. -The DNS or designee would complete weekly audits of all residents on aspiration precautions to ensure staff were following aspiration precautions and that the sign in the room matched the care plan. The audits would be completed weekly for three months and would be reviewed at QAPI until substantial compliance had been met for two quarters. On 11/2/21 at 10:06 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented. 2. Based on interview and record review it was determined the facility failed to ensure a resident received supervision to prevent avoidable accidents for 1 of 3 residents (#15) reviewed for accidents. The facility failed to fully assess Resident 15, who was at risk for elopement, including the need for supervision to eliminate the risk of an accident. This failure resulted in an immediate jeopardy situation. This placed residents at risk for injury and death. Findings include: Resident 15 admitted to the facility on [DATE] with diagnoses including paranoid [CONDITION(S)], anxiety, and a stroke. The 3/4/21 Admission Nursing Database indicated Resident 15 had short term memory loss with moderate impairment. The resident was alert to self and somewhat to her/his surroundings with mild confusion and delayed response time. The resident was anxious and received antipsychotic, antianxiety, antidepressant, and mood stabilizer medications. The 3/5/21 BIMS indicated the resident had a severe cognitive impairment. A 3/8/21 Progress Note indicated Resident 15 was sent to a physician clinic unaccompanied, did not wait for the appointment and left the clinic. The resident unsafely entered a busy intersection in an [NAME] environment. Cars swerved to avoid hitting the resident. The clinic staff escorted the resident around the block until she/he eventually agreed to return to the clinic. The clinic staff indicated the resident was anxious and agitated and exhibited self-injurious behavior when approached by clinic staff. A 3/8/21 Physician Progress Note indicated clinic staff observed Resident 15 acting confused in the parking lot and the resident almost rolled her/himself out into the street multiple times. Clinic staff walked around the building with the resident as the resident yelled leave me alone. I don't trust you guys. The resident did not allow staff to help or assess her/him. The 3/9/21 Code Pink [Elopment Risk] Assessment indicated Resident 15 was an elopement risk, had a diagnosis of [CONDITION(S)] and would hit her/himself when triggered and triggers included: new places, new faces. On 3/11/21 at 2:32 PM Witness 19 (Complainant) stated Resident 15 was dropped off for a medical appointment at her/his physician clinic unaccompanied on 3/8/21 at 3:23 PM. At 3:30 PM Resident 15 was observed outside in her/his wheelchair self-propelling towards traffic into a busy street. Cars swerved to avoid hitting the resident. Clinic staff attempted to talk with the resident, but the resident was unable to provide her/his name or information and was agitated and anxious. Witness 19 called the facility and was told Resident 15 was not their resident. Witness 19 was able to contact staff from Resident 15's former adult foster home to calm Resident 15 down. On 3/15/21 an anti-elopement device was placed after the resident attempted multiple times to leave the facility. On 10/28/21 at 2:43 PM Witness 31 (Former LPN) stated Resident 15 exhibited decreased cognition and exit-seeking behaviors since admission and had previously left the facility and crossed the street. Witness 31 stated the facility did not send staff to appointments with residents and on 3/8/21 she and another nurse were concerned that Resident 15 was sent to an appointment unaccompanied. On 11/2/21 at 11:36 AM Staff 1 (Administrator), Staff 2 (DNS), Staff 25 (Regional RN) and Staff 26 (Regional RN) were notified of the immediate jeopardy (IJ) situation and were provided a copy of the IJ template related to the facility's failure to ensure residents were adequately supervised to prevent accidents related to elopement. An immediate plan of correction (POC) was requested. On 11/2/21 at 3:06 PM the facility submitted a final POC was approved. The IJ Immediacy Removal Plan included: -Current residents need for an appointment attendant would be assessed by a nurse based on cognition, elopement risk and safety concerns. -Residents designated as needing an appointment attendant would be documented in the chart. Residents with appointments in the next two weeks were reviewed to ensure those needing appointment attendants were identified and scheduled within the next 24 hours. -All staff would be in-serviced on the importance of always using appointment attendants for the residents identified. In-servicing would be completed by 11:59 PM on 11/3/21. -All new admissions would be assessed by a nurse based on cognition, elopement risk, and safety concerns. -The Administrator or DNS would audit four resident charts weekly to ensure residents needing an appointment attendant had been identified in the chart. Audits would continue for three months with results brought to QAPI for two quarters or until substantial compliance was met. On 11/4/21 at 9:43 AM Staff 26 (Regional RN) was notified the immediacy was removed based on observations, staff interviews, and record review that the IJ immediacy removal plan was fully implemented. 3. Based on interview and record review it was determined the facility failed to ensure residents were provided appropriate equipment and staff followed the care plan for transfers to prevent accidents for 2 of 4 residents (#s 13 and 24) reviewed for falls and accidents. This failure resulted in Resident 13 sustaining a fall fractures and placed residents at risk for falls and injury. Findings include: 3a. Resident 13 admitted to the facility in 2012 with diagnoses including dementia and a stroke. The 11/17/20 Annual MDS indicated Resident 13 had severe cognitive impairment and required extensive, two or more persons for bed mobility. The 12/17/20 Fall Investigation completed by Staff 31 (LPN) indicated a former Witness 29 (Former CNA) was in Resident 13's room providing care when the resident rolled out of bed onto the floor due to the mattress bending over the edge of the bed. There was no time indicated when the resident fell . When asked if the resident hit her/his head the resident responded yes and stated her/his legs were broken and knees hurting. The resident was assessed as having 5/10 pain and the investigation indicated pain medication was offered but the resident refused. Later in the investigation pain was assessed as 7/10 and the resident reported left shoulder, arm, and torso pain. An x-ray was ordered, and the results determined Resident 13 sustained three left ribs fractures. The investigation summary concluded the mattress was too big and soft for the bed frame and folded over when weight was applied. Maintenance replaced the mattress and applied non-skid strips to the bottom to keep the mattress from sliding and the care plan was updated for the resident to receive two-person cares with bed mobility. Multiple attempts were made to contact Witness 29 but there was no response. On 10/28/21 at 2:48 PM Staff 31 (LPN) stated she recalled Resident 13's mattress not being the correct size and stated after the fall Witness 29 reported the fall occurred due to Resident 13's mattress not being the correct size and slid around the bed frame. Staff 31 stated Witness 29 reported he had brought up the mattress being the wrong size twice to management before and the mattress was never changed. On 10/27/21 at 1:08 PM Witness 30 (Former RNCM) stated she was not aware Resident 13's mattress was too big for the bed. Witness 30 stated during her investigation she had found a couple of CNAs that knew the mattress hung over the side of the bed. Witness 30 stated she did not write-down the interviews with the CNAs and could not recall who she interviewed. On 11/1/21 at 12:58 PM Staff 6 (CNA) stated the facility previously had multiple mattresses that slid very bad over the bed frames and administrative staff were aware and did not replace them. On 11/1/21 at 9:49 AM Staff 25 (Regional RN) confirmed Resident 13 had a fall with rib fractures due to the mattress being the incorrect size for the bed. 3b. Resident 24 admitted to the facility in 2016 with diagnoses including chronic pain. The 9/3/20 Care Plan indicated Resident 24 required two person assistance for transfers to the shower chair. On 11/1/21 at 3:57 PM Staff 10 (Nurse Aide) was observed to enter Resident 24's room independently with a shower chair and closed the door. On 11/1/21 at 4:01 PM Staff 10 was observed to assist Resident 24 to the shower room across the hall. Staff 10 stated Resident 24's care plan indicated she/he preferred only male staff. Staff 10 acknowledged the care plan indicated Resident 24 was to receive two person assistance to the shower chair and Staff 10 transferred the resident to the shower chair independently. On 11/1/21 at 4:36 PM Staff 26 (Regional RN) stated Resident 24's care plan indicated she/he was to receive two person assistance for transfers to the shower chair and stated the expectation was for two staff to assist her/him with transfers.

Based on interview and record review it was determined the facility failed to assess and monitor a pressure ulcers for 1 of 3 sampled residents (#10) reviewed for pressure ulcers. This resulted in a worsening pressure ulcers. Findings include: Resident 10 was admitted to the facility in 8/27/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 8/27/20 Admission Nursing Database revealed Resident 10 was admitted to the facility with blanchable redness to her/his bilateral heels [indicating no pressure ulcers]. The 9/11/20 Facility Investigation revealed Resident 10's right heel had a blood blister or maroon area which measured 3.3 cm x 2.5 cm. The left heel had a blood blister which popped and was now a reddened area which measured 1.7 cm x 3.2 cm. Treatments were implemented for the bilateral pressure ulcers. The 9/2020 TAR revealed a 9/11/20 order to monitor the deep tissue injuries (DTI - a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear), apply skin prep every shift, ensure the heels were floated, and to monitor for signs of infection or worsening of wounds. The 9/12/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 2 cm and a red area which measured 3 cm x 1 cm to the left heel. A formal wound assessment of the bilateral wounds was not completed. The 9/15/20 Weekly Skin Check revealed Resident 10's right heel had a red area which measured 5 cm x 3 cm and the left heel had a red area which measured 3 cm x 1 cm. A formal assessment of the bilateral wounds was not completed. The 9/17/20 Nutrition at Risk assessment revealed the wounds to Resident 10's bilateral heels were pressure ulcers. The 9/22/20 Weekly Skin Check revealed the blister to the right heel had popped, measured 3.2 cm x 3.9 cm The left heel had a blister which measured 2.2 cm x 1.3 cm. A formal assessment of the bilateral pressure ulcers was not completed. The 9/29/20 Weekly Skin Audit indicated the right heel pressure ulcer measured 2.8 cm x 3.6 cm and the left heel pressure ulcer measured 2.1 cm x 1.6 cm. The left heel was dark red in color and very slightly raised. The 9/29/20 Wound and Skin Evaluation indicated Resident 10 had a facility acquired deep tissue injury to the right heel. The 10/6/20 Weekly Skin Audit revealed Resident 10's skin was intact. The 10/6/20 Wound and Skin Evaluation revealed the right heel DTI was first observed on unknown date and measured 2.3 cm x 3.4 cm. A full skin assessment of the right heel was completed. A full skin assessment was not completed for the left heel. The 10/13/20 Weekly Skin Audit revealed no measurements or assessments of the bilateral heel pressure ulcers. The 10/20/20 Weekly Skin Audit revealed Resident 10 had a pressure ulcer to the right and left heels, the left heel contained eschar (a collection of dry, dead tissue within the wound; a Stage III pressure ulcer). The Audit further revealed the nurse was unable to stage the wound and referred to the RN skin/wound sheet for staging of the pressure ulcers [No RN skin wound sheet was completed]. On 11/1/21 at 10:30 AM Staff 25 (Regional RN) and Staff 26 (Regional RN) acknowledged Resident 10 admitted to the facility with red, blanchable heels and on 9/11/20 the facility identified bilateral pressure ulcers to both heels. Staff 26 further acknowledged formal assessments and monitoring of the facility acquired bilateral heel wounds was not initiated until 9/19/20 and the left heel wound worsened to a Stage III pressure ulcer.

