Every finding on record at Clatsop Care Center

Based on interview and record review it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. This placed residents at risk for lack of timely written communications. Findings include:The Facility's Resident Right to Privacy in Communication Policy, dated 1/1/26, stated the facility would ensure each resident received any mail addressed to that resident promptly, defined as delivery within 24 hours of delivery by the postal service. On 1/28/26 at 1:45 PM during the Resident Council group interview, residents stated their mail was not delivered on Saturdays. Resident 9 stated she/he complained to facility staff three times about not receiving mail on Saturdays and was told no staff worked on the weekends who delivered mail. Resident 9 stated this was very frustrating. Resident 27 agreed with Resident 9's statement, and Resident 4 nodded her/his head in agreement. Resident 25 stated she/he made sure not to have any deliveries for Saturdays due to the lack of mail delivery. On 1/28/26 at 4:10 PM, Staff 9 (CNA) stated she was responsible for delivering resident mail. Staff 9 stated she worked Monday through Friday, and any resident mail received over the weekend was placed in a locked office. Staff 9 stated when she arrived at work on Mondays, the mail was delivered to residents. On 1/29/26 at 