Based on interview and record review it was determined the facility failed to ensure residents received pain medications timely for 1 of 6 sampled residents (#7) reviewed for physician orders. This in resulted Resident 7 experiencing unrelieved pain and placed residents at increased risk for pain and psychosocial harm. Findings include: Resident 7 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/26/21 BIMS indicated Resident 7 was cognitively intact. The 9/22/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/2021 narcotic logs and MARs indicated the following: -Resident 7 received a dose of oxycodone on 10/19/21 at 4:00 AM. -Resident 7 did not receive another dose of oxycodone until 10/20/21 at 2:19 AM and had 10/10 pain. The 10/20/21 at 1:14 AM progress note indicated Resident 7 was crying, reported being sick to her/his stomach due to pain and the resident thought she/he was having withdrawal from the medication. The nurse called the pharmacy and the pharmacy indicated a prescription was not received. The provider indicated she would call the pharmacy with a new prescription for oxycodone. On 10/25/21 at 11:18 AM Resident 7 stated there were instances when she/he did not receive oxycodone timely due to staff failure to order oxycodone. The resident stated she/he recently did not receive oxycodone for one day and had a lot of pain, was laying in bed crying and shaking all day long and had withdrawals. Resident 7 stated staff offered her/him Tylenol which did not help the pain. On 10/25/21 at 3:24 PM Staff 3 (LPN) stated Resident 7 ran out of oxycodone due to the physician needing to sign new orders. Staff 3 stated she noticed Resident 7 was running low on oxycodone on 10/19/21 and notified the physician and the oncoming shift. Staff 3 further stated when she returned to work on 10/20/21 Resident 7 did not have oxycodone available and she called the physician to get an order. Staff 3 informed the physician the resident was crying, shaking and reported she/he was hurting all over. Staff 3 stated she received the order for the oxycodone and was able to administer it on 10/20/21. On 10/26/21 at 9:28 AM Staff 4 (LPN) stated on 10/19/21 staff informed him that Resident 7 needed a new order for oxycodone. Staff 4 stated the physician was contacted via email of the need for the new order and the physician did not reply. Staff 4 further stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 4 further stated the physician visited every Wednesday and acknowledged medications were not always reordered timely. On 11/1/21 at 11:45 AM Staff 25 (Regional RN) acknowledged Resident 7 ran out of oxycodone due to staff not reordering it timely. Staff 25 acknowledged Resident 7 received oxycodone on 10/19/21 at 4:00 AM and did not receive an additional dose until 10/20/21 at 2:19 AM and acknowledged the resident had unrelieved pain due to not receiving oxycodone on time.

Based on interview and record review it was determined the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Resident 22 being hospitalized and placed residents at risk for adverse drug reactions. Findings include: 1. Resident 22 admitted to the facility in 1/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/14/21 Skin and Wound Evaluation indicated Resident 22 had a facility acquired open lesion to the lower right abdomen. The wound appeared two weeks prior, measured 1.8 cm x 0.6 cm and had no signs of infection. Treatment was in place. The 9/22/21 Progress Notes revealed the abdominal wound was raised, red, warm to touch, painful with moderate yellow drainage. [Indicative of infection.] The 9/22/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/2021 MARs revealed the order for the [MEDICATION(S)] was not transcribed onto the MAR and was not administered. The 9/24/21 Progress Noted revealed Resident 22 had a temperature of 100.4F [normal is between 97F to 99F] and a pulse of 120 [normal is 60 to 100 beats per minute]. Resident 22 complained of pain at the abdominal wound site. Resident 22's lower abdomen was red and hot to the touch. Resident 22 was transferred to the hospital. The 9/27/21 Hospital Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22 was discharged with a PICC (peripherally inserted central catheter) line for two weeks of IV (intravenous) antibiotics. Resident 22 was to follow up with the infectious disease clinic in one week. On 11/1/21 at 10:47 AM Staff 25 (Regional RN), Staff 26 (Regional RN) and Staff 2 (Interim DNS) acknowledged the 9/22/21 antibiotic order was not transcribed or administered to Resident 22 which resulted in the transfer and admission to the hospital for IV antibiotics to treat the [CONDITION(S)]. 2. Resident 23 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 2/22/20 at 12:36 PM progress note indicated Resident 23 admitted to the facility. The 2/22/20 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/22/20 at 9:24 PM progress note indicated [MEDICATION(S)] was not available. The 2/2020 MAR indicated Resident 23 did not receive her/his first dose of [MEDICATION(S)] until 2/23/20 at 8:00 PM. On 11/2/21 at 9:16 AM Staff 26 (Regional RN) stated Resident 23 admitted to the facility on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review it was determined the facility failed to assess, monitor and treat skin wounds and failed to follow physician orders [REDACTED].#s 1 and 3) reviewed for non-pressure skin conditions. Resident 1 experienced bilateral post-operative infection and dehisced (splitting or bursting open) wounds, hospitalization and surgery; and this placed residents at risk for unmet treatment needs. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 discharged from the facility to the hospital on [DATE]. a. The 12/2010 Facility Skin Program Guideline indicated actual skin areas would have weekly documentation which included measurements and how the wound progressed toward healing such as improvement, worsening or if the wound remained unchanged. The 7/9/20 Hospital admission orders [REDACTED] *Monitor thigh incisions *Wound care per (facility) protocol The 7/9/20 Admission Nursing Database (per Staff 3 (LPN) documentation) revealed Resident 1 admitted with R thigh 6cm surgical incision x3 0.5cm surgical incisions, L thigh 6cm surgical incision x3 0.5cm surgical incisions, L inner thigh stg (sic) 2. No full skin assessment were completed for the two surgical incisions and the left inner thigh/groin wound and the left thigh wound was not documented to have drainage. On 7/28/20 at 9:29 AM Staff 3 indicated on admission both the left and right surgical incisions were open to air, the left incision had serous (thin, watery and clear substance) drainage and looked worse than the right incision. Staff 3 stated he documented the left inner thigh (groin) wound as a Stage two pressure ulcer (partial-thickness skin loss with exposed dermis - not be used to describe moisture associated skin damage including medical adhesive related skin injury) although he did not know much about the wound. Staff 3 stated the wound was scabbed over, not over a bony prominence and not a pressure ulcer. Review of Resident 1's medical record revealed no progress notes or wound assessments until a 7/16/20 progress note which indicated the lateral left thigh incision continued to drain with creamy slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) present and the wound edges were barely approximated (well approximated means the two edges are even with no puckering or gaps and the wound/incision is healing properly). Additionally, there was a large skin impairment to the left upper, inner thigh with firm slough present. There was no documentation to indicate treatment was provided. A 7/17/20 Progress Note indicated the bilateral thigh surgical wound incisions were dehiscing. The left thigh wound had slough and the right thigh wound was beefy red and the edges were not approximated. The Orthopedic Office was notified and Resident 1 was transferred to the Hospital Emergency Department. The July TARs revealed the staff were to Monitor thigh incisions every shift. All shifts except one had a checkmark documented which meant the thigh wounds was observed. There were no notes associated with the TAR to indicate the wounds had slough, drainage, dehisced or remained unchanged until 7/16/20. The 7/19/20 Transfer Discharge form indicated Resident 1 admitted to the facility with bilateral thigh surgical incisions. The left thigh incision drained serosanguinous (discharge containing both blood and a clear yellow liquid) drainage since admission. On 7/17/20 Resident 1's right thigh incision had dehisced and the two incisions on the left thigh had slough in both wounds and the edges were not well approximated. Resident 1 was transferred to the hospital. The current Kardex (CNA care plan) instructed staff to perform daily skin inspections and report any abnormalities to the nurse. A complete medical record review was completed the morning of 7/24/20. Resident 1's medical record did not include CNA documentation of daily skin inspections. The bilateral thigh surgical incisions did not have an admission or weekly skin assessments and the wound monitoring did not include the status of the bilateral thigh wounds so staff would be able to recognize if the surgical wounds worsened. Although the left thigh wound was draining on admission the lack of wound treatment was not clarified with the physician. There was no physician notification of the thigh wounds until 7/17/20. There was no documentation of assessment, monitoring or treatment of [REDACTED]. The physician was not notified of the left groin wound. The afternoon on 7/24/20 the following late-entry progress notes were documented into Resident 1's medical record: *7/14/20: The incisions were approximated well. The superior, lateral left leg continued to have moderate drainage. The left lower incision continued with moderate drainage. The drainage was clear to tan in color to both sites. The left groin was scabbed over with minor redness to the surrounding skin. (This entry, written 10 days after Resident 1's discharge, revealed three wounds to the left leg. Resident 1 had two wounds on the left leg and one wound on the right leg.) *7/15/20: The incisions were approximated well. The superior, lateral left leg continued to have moderate drainage. The left lower incision continued with moderate drainage. The drainage was clear to tan in color to both sites. The left groin was scabbed over with minor redness to the surrounding skin. (This entry, written nine days after Resident 1's discharge using the same verbiage as the 7/14/20 entry, revealed three wounds to the left leg. Resident 1 had two wounds on the left leg and one wound on the right leg.) *7/16/20 at 2:22 PM: Bilateral incision sites were heavily scabbed over with dry blood. Telephone call out to physician (physician did not return phone call. This entry, written eight days after Resident 1's discharge did not indicate the left thigh incision was draining). *7/16/20 3:05 PM: Bilateral incision sites were intact. (This entry, written nine days after Resident 1's discharge and timed 43 minutes after the previous entry, contradicted how the bilateral incision sites presented on the previous shift. The 7/29/20 Hospital Records revealed Resident 1 was admitted to the hospital for bilateral wound infections and dehiscence. Resident 1 had surgery for [REDACTED]. The wounds were debrided (removal of dead or infected tissue from a wound in order to allow healthy new tissue to form) and negative pressure wound therapy devices were applied. During the debridement surgery the surgeon observed necrotic (dead) fat tissue in the right distal femoral wound. The surgeon noted the left femoral wound had a full-thickness necrosis (death) of the skin and during the process of debridement found the fascia (a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes, encloses, and separates muscles) was disrupted and the (bone) plate visible. The debridement was completed down to the level of the bone. The surgeon noted the left wound was worse than the right wound and the left side fascia was repaired. On 7/22/20 at 4:32 PM Witness 1 (Complainant) stated Resident 1 presented to the Emergency Department with three open wounds. The left groin area, the left thigh surgical incision was open with slough and the right thigh surgical incision dehisced. The right thigh incision was red, bloody and fatty tissue was observed. Witness 1 stated no wound care was completed during Resident 1's stay at the facility. On 7/28/20 at 10:30 AM Staff 5 (LPN) stated the left thigh groin wound looked like a tape burn and the left surgical incision had drainage since admission. Staff 5 stated on 7/16/20 both wounds on the left thigh had slough present. On 7/27/20 at 2:00 PM Staff 7 (LPN) acknowledged she wrote a late entry progress for 7/16/20 seven days after Resident 1's discharge which indicated the incision sites were intact bilaterally. Staff 7 acknowledged the previous shift charted the incision sites were heavily scabbed over with dry blood, the physician was called and the information was passed onto the next shift but stated she did not remember receiving this information in report and did not talk to Resident 1's physician. Staff 7 stated she only cared for Resident 1 twice and was unable to express much in her charting documentation. On 7/29/20 at 5:43 AM Staff 4 (RN) verified he worked the night shift on 7/16/20 and stated he did not receive any untoward report regarding any wound. On 7/29/20 at 6:00 AM Staff 8 (LPN) stated he cared for Resident 1 on 7/14/20 and 7/15/20, did not know the resident well, reported to the RNCM the wounds were draining and was informed the wounds were supposed to be open to air. Staff 8 stated he was called on 7/24/20 and instructed by Staff 13 (SDC - Staff Development Coordinator) to come into the facility that day to complete late entry charting for 7/14/20 and 7/15/20 on Resident 1. On 7/29/20 at 7:50 AM Staff 6 (RNCM) verified she was summoned to Resident 1's room on 7/17/20. Staff 6 stated the right wound was split open showing beefy red tissue. The left wound had heavy scabbing around the edge with noticeable slough in the middle of the incision. Staff 6 stated this was a change of condition from when she last observed the wounds for Resident 1's 72 hour huddle (care conference). Staff 6 verified there were no full skin assessments or wound treatments completed on the bilateral thigh surgical incisions and the left groin wound. Staff 6 acknowledged the Kardex instructed staff to perform daily skin inspections and report any abnormalities to the nurse and further acknowledged there was no documentation in Resident 1's medical record this was completed. On 7/29/20 at 11:26 AM Staff 2 (DNS) stated since the bilateral thigh wounds were surgical incisions they were not followed on wound rounds and wound status was not documented. Staff 2 acknowledged with multiple staff members documenting the bilateral thigh wounds were monitored on the July 2020 TARs with no additional information, the staff were not able to recognize a change in condition to the bilateral incisions. Staff 2 acknowledged no formal skin assessment or monitoring was in place for the left groin wound. Staff 2 was unsure why the left thigh surgical incision treatment orders were not clarified with the physician since the wound was draining on admission to the facility. Staff 2 stated on 7/24/20 she initiated an incident report related to Resident 1's skin issues, discovered Resident 1's skin issues were not documented and instructed the nursing and therapy staff to document late entries. On 7/28/20 at 8:17 AM Witness 2 (Orthopedic Medical Assistant) stated the office was not notified of any change of condition until 7/17/20 when the Nurse Practitioner was informed of the one wound dehiscence and told there were no signs of infection. Witness 2 stated the facility did not notify the office the left thigh incision was draining, request wound treatment orders, notify the office of the left groin wound or inform them the two wounds on the left thigh had slough in them. Witness 2 stated the facility should have called to inform the office of the drainage, slough and any change of condition they identified. Resident 1 admitted to the facility with two surgical incisions to her/his bilateral thighs and one wound on the upper left thigh/groin area. The facility failed to fully assess the surgical and groin wounds on admission, did not thoroughly monitor the wounds until 7/16/20, seven days after Resident 1's admission, did not clarify or request treatment orders and failed to identify and report the change of condition to the left thigh wounds which resulted in the subsequent hospitalization and surgery for [REDACTED]. b. The 7/9/20 Hospital admission orders [REDACTED] Review of Resident 1's medical record revealed weights were obtained on 7/13/20 and 7/17/20. There was no evidence in the medical record the daily weight checks were completed as ordered. On 7/29/20 at 7:50 AM Staff 6 (RNCM) acknowledged daily weights were not completed as ordered and the physician was not notified the order was not followed. 2. Resident 3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/2010 Facility Skin Program Guideline indicated actual skin areas would have weekly documentation which included measurements and how the wound progressed toward healing such as improvement, worsening or if the wound remained unchanged. The 1/27/20 Admission Nursing Data Base revealed Resident 3 had four surgical incisions to the right lower extremity and a small fluid filled blister just below the proximal incision most likely from tape. Review of the medical record revealed no weekly skin assessments for the four surgical incisions and the blister. Review of the January 2020, February 2020 and March 2020 TARs revealed wound treatments were completed as ordered. Review of the progress notes indicated no signs of infection to the the surgical incisions. On 7/29/20 at 8:01 AM Staff 6 (RNCM) verified no skin assessments were completed for Resident 3's four surgical incisions and blister.

Based on observation interview and record review it was determined the facility failed to ensure a safe smoking environment for 1 of 1 sampled resident (#5) reviewed for smoking. This failure was determined to be an immediate jeopardy situation which constituted substandard quality of care; Resident 5 was observed be unsafe while smoking. Findings include: Resident 5 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 5/18/19 care plan indicated Resident 5 was safe to smoke independently and had numbness in her/his fingers. The care plan further indicated an additional smoking assessment was to be completed if the resident [MEDICAL CONDITION] her/his self or clothing. A 9/30/19 progress note indicated Resident 5 was noted in upstairs dining room face-down in (her/his) lunch plate. The resident continued to be unresponsive and was sent to the hospital via ambulance. The 10/8/19 hospital records indicated Resident 5 spent eight days in the hospital and was treated for [REDACTED]. The resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/7/19 and 10/8/19 Smoking Assessments indicated Resident 5 was able to smoke independently and noted the resident took medications which could cause drowsiness. A 10/11/19 progress note indicated Resident 5 missed her/his [MEDICAL TREATMENT] appointment. On 10/22/19 at 11:30 AM Staff 6 (CNA) stated Resident 5 was observed smoking earlier on 10/22/19 and dropped her/his lit cigarette on her/himself three times and was able to pick up the lit cigarette after dropping it. Staff 6 stated the fourth time the cigarette was dropped by Resident 5, Staff 6 picked up the cigarette and handed it the resident. Staff 6 stated he reported the incident to Staff 7 (LPN), and Staff 7 replied we will keep an eye on it. Staff 6 stated Resident 5 was an independent smoker and kept her/his cigarettes and lighter with her/him during the day. On 10/22/19 at 11:33 AM Witness 9 (Former LPN) stated Resident 5 had previous narcoleptic episodes and would pass out in her/his wheelchair and had to be aroused by staff to ensure the resident was okay. On 10/25/19 at 9:37 AM Witness 19 (Spouse) stated Resident 5 was bobbing up and down for the past couple months. Witness 19 further stated the resident had refused several [MEDICAL TREATMENT] appointments in the past few months. Observations on 10/22/19 revealed the following: -11:46 AM Resident 5 was observed in her/his wheelchair and had a round hole with burnt edges on her/his right pant leg. When asked, Resident 5 was unable to state how she/he received the burn mark on her/his pants. Resident 5 was further observed in her/his room to have ashes scattered on top of her/his cell phone, a lighter and a package of cigarettes on her/his lap. -12:35 PM Resident 5 lit a cigarette independently while a cigarette butt sat unlit on her/his left leg. No staff were present in the designated smoking area. Resident 5 continuously closed her/his eyes and her/his head bobbed up and down while smoking. -12:43 PM Resident 5 extinguished the lit cigarette between her/his left fingers and placed the extinguished cigarette butt on the left pant leg. -From 12:43 PM until 1:13 PM Resident 5 was observed to be repeatedly hunched over with her/his eyes closed, bobbing her/his head up and down, head touching her/his lap, and her/his chest resting on her/his package of cigarettes and lighter. -1:16 PM Staff 6 (CNA) came to the smoking area per surveyor request to observe Resident 5 smoking. -1:22 PM Resident 5 was observed by Staff 6 and surveyors to extinguish her/his lit cigarette between her/his left fingers and place the extinguished cigarette butt on her/his left leg next to the previous cigarette butts. Resident 5 knocked one cigarette butt off of her/his lap onto the ground when bobbing up and down. Staff 6 acknowledged he believed Resident 5 was unsafe to smoke independently. -1:26 PM Staff 7 came to the smoking area per surveyor request to observe Resident 5. Staff 7 confirmed Staff 6 reported Resident 5 dropped her/his lit cigarette four times at approximately 7:00 AM on 10/22/19. Staff 7 stated she planned to report the incident to Staff 3 (RNCM), however had not reported the incident. Staff 7 acknowledged the resident had a burn hole on the right leg of her/his pants and could not tell if it was new or not. Staff 6 and Staff 7 both acknowledged Resident 5 was nodding off repeatedly for the past few weeks while smoking and it was continually getting worse. Staff 6 and Staff 7 stated Resident 5 was unsafe to smoke independently. -1:30 PM Staff 6 and Staff 7 were observed to reenter the building and Resident 5 was left outside unsupervised with her/his cigarettes and lighter in the smoking area. Surveyors continued to observe Resident 5. -1:34 PM Staff 2 (DNS) was requested by surveyors to observe Resident 5 in the smoking area. The previously identified findings were reviewed with Staff 2. Staff 2 acknowledged Resident 5 had two extinguished cigarette butts on her/his left leg and one on the ground next to the resident. Staff 2 removed the cigarette butts from Resident 5's leg and the ground and put them into the cigarette receptacle and stayed with the resident. -2:13 PM Staff 2 stated there were no smoking aprons in the facility and Staff 1 (Administrator) left the facility to retrieve a smoking apron for Resident 5 to wear. -2:52 PM Staff 2 stated the expectation is residents are to turn in smoking materials, including cigarettes and lighters, before and after each time they return from smoking outside. Staff 2 stated Resident 5 would now be a supervised smoker. -3:19 PM Staff 1 stated all smokers in the building currently are independent. She further stated the facility was currently reassessing all residents' smoking status. On 10/22/19 at 4:45 PM Staff 1 (Administrator) and Staff 2 were informed of the identified Immediate Jeopardy for the failure to ensure resident safety while smoking and identify, assess and reassess all residents' smoking status to prevent smoking related accidents. On 10/22/19 at 5:57 PM the IJ Removal Plan, was received and approved. The Plan included: -The facility reevaluated Resident 5's smoking assessment, identified new interventions and updated the care plan. -Resident 5 was to be supervised by staff while smoking and wear a smoking apron at all times when smoking. Smoking times were 8:30 AM, 1:00 PM, 6:00 PM and 10:30 PM. -All smoking paraphernalia was to be turned into the nurse and locked up in the lock box. -Two cases of smoking aprons were ordered on [DATE]. -The facility will update the care plans and/or interventions for all current residents to ensure their safety. -Resident 5's care plan will be audited to ensure that identified interventions are in place. Additionally the care plan and smoking assessments for all residents who smoke will be evaluated for accuracy within the next 24 hours. -All staff will be reeducated prior to the beginning of their next shift, on the importance of ensuring the resident smoking policy and interventions are in place. Staff reeducation will be done on reporting any violations of the resident smoking policy. For resident safety, smoking assessments and care plans will be in place for residents who regularly and occasionally smoke. -RCMs or the designee will audit to ensure the accuracy of smoking assessments and care planning, as indicated, upon admission and as changes occur through the 24-hour report process. This audit will be completed for four weeks Monday through Friday and bi-monthly for two months or until the threshold obtained. The audits will be conducted and reported to the DNS. Results of audits will be reviewed by the QAPI committee. On 10/23/19 at 4:02 PM the IJ Removal Plan was reviewed for implementation. Observations, staff interviews and record reviews confirmed the Plan was completed.

Based on interview and record review it was determined the facility failed to ensure the right to refuse end of life treatment was honored for 1 of 3 sampled residents (#5) reviewed for respiratory services. This caused Resident 5 to receive CPR (cardiopulmonary resuscitation) when Resident 5 had a documented end of life wish to be DNR (do not resuscitate) status. Findings include: Resident 5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's POLST (Physician order [REDACTED]. The [DATE] at 9:20 AM Progress Note revealed Resident 5 was unresponsive at 7:40 AM. An RN and two CNAs placed Resident 5 on her/his bed. The RN did a sternal rub (direct pressure on sternum to arouse resident) with no response. The RN then suctioned Resident 5 who gasped for air two to three times. Another RN checked the code status and determined there was no POLST on file although family had previously informed the facility of Resident 5's DNR status. The progress note indicated due to no POLST on file CPR was initiated. The paramedics were called and CPR was started. Three nurses responded to the overhead page for the code. Resident 5 remained pulseless and unresponsive. The fire department arrived and CPR continued. Resident 5's family was called and requested a copy of the POLST be sent to the facility. When the copy of the POLST was received the fire department discontinued the CPR. The [DATE] at 9:37 AM Progress Note revealed Staff 18 (RN) attempted to locate Resident 5's code status in the electronic medical record and admission paperwork, but was unable to locate the POLST. On [DATE] at 7:15 AM an observation of the second floor nursing station revealed two big white POLST binders, one unlabeled and one labeled medical records. These binders contained resident POLST forms in plastic sleeves and organized by room number. Additionally, there were four small white binders one of which had bright pink side and front labeling (same color as the POLST form) which indicated it was the Code Pink Binder - Elopement Risks). The first floor nursing station had two large white POLST binders. The first had tabs to identify residents alphabetically, the second was also alphabetical but had no tabs for organization. On [DATE] at 12:40 PM and 6:09 PM Witness 5 (Family) stated she/he gave the original POLST to Staff 12 (LPN) on [DATE] between 9:00 PM and 10:30 PM. Witness 5 stated Staff 12 copied the POLST, offered an additional copy to her/him, placed the original POLST in a plastic sleeve and put it in a white notebook. On [DATE] at 1:05 PM Staff 12 (LPN) stated she did not recall receiving the POLST from Resident 5 or her/his family. On [DATE] at 6:28 PM Staff 14 (RN) stated he did not recall receiving a POLST from Resident 5's family. On [DATE] at 8:57 AM Staff 5 (RNCM) stated she was outside Resident 5's door when she was called into her/his room because Resident 5 collapsed. Staff 5 verified Resident 5 had no pulse, had Staff 18 verify the code status, was informed Resident 5 was a full code and initiated CPR on Resident 5. Staff 5 further stated she did not recall receiving the original POLST from Resident 5's family. On [DATE] at 3:45 PM Staff 18 verified she checked Resident 5's code status by looking in the POLST form book and the admission packet, but was unable to locate the POLST. Staff 18 stated she went to Resident 5's room and informed staff they needed to initiate CPR. On [DATE] at 12:58 PM and 1:13 PM Staff 13 (Medical Records) stated Resident 5's POLST form was uploaded to the incorrect resident's electronic health record on [DATE] at 3:03 PM; after the resident had passed. Staff 13 stated after residents passed away she shredded the original POLST form and could not recall if Resident 5's POLST was an original or a copy. On [DATE] at 1:39 PM Staff 2 (DNS) and Staff 15 (Regional RN) verified the facility had the original POLST form indicating Resident 5's DNR status at the time the resident was resuscitated. Both Staff 2 and Staff 15 acknowledged CPR was performed on Resident 5 who had an active POLST and DNR status. On [DATE] at 10:10 AM Staff 15 (Regional RN) stated no facility investigation was completed into Resident 5's death in the facility. On [DATE] at 1:58 PM Staff 15 (Regional RN) and Staff 16 (Regional RN) stated every Resident POLST form should be available to all staff immediately and it sounds like there may have been a mistake in receiving and processing Resident 5's POLST form per facility policy. On [DATE] at 10:15 AM the facility was informed of the identified Immediate Jeopardy concern for failure to ensure residents had the right to refuse treatment. If a resident through an advance directive declined treatment the resident may not be treated against her/his wishes. The ability of a dying person to control decisions about medical care and daily routines was identified as one of the key elements of quality care at the end of life. By performing CPR for Resident 5 who had a DNR status there was potential to cause avoidable pain which was excruciating and more than transient and decline in physical and psychosocial functioning from the resuscitation process if the resident was revived. If Resident 5 was revived she/he would likely have multiple broken ribs and the potential for intubation and an intensive care hospital stay. Resident 5's family stated they worried another hospital stay would negatively affect Resident 5's mental well-being. An immediate Plan of Correction (P[NAME]) was requested. On [DATE] at 11:48 AM the IJ Abatement Plan, was received and approved. The Plan included 1) a facility wide audit to ensure all residents had a POLST or advance directive or was offered the opportunity to initiate one; 2) The POLST books throughout the facility would be reorganized; 3) In-service of nursing staff regarding policy and procedures of receiving and processing POLST forms before their next shift and within 24 hours. On [DATE] at 11:55 AM the Plan was reviewed for implementation. Observations and staff interviews were completed. The facility wide audit was completed, the POLST books were reorganized and the in-service of staff was initiated. On [DATE] at 10:30 AM observations and interviews confirmed the Plan was completed.

Based on interview and record review it was determined the facility failed to clarify and follow physician orders [REDACTED].#s 5 and 11) reviewed for respiratory services and medications. This failure cased Resident 11 to experience exacerbated symptoms of heart failure including [MEDICAL CONDITION] and weight gain. This failure also placed residents at risk for untreated respiratory needs, uncontrolled blood sugars and incorrect medication administration. Findings include: 1. Resident 11 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/4/19 admission orders [REDACTED]. There were no orders for diuretic medication. The 6/8/19 RD Assessment noted a significant 5.2% weight gain since admission and indicated Resident 11 was at risk for weight variances related to fluid shifts as evidenced by heart failure. The 6/26/19 Physician Visit Summary listed Resident 11's current medications and included [MEDICATION NAME] 40 mg (diuretic) daily. The medication list was sent to the pharmacy on 6/26/19 at 4:08 PM. The (MONTH) 2019 and (MONTH) 2019 MARs revealed the potassium was administered as ordered. The [MEDICATION NAME] was not administered in (MONTH) or (MONTH) 2019. A 7/16/19 nutritional note revealed a significant weight gain and 2+ [MEDICAL CONDITION] (2-4 mm indent which disappears in 10-25 seconds) to Resident 11's lower extremities. Resident 11's weight record revealed her/his admission weight was 121.2 on 6/4/19 and a discharge weight of 134.8 on 7/15/19. On 7/25/19 at 10:20 AM Witness 10 (Complainant) stated while a resident at the facility Resident 11's legs were so swollen you could not see (her/his) feet. Witness 10 stated when Resident 11 was preparing to discharge, the new facility noted the resident was not taking diuretic medication. Witness 10 stated two days after Resident 11 discharged from the facility Resident 11 was readmitted to the hospital for fluid overload which included fluid in her/his lungs. Attempts on 7/29/19 and 7/30/19 to reach Witness 12 (physician) were unsuccessful. On 7/25/19 at 1:20 PM Staff 16 (Regional RN) acknowledged Resident 11 admitted to the facility with an order for [REDACTED]. Staff 16 acknowledged the 6/26/19 Physician Visit Summary listed both the potassium and [MEDICATION NAME] medication, verified this type of medication list was considered a physician's orders [REDACTED]. Staff 16 acknowledged the [MEDICATION NAME] was not added to Resident 11's MAR and acknowledged the potassium and [MEDICATION NAME] medications needed to be clarified. Staff 16 acknowledged the resident's 13.6 pound weight gain from admission to discharge and stated she did not know what happened. 2. Resident 5 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. a. The 5/15/19 admission orders [REDACTED]. The (MONTH) 2019 MAR revealed the 5/15/19 8:00 PM dose of [MEDICATION NAME]was not administered per physician order [REDACTED]. On 7/23/19 at 10:58 Staff 2 (DNS) and Staff 15 (Regional RN) stated the 5/15/19 8:00 PM dose of [MEDICATION NAME]was not administered per physician order [REDACTED]. b. The 5/15/19 admission orders [REDACTED] Review of Resident 5's medical record revealed Resident 5 was placed on oxygen on 5/16/19 and remained on oxygen until her/his passing on 5/17/19. There was no order for oxygen in the medical record. On 7/23/19 at 8:57 AM Staff 5 (RNCM) stated Resident 5 received oxygen on 5/16/19 day shift, she did not notify the physician or obtain a physician order [REDACTED]. On 7/23/19 at 10:58 AM Staff 2 (DNS) and Staff 15 (Regional RN) verified after Resident 5 was placed on oxygen the expectation was to follow-up with the physician to request oxygen orders. Staff 15 acknowledged Resident 5 received oxygen without a physician order.

Based on interview and record review it was determined the facility failed to ensure pain interventions were provided in a timely manner for 1 of 1 sampled resident (#7) reviewed for pain management. This failure resulted in Resident 7's hospitalization for severe pain. Findings include: Resident 7 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. A 5/21/19 Pain Evaluation indicated Resident 7 had no observed or documented pain. The 5/2019 MAR indicated [REDACTED]. No nursing note was found in the resident's clinical record regarding the overnight shift from the evening of 5/21/19 to the morning of 5/22/19. A 5/22/19 nursing note written at 6:40 AM indicated Staff 28 (LPN) arrived for her shift and was called to Resident 7's room by another patient. The note indicated, (Resident 7) states (her/his) pain is uncontrollable and was crying and yelling. Pain medications were administered an hour prior. Repositioning and ice were also administered but were not helping for pain relief. (Resident 7) stated (she/he) wanted to go to the hospital. The resident was then transferred to the hospital. On 7/25/19 at 8:15 AM Resident 7 stated she/he was ignored completely at the facility. Resident 7 stated she/he was in pain and had medication available but could not get the staff's attention. Resident 7 stated she/he pushed the call light, yelled out and banged on things in the room but staff did not come and it continued all night long. Resident 7 stated she/he eventually did get medication but requested to go to the hospital because she/he was still in so much pain. Resident 7 stated her/his roommate got out of bed and went into the hallway to get staff's attention because no one came to check on the resident. On 7/25/19 at 8:49 AM Staff 28 stated when she arrived for the 5/22/19 shift Resident 7 was in pain and crying. Staff 28 stated Resident 7's roommate came out of the room and yelled down the hall for someone to assist Resident 7. On 7/25/19 at 12:18 PM Staff 27 (CNA) acknowledged she worked in Resident 7's area during the overnight shift from 5/21/19 to 5/22/19. Staff 27 stated she did not remember Resident 7. On 7/29/19 at 8:40 AM Staff 19 (LPN) acknowledged she was the charge nurse in Resident 7's area during the overnight shift from 5/21/19 to 5/22/19. Staff 19 stated she barely remembered Resident 7 and did not remember anything unusual that occurred on the identified night. On 7/29/19 at 10:16 AM Staff 16 (Regional RN) acknowledged Resident 7 experienced severe pain resulting in the resident's hospitalization on [DATE]. Staff 16 acknowledged there was no nursing note regarding the overnight shift from 5/21/19 to 5/22/19 and stated nurses were expected to document on each shift for the first three days of resident admissions. Refer to F725.

Based on observation, interview and record review it was determined the facility failed to ensure adequate staffing to provide quality nursing services in a timely manner for 2 of 2 resident floors reviewed for staffing. This failure resulted in Resident 7's hospitalization for severe pain and placed all residents at risk for negative outcomes related to lack of timely assistance. Findings include: a. Resident 7 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. admission orders [REDACTED]. The 5/2019 MAR indicated [REDACTED]. A 5/22/19 nursing note written at 6:40 AM indicated Staff 28 (LPN) arrived for her shift and was called to Resident 7's room by another patient. The note indicated, (Resident 7) states (her/his) pain is uncontrollable and was crying and yelling. Pain medications were administered an hour prior. Repositioning and ice were also administered but were not helping for pain relief. (Resident 7) stated (she/he) wanted to go to the hospital. The resident was then transferred to the hospital. On 7/25/19 at 8:15 AM Resident 7 stated she/he was ignored completely at the facility. Resident 7 stated she/he was in pain and had medication available but could not get the staff's attention. Resident 7 stated she/he pushed the call light, yelled out and banged on things in the room but staff did not come and it continued all night long. Resident 7 stated she/he eventually did get medication but requested to go to the hospital because she/he was still in so much pain. Resident 7 stated her/his roommate got out of bed and went into the hallway to get staff's attention because no one came to check on the resident. On 7/25/19 at 8:49 AM Staff 28 stated when she arrived for the 5/22/19 shift Resident 7 was in pain and crying. Staff 28 stated Resident 7's roommate came out of the room and yelled down the hall for someone to assist Resident 7. On 7/29/19 at 10:16 AM Staff 16 (Regional RN) acknowledged Resident 7 experienced severe pain which resulted in the resident's hospitalization on [DATE]. b. Observations of the second floor on 7/24/19 at 7:15 AM revealed six call lights on. The licensed nurses appeared rushed and no CNAs were observed. c. Observations of the first floor on 7/24/19 from 9:45 AM through 10:26 AM revealed residents in the hallway outside their room doors waiting for assistance from staff. The staff appeared hurried, as they rushed from room to room. Staff told residents they had to wait for assistance and they would return as soon as they could, stating, We're trying, we're trying. Staff were observed to walk by rooms with call lights on while on their way to assist residents who previously requested assistance, but the call light was already deactivated. Call lights were observed to be activated for greater than 15 minutes prior to residents receiving their first contact with staff. On 7/24/19 at 9:56 AM Resident 3 put her/his call light on and indicated she/he wanted assistance to get out of bed. The resident was observed to wait more than 30 minutes for assistance. On 7/24/19 at 10:04 AM Resident 59 asked staff to assist with her/his wet brief and staff stated they would get to her/him as soon as they could. Resident 59 stated her/his brief was soaked. Resident 59 stated this was the third staff member she/he asked for assistance and stated, It is like this all the time. d. Resident and witnesses from both floors of the facility reported the following: A 5/22/19 grievance indicated Resident 63 waited seven hours for assistance. On 7/11/19 at 11:47 PM Witness 11 (Complainant) stated the facility did not provide a sufficient number of staff for resident care and residents were improperly cared for and did receive incontinence care, repositioning assistance and showers. A 7/16/19 Customer Satisfaction Survey indicated Resident 65 strongly disagreed that her/his call light was answered in a timely manner. A 7/17/19 grievance indicated Resident 3 expressed a concern over call light wait times. On 7/22/19 at 8:22 AM Resident 16 stated she/he experienced incontinence as a result of waiting for staff assistance. On 7/22/19 at 8:35 AM Resident 23 stated she/he experienced incontinence as a result of waiting for staff assistance. On 7/22/19 at 9:03 AM Resident 28 stated she/he experienced incontinence as a result of waiting for staff assistance. On 7/24/19 at 9:45 AM Resident 3 stated staff did not respond in a timely manner when she/he activated the call light. On 7/25/19 at 10:20 AM Witness 10 (Family Member) stated her family member went three days without changing clothes and had incontinence as a result of insufficient staff. On 7/25/19 at 11:00 AM Resident 59 stated she/he waited 45 minutes for assistance the previous night and did not get showers as scheduled. On 7/25/19 at 11:03 AM Resident 24 stated she/he waited one and a half to two hours for assistance at night. e. Care Conference Records from 4/17/19 through 7/17/19 for Resident #s 3, 14, 17, 19, 22, 24, 32, 33, 38, 39, 41, 47, 48, 54 revealed concerns related to call light response time. f. The 5/30/19 Resident Council Meeting notes stated, Call light wait times are at an all time high, often as long as two hours, reported by four residents (on) both floors. The 6/27/19 Resident Council Meeting notes indicated a concern that staff ignored residents and call lights. The notes stated residents requested to get up and were told the staff can't get them up now. The 7/18/19 Resident Council Meeting notes indicated, Call lights continue to have long wait times with day shift being worse and indicated residents' care planned care and services were not provided. On 7/25/19 at 10:47 AM Resident 61 stated residents at the resident council meetings regularly complained about waiting too long for assistance from staff. Resident 61 stated the staffing complaints involved the entire building and all shifts. Resident 61 stated she/he thought the state agency dictated the number of staff the facility was able to provide. g. The following staff were interviewed from 7/22/19 through 7/29/19: Staff 4 (LPN Resident Care Manager), Staff 5 (RNCM), Staff 6 (LPN Resident Care Manager), Staff 17 (CNA), Staff 20 (LPN), Staff 21 (LPN), Staff 22 (CNA), Staff 23 (CNA), Staff 24 (LPN), Staff 25 (CNA), Staff 26 (CNA), Staff 27 (CNA), Staff 28 (LPN), Staff 31 (CNA), Staff 32 (CNA), Staff 33 (CNA), Staff 34 (LPN), Staff 35 (CNA), Staff 36 (CNA) and Staff 38 (CNA). Staff interviewed worked on both floors of the facility and reported the following: - There were 14 residents on the first floor South Hall who required two person assistance, including nine residents who used a mechanical lift for transfers, but there were only three staff working in that area during day shift. - Staffing numbers were determined by state minimum requirements and did not change based on resident acuity. The facility was poorly staffed and was not safe for residents. - Staff were regularly unable to take breaks due to being too busy. - Staff were too busy to read the residents' care plans. - Staff clocked out for breaks or at the end of their shift but continued to work in order to provide care to residents. - Due to insufficient staff, residents went without their care-planned assistance and CNAs regularly provided one person assistance when two-person assistance was care-planned. - Residents experienced outcomes related to insufficient staff including incontinence, delayed assistance, anger, unsafe transfers, lack of communication, falls and lack of hygiene and repositioning assistance. - It was normal for residents to wait more than 20 minutes for assistance, an hour for transfers or up to 1.5 hours for assistance during meal times. - Resident frequently complained of a lack of staffing and long waits for assistance. - There were times when staff could not find an aide to help assist residents. - Nursing staff did not have the opportunity to be involved in staffing decisions. - The facility did not replace staff who had to leave their shift early. - Staff reported staffing concerns to facility administration but were told that additional staff members were not available due to the budget. h. The 3/22/19 Facility Assessment indicated the facility had a high percentage of residents who required two person assistance. The assessment indicated the staffing for provision of ADL needs including transfers was sufficient. No information was found to indicate how the facility determined the staffing was sufficient other than the statement, the resident census determines the staffing ratios that are followed for each shift. i. On 7/24/19 at 2:22 PM Staff 9 (Staffing Coordinator) stated the facility was staffed to state minimum staffing ratios and the number of residents was equally divided by the number of staff on duty to determine how many residents each staff member was assigned. On 7/26/19 at 10:50 AM during an interview with Staff 1 (Administrator), Staff 15 (Regional RN) and Staff 16 (Regional RN), Staff 1 stated the facility was staffed according to the state minimum staffing ratios. Staff 1 acknowledged the facility administration was aware of long term concerns and complaints related to staffing. Staff 1 stated some teams within the facility functioned more efficiently than other teams. When asked how it was determined that the facility was staffed sufficiently, Staff 1 stated We pay attention. Staff 1 was asked to provide any additional information to support the determination that the facility was staffed sufficiently based on the needs of the residents, but no additional information was provided.

1. Based on observation, interview and record review it was determined the facility failed to provide supervision for swallowing safety for 2 of 18 residents (#s 56 and 73) identified at risk for aspiration and/or choking and who were to be supervised while eating. Resident 56 was hospitalized following a choking episode with decreased oxygen saturation levels. Resident 73 was observed to eat a restricted food item and was not supervised while she/he ate. This placed resident 73 at risk for aspiration and death. Findings include: There were 33 residents with pink Aspiration Precaution signs above the head of the bed. 18 residents were identified to need supervision when the residents ate. a. Resident 73 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/2/18 Aspiration Precautions sign posted above Resident 73's head of bed revealed the resident was on a mechanically altered diet (level two-only moist soft foods, regular food needs to be modified to make them easier to chew and swallow and breads were to be moistened), was to eat while sitting at a 90 degree angle (upright) and was to be supervised with meals. The 11/3/18 Speech Therapy Evaluation and Plan of Treatment indicated the resident was placed on Speech Therapy Services for dysphasia (difficulty swallowing) to assess and evaluate the least restrictive oral intake to minimize aspiration. The resident had mild clinical signs of dysphasia, grimaced when swallowing and the resident was changed from a regular texture diet to a soft diet. To facilitate safety and efficiency it was recommended the resident alternate liquids with solids and be in an upright posture for meals. The recommendation was to continue the recommended diet with aspiration precautions. On 11/7/18 at 2:41 PM Resident 73 was observed in her/his room. The resident's head of the bed was at a 45 degree angle and not a 90 degree angle. The resident was eating dry graham crackers. There were no staff supervising the resident to eat to ensure the resident did not aspirate. On 11/7/18 at 2:43 PM Staff 17 (CNA) indicated she just checked on Resident 73 and the resident was eating a snack. Staff 17 indicated she would need to look at the Aspiration Precaution sign to determine if the the resident required supervision while the resident ate. Staff 17 checked the sign and stated the resident was to be supervised when the resident ate food. On 11/7/18 at 2:45 PM Staff 16 (Speech Therapist) indicated Resident 73 required supervision when she/he ate and graham crackers were not included in a dysphasia level two diet. On 11/7/18 at 5:00 PM the facility was notified the failure to provide supervision for Resident 73 who was at risk for aspiration was determined to be an immediate jeopardy situation, following consultation with survey management. An acceptable plan to abate the immediate jeopardy situation was submitted to the survey team by the facility on 11/7/18 at 5:52 pm. The plan included: -Immediately: All resident care plans will be audited to assure care plans reflected appropriate diets and swallow precautions. All residents with swallow precautions had appropriate signs above their beds. -Education: All staff currently in the building will be educated prior to leaving their shift regarding pink swallow precaution signs, kardex and care plans. All oncoming staff will receive education prior to giving any resident care. This will include nursing and department managers. This education will be completed by the DNS or designee to ensure all staff received the in-service and answer any question they may have. -Ongoing Education: All new hires will receive swallow precaution training upon hire. There will also be ongoing education for all nursing staff and department managers regarding diet textures, fluids and swallow precautions no less often than quarterly. This education will be completed by the DNS or designee. -Audits: Resident Care Managers/DNS or designee will complete weekly audits to assure the pink slips are posted in appropriate resident rooms and random staff will be asked regarding our policy on swallow precautions. -Results of these audits will be reviewed monthly at Quality Assurance Performance Improvement for six months and quarterly at Quality Assurance for two quarters or until substantial compliance is met. On 11/7/18 at 6:00 PM the facility's implementation of the abatement plan was verified with staff interviews to ensure the staff were educated on aspiration precautions. On 11/16/18 at 6:00 PM the facility administrator was notified the immediate jeopardy was removed. b. Resident 56 was admitted to the facility 10/2018 with [DIAGNOSES REDACTED]. Care Plan dated 10/2/18 indicated Resident 56 was on a puree diet with thickened liquids for identified swallowing issues. She/he was to have one-on-one supervision during meals. An Incident report dated 10/17/18 indicated on 10/15/18 Resident 56 received a dinner tray in her/his room and was left unattended. Resident 56 began coughing during the meal. Resident 56 was placed on two liters of oxygen via nasal cannula as her/his saturation was fluctuating in the 70's. (Normal range is above 90%). Oxygen saturation remained low and the resident was sent to the hospital for evaluation and was diagnosed with [REDACTED]. The conclusion of the 10/17/18 facility incident report was Resident 56's care plan was not followed when she/he was left unsupervised with her/his meal. On 11/7/18 at 2:24 PM Staff 17 (CNA) was asked if she was aware of what the pink signs above resident beds meant. Staff 17 stated the signs indicated swallow precautions. Staff 17 stated there was no training regarding the signs even in orientation and stated, We figure it out for ourselves. On 11/7/18 at 2:41 PM Staff 31 (CNA) was asked if she was aware of what the pink signs above resident beds meant. Staff 31 knew the signs pertained to swallowing precautions and denied receiving training about the signs. She stated I just read it (the sign) then followed up with my nurse to make sure it was accurate. On 11/7/18 at 4:15 PM Staff 12 (RN) stated Resident 56 did not likely have the meal tray for long when she heard coughing and saw a call light on for the resident's roommate. Staff 12 confirmed the resident was not on oxygen prior to the incident and her concern was the resident's low oxygen saturation. 2. Based on observation interview and record review it was determined the facility failed to ensure a resident at risk for falls was supervised when in a wheelchair in her/his room and failed to ensure the fall investigation was accurate for 1 of 3 sampled residents (#55) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 55 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 7/9/18 admission CAAs indicated Resident 55 was at risk for falls related to impaired balance and impaired cognition. A Fall investigation indicated Resident 55 fell on [DATE]. The resident was found in her/his room on the floor. The resident attempted to transfer without assistance and fell . The resident was assisted back into her/his wheel chair. The Care Plan was updated on 7/8/18 after the 7/6/18 fall. The new intervention was for staff to ensure the resident was not left in her/his room in the wheelchair unsupervised. On 11/7/18 at 10:10 AM Resident 55 was observed in her/his room in a wheelchair. Staff were not in the resident's room. A treatment nurse was outside of the resident's room, her back was to the resident's room and then the staff left the area. On 11/7/18 at 10:16 AM Staff 5 (LPN Resident Care Manager) reviewed the care plan and acknowledged the resident was to be supervised when in the wheelchair in her/his room. b. A Fall investigation indicated on 10/31/18 at 7:00 PM Resident 55 was found on the floor on her/his back. The resident reported she/he attempted to transfer from the wheelchair to the armchair. The resident was assessed to have no injuries. The investigation revealed the resident had a history of [REDACTED]. The resident was last visualized 30 minutes before the fall and the resident was in her/his wheelchair. Abuse and neglect were ruled out and staff were not to leave the resident unsupervised in her/his room. On 11/7/18 at 10:16 AM Staff 5 (LPN Resident Care Manager) reviewed the care plan and acknowledged when the resident fell on [DATE] the resident was in her/his wheelchair and room unsupervised. The investigation did not address the fact the care plan was not followed.

Based on interview and record review it was determined the facility failed to ensure a resident was provided adequate supervision to ensure pain patches were properly disposed of to prevent excess medication use for 1 of 2 sampled residents (#1) reviewed for pain patch use. This put residents at risk for over medication. Resident 1 was found unresponsive and sent to the emergency room for evaluation and was admitted . Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A public complaint was received on 1/8/18 which indicated the resident was unresponsive on 1/3/18 and was transported to the hospital. The resident was found to have three pain patches on her/his body. The resident's physician orders [REDACTED]. The resident's (MONTH) (YEAR) and (MONTH) (YEAR) MARs contained no information on missing pain patches. The resident's (MONTH) (YEAR) through (MONTH) (YEAR) narcotic administration sheets reflected the appropriate order for Buprenorphine 15 mcg patch weekly. The narcotic flow sheets reflected the medication counts and staff signatures. The narcotic flow sheets contained no information regarding problems with pain patch disposal or missing pain patches. The (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. NNs for (MONTH) (YEAR) through (MONTH) (YEAR) showed no documentation regarding resident refusals to allow the old pain patch to be removed prior to application of a new pain patch. Additionally, there was no information regarding any missing pain patches as a result of the resident removing them. There was no documentation the physician was informed of ongoing problems with the resident allowing the nurses to remove the pain patch. A NN dated 1/1/18 at 1:27 pm indicated the resident refused to let the nurse remove the previous pain patch when the new pain patch was applied. The NN indicated the nurse returned a few hours later but could not find the old patch to remove it. The NN further indicated the physician was notified previously on (MONTH) 30, (YEAR) the resident would not allow the nurse to remove old patches right away and the physician stated to let the resident do what she/he wanted. The entire NN was crossed out and labeled as incomplete documentation. There were no additional NN on 1/1/18 regarding the resident's pain patch. A NN dated 1/3/18 at 10:55 am indicated the resident was found non-responsive at 7:00 am. The resident had mucus/vomiting present, very labored breathing, slightly elevated heart rate of 102 and was very hard to get the resident to respond to verbal cuing. 911 was called and the resident was transferred to the hospital at 7:30 am. A second note on 1/3/18 indicated the physician was talked with last month about the resident refusing to take off the old pain patch. A hospital discharge summary dated 1/9/18 indicated the resident had a history of [REDACTED]. The resident was found unresponsive, sent to the hospital for evaluation and found to have three pain patches on her/his body. The pain patches were removed and 1.0 mg of [MEDICATION NAME] (medication to treat narcotic overdose) was given. The resident became somewhat more alert with garbled speech. The resident was treated in the ICU for acute and chronic [MEDICAL CONDITION]. The resident was noted to have had similar presentations in the past. The resident continued to receive [MEDICAL TREATMENT] treatments and cognition improved likely due to narcotic overuse. The resident was discharged back to the nursing facility on 1/9/18. The resident's Kardex (CNA care plan) dated 1/9/18 indicated the resident had increased auditory and visual hallucinations leading to refusal of care and [MEDICAL TREATMENT]. Staff were to approach the resident calmly and unhurriedly, not engage in arguments with the resident, keep personal belongings organized, fax all concerns about the resident refusals and resistance to care to the physician and reapproach if the resident became hostile. The resident has a history of substance abuse per the resident's family and medical record. The resident was an independent [MEDICATION NAME] outside the facility and was to be reminded of the expectations regarding leaving the facility. A comprehensive care plan review dated 2/5/18 indicated the resident was alert and oriented to person, place, time and situation. The resident was resistive to care and medication regimen. The resident wanted to do all things her/his way and made needs known. The resident could be condescending towards staff when not getting her/his own way. The resident had significant mental health concerns but frequently refused to answer questions as she/he believed it was none of the staffs' business. Interview on 3/8/18 at 11:15 am Staff 8 (LPN) indicated the resident frequently refused to let her remove the previous pain patch before applying the new pain patch. Staff 8 stated normally the proper procedure for application of a pain patch was to remove the old patch, check the area, apply new pain patch and dispose of the old patch into the sharps container. Staff 8 placed the new patch then returned in roughly an hour to remove the old pain patch but it was gone. Staff 8 could not find it anywhere in the room and the resident would not let her/him search personal belongings or on her/his person. Staff 8 stated she never reported the problem with patch removal to the physician but she knew the physician was aware from other staff. Staff 8 did not report the missing patch to the RNCM or DNS, she was not sure why she did not document the information in the chart at the time of the occurrences. Staff 8 no longer applied the new pain patch until the old pain patch was removed. Interview on 3/8/18 at 1:02 pm Staff 7 (LPN) indicated she only dealt with the resident's pain patch a few times. The first time she went to change the resident's pain patch was several months ago and the resident asked her to put the new patch on first. Staff 7 was unaware of any problem with the resident and the pain patch so Staff 7 put on the new pain patch. The resident then would not allow her to remove the old patch. When she went back to remove the patch a few hours later the old patch was gone and she was unable to find it in the resident's room or visible on the resident. Staff 7 went to report the information to the RNCM and found the resident's physician in the process. Staff 7 explained the issue and was told by Witness 1 (physician) to let the resident do as she/he wanted. Staff 7 did not document the information discussed with the physician at that time. When Resident 1 was sent to the hospital in (MONTH) an investigation was initiated and she was asked to document what she knew. Staff 7 stated the normal procedure was to remove the old patch and then apply the new patch. Resident 1's new pain patch was no longer placed prior to the removal of the old patch. Interview on 3/8/18 at 11:30 am Staff 3 (RNCM) indicated the resident was very non-compliant with care, refused medications, treatments and [MEDICAL TREATMENT]. The resident was alert, oriented and directed her/his own care. The resident understood what was explained to her/him but chose her/his own actions. Staff 3 stated Staff 8 came to her sometime in (MONTH) because the resident was not allowing the old pain patch to be removed. Staff 3 advised Staff 8 it was not okay to place a new patch without the removal of the old pain patch first. Staff 3 told Staff 8 to inform the physician about the problem with the resident and the pain patch. Staff 3 never heard any additional information regarding the issue and saw no charting to cause her to believe it was an ongoing problem. Staff 3 was made aware of the ongoing problem with the pain patches and patches being gone when staff returned for removal, after the resident was sent to the hospital in (MONTH) (YEAR). The resident had a history of [REDACTED]. Interview on 3/8/18 at 10:11 am Witness 1 (Physician) indicated the resident could be very difficult and frequently refused care including [MEDICAL TREATMENT]. She was not made aware of the the resident refusing the removal of the old pain patches until after the resident was sent to the hospital in January. Witness 1 indicated the facility attempted to document after the fact and referenced supposed conversations. Witness 1 stated this type of issue would not be a casual conversation at the nurses station but should have fax communication, order documentation and any decisions should be documented at the time it was discussed not months later. Witness 1 further stated she would not okay the resident to control the pain patch use, the resident cannot dictate narcotic use in this manner. Witness 1 indicated she expected to be notified each time there was a problem with the patch and she was not notified until the resident was hospitalized . Witness 1 further stated a new pain patch should not be placed before the old patch was removed. Interview on 3/8/18 at 10:45 am Staff 2 (DNS) indicated all pain patches should be signed and dated when they are changed. The old pain patch should be removed, skin inspected and then new pain patch placed in a different location than the last patch. A new pain patch should not be put in place while the old patch was still on the resident; the medication would still be active in the patch as well as in the resident's system. Staff 2 stated if the old pain patch was not found on the resident's body then the staff must follow up, document the issue and try to determine where the old patch went. Staff 2 stated patches sometimes fall off but follow up must be made to try and determine what happened and staff must inform either the RNCM or herself if the pain patch could not be located. Staff 2 was not working at the facility at the time of the resident's incident.

Based on interview and record review it was determined the facility failed to ensure a resident was provided adequate supervision to ensure pain patches were properly disposed of to prevent excess medication use for 1 of 2 sampled residents (#1) reviewed for pain patch use. This put residents at risk for over medication. Resident 1 was found unresponsive, discovered to have three pain patches on her/his body and was admitted to the hospital. Findings include: The facility's policy and procedure for administering topical medications indicated for [MEDICATION NAME]es: clean and dry a selected area that is approved for application of the patch. Rotate sites with each new application if possible. Remove the old patch, remove wrapper from the patch and do not touch the adhesive surface, apply to the skin pressing firmly for approximately 10 seconds, remove gloves and wash/dry hands thoroughly. The facility's designated pharmacy's policy and procedure for [MEDICATION NAME] application indicated to identify the location on the body for patch placement, remove old patch from the body folding it into itself and disposing appropriately, cleanse area of old patch with alcohol wipe, remove new patch from package and envelope, label patch with date and nurse's initials, choose a clean dry area to apply the new patch, remove the patch from its protective covering and immediately apply patch pressing firmly. Staff were to cleanse hands and document placement site on the MAR indicated [REDACTED] Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A public complaint was received on 1/8/18 which indicated the resident was unresponsive on 1/3/18 and was transported to the hospital. The resident was found to have three pain patches on her/his body. The resident's physician orders [REDACTED]. The resident's (MONTH) (YEAR) and (MONTH) (YEAR) MARs contained no information on missing pain patches. The resident's (MONTH) (YEAR) through (MONTH) (YEAR) narcotic administration sheets reflected the appropriate order for Buprenorphine 15 mcg patch weekly. The narcotic flow sheets reflected the medication counts and staff signatures. The narcotic flow sheets contained no information regarding problems with pain patch disposal or missing pain patches. The (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. NNs for (MONTH) (YEAR) through (MONTH) (YEAR) showed no documentation regarding resident refusals to allow the old pain patch to be removed prior to application of a new pain patch. Additionally, there was no information regarding any missing pain patches as a result of the resident removing them. There was no documentation the physician was informed of ongoing problems with the resident allowing the nurses to remove the old pain patch when the new pain patch was placed. A NN dated 1/1/18 at 1:27 indicated the resident refused to let the nurse remove the previous pain patch when the new pain patch was applied. The NN indicated the nurse returned a few hours later but could not find the old patch to remove. The NN further indicated the physician was notified previously on (MONTH) 30, (YEAR) the resident would not allow the nurse to remove old patches right away and the physician stated to let the resident do what she/he wanted. The entire NN was crossed out and labeled as incomplete documentation. There were no additional NN on 1/1/18 regarding the resident's pain patch. A NN dated 1/3/18 at 10:55 am indicated the resident was found non-responsive at 7:00 am. The resident had mucus/vomiting present, very labored breathing, slightly elevated heart rate of 102 and was very hard to get the resident to respond to verbal cuing. 911 was called and the resident was transferred to the hospital at 7:30 am. A second note on 1/3/18 indicated the physician was talked with last month about the resident refusing to take off the old pain patch. A hospital discharge summary dated 1/9/18 indicated the resident had a history of [REDACTED]. The resident was found unresponsive, sent to the hospital for evaluation and found to have three pain patches on her/his body. The pain patches were removed and 1.0 mg of [MEDICATION NAME] (medication to treat narcotic overdose) was given. The resident became somewhat more alert with garbled speech. The resident was treated in the ICU for acute/chronic [MEDICAL CONDITION]. The resident was noted to have had similar presentations in the past. The resident continued to receive [MEDICAL TREATMENT] treatments and cognition improved likely due to narcotic overuse. The resident was discharged back to the nursing facility on 1/9/18. Interview on 3/8/18 at 11:15 am Staff 8 (LPN) indicated the resident frequently refused to let her remove the previous pain patch before applying the new pain patch. Staff 8 stated normally the proper procedure for application of a pain patch was to remove the old patch, check the area, apply new pain patch and dispose of the old patch into the sharps container. Staff 8 placed the new patch then returned in roughly an hour to remove the old pain patch but it was gone. Staff 8 could not find it anywhere in the room and the resident would not let her/him search personal belongings or on her/his person. Staff 8 stated she never reported the problem with patch removal to the physician but she knew the physician was aware from other staff. Staff 8 did not report the missing patch to the RNCM or DNS, not sure why she did not document the information in the chart at the time of the occurrences. Staff 8 no longer applied the new pain patch until the old pain patch was removed. Interview on 3/8/18 at 1:02 pm Staff 7 (LPN) indicated she only dealt with the residents pain patch a few times. The first time she went to change the resident's pain patch was several months ago and the resident asked her to put the new patch on first. Staff 7 was unaware of any problem with the resident and the pain patch so Staff 7 administered the new pain patch. The resident then would not allow her to remove the old patch. When she went back to remove the patch a few hours later the old patch was gone and she was unable to find it in the resident's room or visible on the resident. Staff 7 went to report the information to the RNCM and found the resident's physician in the process. Staff 7 explained the issue and was told by Witness 1 (Physician) to let the resident do as she/he wanted. Staff 7 did not document the information discussed with the physician at that time. When Resident 1 was sent to the hospital in (MONTH) an investigation was initiated and she was asked to document what she knew. Resident 1's new pain patch was no longer placed prior to the removal of the old patch. Interview on 3/8/18 at 11:30 am Staff 3 (RNCM) indicated the resident was very non-compliant with care, refused medications, treatments and [MEDICAL TREATMENT]. The resident was alert, oriented and directed her/his own care. The resident understood what was explained to her/him but chose her/his own actions. Staff 3 stated Staff 8 came to her sometime in (MONTH) because the resident was not allowing the old patch to be removed. Staff 3 advised Staff 8 it was not okay to place a new patch without the removal of the old pain patch. Staff 3 told Staff 8 to inform the physician about the problem with the resident and the pain patch. Staff 3 never heard any additional information regarding the issue and saw no charting to cause her to believe it was an ongoing problem. Staff 3 was made aware of the ongoing problem with the pain patches and patches being gone when staff returned for removal, after the resident was sent to the hospital in (MONTH) (YEAR). The resident had a history of [REDACTED]. The resident would travel independently out of the facility including to her/his appointments and was unwilling to provide information about what she/he had done or where the resident went. Interview on 3/8/18 at 10:11 am Witness 1 (Physician) indicated the resident could be very difficult and frequently refused care including [MEDICAL TREATMENT]. She was not made aware of the the resident refusing the removal of the old pain patches until after the resident was sent to the hospital in January. Witness 1 indicated the facility attempted to document after the fact and referenced supposed conversations. Witness 1 stated this type of issue would not be a casual conversation at the nurses station but should have fax communication, order documentation and any decisions should be documented at the time it was discussed not months later. Witness 1 further stated she would not okay the resident to control the pain patch use, the resident cannot dictate the narcotic use in this manner. Witness 1 indicated she expected to be notified each time there was a problem with the patch and she was not notified until the resident was hospitalized . Witness 1 further stated a new pain patch should not be placed before the old patch was removed. Witness 1 stated the resident was very compromised and it would be difficult to say the patches caused the unresponsive episode but it was certainly a factor in the resident's decline. Witness 2 (Pharmacist) indicated there have been no studies regarding the amount of medication left in the patch at the end of the seven day cycle; there would be some medication but should not be much. Witness 2 stated if the patch was removed and reapplied it would not affect the medication that was left, the patch would deliver whatever medication was left the same as if it had stayed in contact with the skin. The only variance would be if the patch was off for a very extended period it would likely lessen. Witness 2 stated the medication decreased approximately every 24-36 hours when the patch was left in place. The resident's health and tolerance were factors in how their body disperses the medications. Witness 2 contacted the manufacturer regarding the medication and it was confirmed there were no definitive studies on how much medication was left in the Buprenorphine patch at the seven day mark; there was residual medication left in the patch so keeping the patch on and applying another patch was a potential safety concern. He was advised for the medication to be 100% out of the patients system, regardless of the individual variance between patients, it would take 21 days with no patches in place. Interview on 3/8/18 at 10:45 am Staff 2 (DNS) indicated a new pain patch should not be in place while the old patch was still on the resident as medication was still active in the patch as well as in the resident's system. Staff 2 was not working at the facility at the time of the resident's incident.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#2) who had a [MEDICAL CONDITION] (trach). As a result, Resident 2's [MEDICAL CONDITION] occluded and the resident was hospitalized . Findings include: Resident 2 was admitted to the facility in June 2015 with [DIAGNOSES REDACTED]. The hospital transfer orders identified the resident had a Shirely #4 [MEDICAL CONDITION] included an order to keep [MEDICAL CONDITION] at the resident's bedside. The transfer orders indicated the resident was sent to the facility with supplies which included [MEDICAL CONDITION] and 30 inner cannulas. On 1/21/16 at 9:56 am a progress note identified Resident 2's inner cannula to [MEDICAL CONDITION] missing. The note indicated the facility would order new inner cannulas for the resident. On 1/23/16 a Physician's Telephone Order identified the Physician ordered the facility to call either the ENT (ear, nose, throat) Clinic or the [MEDICAL CONDITION] Clinic to replace the resident's trach. On 1/27/16 at 9:52 am a progress note indicated Resident 2's inner cannula was replaced. The resident'[MEDICAL CONDITION] without an inner cannula for six days. On 6/27/16 a Physician note identified an order to change Resident 2'[MEDICAL CONDITION] a(NAME)#4, cuffed trach. The order was noted by the RCM on 8/17/16. There was no evidence in the resident's record that Resident 2'[MEDICAL CONDITION] was replaced as ordered by the Physicians on 1/23/16 and on 6/27/16. The resident was sent out to the hospital on [DATE] related to acute respiratory distress and did not return to the facility. On 7/17/16 a hospital Admission History and Physical indicated the resident had a cuffless [MEDICAL CONDITION] that had been in place 1 1/2 years since it was first placed after the resident's stroke. On 7/17/16 Resident 2's [MEDICAL CONDITION] had a large amount of purulent material coming out from around the [MEDICAL CONDITION] and the [MEDICAL CONDITION] itself appeared occluded with rock-like calcified material encasing [MEDICAL CONDITION] and occluding the end. The resident had [DIAGNOSES REDACTED]. In interview on 10/10/16 at 5:05 pm Witness 4 (Pulmonologist) reported tracheotomies should be changed every three to six months. The witness stated Resident 2 was hosptalized on [DATE] for respiratory distress due to [MEDICAL CONDITION] obstruction related to encrustation. Witness 4 reported Resident 2'[MEDICAL CONDITION] in place for 1 1/2 years and if it would have been changed, encrustation would have been less likely. In interview on 10/26/16 at 10:54 am Staff 1 (Administrator) confirmed there was no evidence physician's orders [REDACTED].

Based on interview and record review it was determined the facility failed to provide care and services to prevent the worsening of a pressure ulcer for 1 of 3 sampled residents (# 105) with pressure ulcers of the 4 residents identified with pressure ulcers. The resident experienced a worsening of a pressure ulcer from a Stage 2 to a Stage 3 five days after admission to the facility. Findings include: Resident 105 was admitted to the facility on [DATE] (and discharged in July 2012) with [DIAGNOSES REDACTED]. Hospital Routine Nursing Facility admission orders skin issue" on the buttocks. Facility NN dated 4/28/12 at 4:30 pm indicated the resident had a Stage 2 pressure ulcer on the coccyx. (A Stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister.) The Patient Nursing Evaluation dated 4/28/12 indicated the resident had a pressure ulcer on the coccyx but included no further assessment. NN dated 4/29/12 indicated staff removed the dressing from the resident's pressure ulcer and documented "open area .5 cm circle st II (Stage 2). wound bed pink." NN from 4/29/12 night shift through 5/6/12 did not mention the resident's pressure ulcer. The Interim Plan of Care dated 4/29/12 indicated the resident had impairment of the skin integrity and interventions included "treatments as ordered." Review of the clinical record revealed no physician's orders for treatment of [REDACTED]. The Pressure Ulcers CAA dated 5/7/12 revealed the resident was at risk for pressure ulcers due to a current pressure ulcer and needing "total assist with bed mobility." The Pressure Ulcer Interdisciplinary Care Plan dated 5/7/12 revealed the resident was admitted with a 0.5 cm Stage 2 pressure ulcer on the coccyx. Interventions included "Complete Skin Condition check at 24 hrs, 48 hrs and 72 hrs after admission" and "Follow MD Orders for skin care and treatments." Review of the April 2012 TAR revealed no documentation of treatment or dressing of the resident's pressure ulcer. Review of the May 2012 TAR revealed an order dated 5/6/12 to apply Baza (a moisture barrier, antifungal cream) to the area. Review of the Weekly Pressure Ulcer Report dated 5/3/12 revealed the resident had a Stage 3 pressure ulcer on the coccyx that measured 1.2 cm by 1 cm. (A Stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling.) "[MEDICATION NAME] (moisture barrier cream) tx (therapy) effective in treating wound." On 10/2/12 at 11:07 am Staff 13 (MDS Coordinator/Former RNCM) was asked to provide documentation facility staff provided care for the resident's pressure ulcer between admission on 4/28/12 and 5/3/12 that would indicate the increase in size and severity of the wound was unavoidable. At 12:02 pm Staff 13 acknowledged there were no physician's orders, including standing orders, for treatment until 5/6/12. Staff 13 stated staff were to get physician orders for all treatments. On 10/2/12 at 12:40 pm Staff 1 (Administrator) and Staff 2 (DNS) were asked to provide evidence staff: completed and documented a thorough assessment; contacted the physician for treatment and dressing orders; and provided care to prevent a worsening of the resident's pressure ulcer from a Stage 2 to a Stage 3 five days after admit. At 2:37 pm Staff 2 confirmed there was no evidence.

Based on interview and record review it was determined the facility failed to comprehensively assess 2 sampled residents (#s 46 and 63) for [MEDICAL TREATMENT] and use of a catheter, and failed to assess pain for 1 sampled resident (#46) for 5 of 22 assessments reviewed. Resident 46 experienced severe pain. Findings include: 1. Resident 46 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. a. Review of a Pain Care Area Assessment (CAA) dated 6/1/11 indicated the resident had pain which affected the resident's sleep and activities. The assessment indicated the resident had recent surgery and a fractured left arm. The resident was able to verbalize pain and the need for pain management. The resident would wake up due to pain and PRN pain medication would allow resident to get back to sleep. The pain assessment did not indicate the characteristics of the resident pain, contributing factors or conditions affecting the resident's pain, history of pain, interventions past and present used to manage the resident's pain and the effectiveness of the interventions. In an interview on 6/28/11 at 3:56 pm Staff 2 (RNCM) acknowledged the pain assessment did not include characteristics of the resident's pain, contributing factors, pain history and current pain management effectiveness. Refer to F-309 b. Review of an Urinary Incontinence CAA dated 6/1/11 indicated Resident 46 went to [MEDICAL TREATMENT] three times a week at an outside facility. The resident had a right intra-jugular tunneled catheter and had refused at times to go to [MEDICAL TREATMENT]. The CAA assessment did not include vital sign status such as blood pressure history, psychosocial needs related to [MEDICAL TREATMENT] and potential risk factors or complications due to the resident's [MEDICAL CONDITION]. Complications could include bleeding, altered fluid volume, nutrition or blood sugars fluctuation and the potential for infection. In an interview on 6/28/11 at 3:56 pm Staff 2 (RNCM) acknowledged the resident's Urinary CAA should have included the location of the resident's [MEDICAL TREATMENT] catheter site and possible risk factors or complications such as bleeding and infection. 2. Resident 63 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. a. The ADL CAA dated 5/27/11 revealed the resident was totally dependent with most care due to dementia and decreased mobility. The CAA did not indicate the resident had an indwelling urinary catheter related to a [DIAGNOSES REDACTED]. On 6/28/11 at 9:00 am Staff 2 (RNCM) acknowledged the resident had an indwelling catheter which could be a contributing factor or potential limitation to the resident's ADLs. b. Review of an Urinary Incontinence and Indwelling catheter CAA dated 5/27/11 revealed the resident required assistance with toileting and had an indwelling catheter related to the [DIAGNOSES REDACTED]. Fluid intake and hydration status and contributing factors related to recurring or chronic urinary tract infections (UTIs) were not addressed. On 6/28/11 at 9:00 am Staff 2 acknowledged the Urinary CAA did not contain a clinical rationale for use of a catheter, address possible complications, such as UTIs, or the resident's hydration status.

Based on interview and record review it was determined the facility failed to provide care and services for pain management and to care plan for emergency [MEDICAL TREATMENT] care for 1 of 1 sampled residents reviewed for [MEDICAL TREATMENT] (#46). Resident 46 experienced unrelieved pain. Findings include: 1. Resident 46 was readmitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a Nursing Facility Transfer Discharge Medications form dated 5/19/11 indicated the resident was to receive Tylenol every four hours PRN for pain. Review of an Alert Charting form dated 5/19/11 indicated the resident's problems included "Admit." The form did not indicate the resident had any problems with pain or list any immediate interventions to control pain. Review of an initial nursing assessment dated [DATE] indicated the resident was alert and oriented and was able to follow commands. The assessment indicated the resident's current medications did not include pain medication. Review of an unsigned, undated Pain Assessment indicated the resident verbalized pain in the left arm which was "con't (continuous) all the time" and was rated an 8 on a pain scale of 1 to 10. The pain was described as an "ache" and "throbbing" and the resident expressed non-verbal pain in the form of grimacing and grunting. The assessment indicated the resident's pain was due to a "broken arm" and the pain increased with "movement." The resident's acceptable pain level was noted as a 4 out of 10. The assessment indicated the resident was not on scheduled pain medication and was to receive PRN medication in the form of Tylenol. The assessment indicated the resident's pain medications were effective. The admission NN dated 5/19/11 at 6:15 pm indicated the resident complained of left arm pain. A Pain Monitoring Flowsheet (PMF) dated 5/19/11 at 11:00 pm indicated the resident had pain rated 10 out of 10 and the resident stated "I've been here for 3 wks (weeks) and I'm still hurting." The form indicated the resident was given Tylenol with minimal results and the resident was restless. NNs dated 5/20/11 indicated the resident was found "crawling OOB (out of bed) at onset of shift. Yelling that he/she doesn't belong here - that we cannot meet his/her pain needs." The note indicated the resident complained of upper extremity pain and was given Tylenol. NNs dated 5/21/11 at 9:00 pm indicated "Res (resident) very demanding wants [MEDICATION NAME] wants to leave." NNs dated 5/22/11 at 10:00 pm indicated the resident was requesting Tylenol PM for sleep and was given Tylenol 650 mg. "Res aware there is no order for Tyl (Tylenol) PM." A PMF dated 5/22/11 at 10:15 pm indicated the resident had pain rated at 8 out of 10 and was given Tylenol. The form did not indicate the effectiveness of the medication. NNs dated 5/23/11 at 8:00 pm indicated the resident had returned to the facility after several doctors appointments. The resident's physician inquired about the resident's narcotic use. The note indicated a phone call was placed to the resident's physician who was informed of the resident's complaints of pain and the discontinuation of the resident's narcotic pain medications during the resident's last hospitalization . The resident's physician would follow up in the morning. A PMF dated 5/24/11 at 2:00 am indicated the resident had pain rated at 8-9 out of 10, was grimacing and complained of general overall discomfort. The resident was given Tylenol which decreased the resident's pain. NN dated 5/24/11 indicated a call was placed to the resident's physician requesting pain medication for the resident prior to [MEDICAL TREATMENT] on 5/25/11. The resident complained of having arm pain and the facility needed to call the resident's physician to get a prescription for pain medication. The note also indicated the resident's physician was out until tomorrow and the on call physician would not prescribe narcotics. "Furthermore res (resident) stated, when he/she got back from [MEDICAL TREATMENT], that he/she did not want to do any more [MEDICAL TREATMENT]. Pain med or no pain med." NNs dated 5/25/11 at 10:20 am indicated a call was placed to the resident's physician with information that the resident refused to go to [MEDICAL TREATMENT] and was refusing scheduled medications. The resident's physician was asked for an order for [REDACTED]. NNs dated 5/25/11 at 5:30 pm indicated a physician's orders [REDACTED]. On 5/27/11 the facility received a physician's orders [REDACTED]. A PMF dated 5/25/11 through 5/30/11 indicated the resident complained of pain, which was rated between 7-10 out of 10, on 11 occasions. There was no documentation of effectiveness of the pain medication given to the resident on 7 of the 11 occasions. The resident's care plan dated 5/31/11 indicated the resident had frequent chronic, acute and breakthrough pain which was mild, moderate, severe and very severe. Interventions were to administer [MEDICATION NAME] as ordered, notify the resident's physician if pain not adequately relieved with current regimen, monitor for effectiveness and possible side effects. A Pain CAA dated 6/1/11 indicated the resident had pain which affected sleep and activities. The resident had a recent surgery and a left arm fracture. The CAA indicated the resident was able to verbalize pain and the need for pain management. The resident would wake up from sleep due to pain but would be able to get back to sleep after receiving pain medication. The June 2011 MAR indicated [REDACTED]. Documentation on the effectiveness of the pain medication could be located for 8 occasions. In an interview on 6/28/11 at 3:56 pm Staff 2 (RNCM) stated the resident was not on narcotic pain medication when admitted to the facility and narcotic pain medication was added later due to the resident's "severe pain." Staff 2 said that the resident received a physician's orders [REDACTED]. Staff 2 acknowledged the resident's pain management was not re-evaluated after admission and did not know why it took so long for the resident to receive narcotic pain medication. 2. An Alert Charting form dated 5/19/11 indicated the resident's problems included "Admit." The form did not indicate the resident had a [MEDICAL TREATMENT] catheter, the location of the catheter or emergency interventions in case of bleeding. An initial nursing assessment dated [DATE] indicated the resident had a [DIAGNOSES REDACTED]. The assessment did not indicate the location or appearance of the residents [MEDICAL TREATMENT] catheter site. The care plan dated 5/31/11 indicated the resident had [MEDICAL CONDITION] and was on [MEDICAL TREATMENT]. The care plan indicated the resident's [MEDICAL TREATMENT] catheter was in the right arm. The care plan did not indicate any emergency [MEDICAL TREATMENT] catheter care in the case of bleeding or infection. The Urinary CAA dated 6/1/11 indicated resident went to [MEDICAL TREATMENT] three times a week to an outside facility. Resident 46 had a right intra-jugular tunneled [MEDICAL TREATMENT] catheter. The CAA assessment did not include potential risk factors or complications such as bleeding or infection or emergency procedures in case of catheter failure. In an interview on 6/28/11 at 3:56 pm Staff 2 (RNCM) indicated the resident's initial nursing assessment should have included the location and type of catheter, signs of infection, any discomfort and days of [MEDICAL TREATMENT]. Staff 2 acknowledged the assessment and care plan did not include possible risk factors, complications or emergency procedures in case of bleeding or infection.

Based on observation, interview and record review it was determined the facility failed to maintain nutritional status for 1 of 4 sampled residents (#55) reviewed for weight loss. Resident 55 experienced severe weight loss. Findings include: Resident 55 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. The facility's Diet History/Food Preferences Policy dated 1/9/06 indicated a diet history and food preference form would be completed for each resident within 72 hours of admission to ensure residents would receive food according to past habits and preferences. The December 2010 MDS indicated Resident 55 was 69 inches tall and weighed 203 pounds. Resident 55 was on a therapeutic diabetic diet and had no problems with chewing or swallowing. His daily preferences interview indicated it was very important to have snacks available between meals. On 6/23/11 at 1:00 pm, Resident 55 stated his lunch was good and he liked breakfast but "they keep serving me a whole plate of beans at night and I do not like beans." On 6/24/11 at 10:15 am, Staff 4 (Dietary Manager) stated she was unable to locate a dietary history and food preference form for Resident 55. Staff 4 stated the Resident Council had chosen a southern menu for the current time period and was aware that it frequently included beans. Staff 4 stated she was aware that some residents did not like the menu. The Medical Nutrition Therapy Review assessment dated [DATE] indicated a weight loss of 6.7% over the past 6 months and a 3% weight loss during the current month. Staff 3 Registered Dietician, (RD) reported weight trending downwards but "was not concerned as the resident remained 118% of ideal body weight (IBW)." Staff 3 indicated in her notes that the resident's intake at lunch and dinner was only fair and that meal replacements were to be offered. The Medical Nutrition Therapy Review assessment dated [DATE] reflected meal intake and weight loss for Resident 55. The resident lost eight pounds between April and May 2011. The May 2011 meal intake record indicated Resident 55's intake for dinner was less than 50% for 18 of 31 days and had blanks recorded for 7 evening meals. The meal monitor for May 2011 did not indicate if an alternate meal or snack was offered to Resident 55 when he refused or ate less than 50% of his meal. The Medical Nutrition Therapy Review Assessment did not reflect these issues and no new interventions were put in place to prevent further weight loss. Resident 55's meal intake records for May and June 2011 continued to show multiple lapses in recording meals, many meals at less than 50% completed and no alternates or snacks were shown to be offered to the resident. On 6/24/11 at 11:15 am this information was shared with Staff 8 (DNS) and no further information was provided. On 6/28/11 at 10:00 am, Staff 3 (RD) stated that errors had been made in the 5/17/11 Nutritional Therapy Assessment for Resident 55 and incorrect weights had been used. Staff 3 indicated Resident 55 was reweighed on 6/28/11 and currently weighed 169 pounds. This reflected a weight loss of 14.9% in the past 6 months. From December 2010 to July 2011 Resident 55 had lost a total of 34 pounds. This drop in weight indicated a severe weight loss for Resident 55. On 6/28/11 at 4:15 pm, Staff 9 (CNA) stated Resident 55 was eating better this month. She stated if a resident did not eat a meal the CNA should notify the nurse. She stated that the meal monitor documentation had not been thoroughly completed for Resident 55 and staff would document a resident meal intake "when they could find the time."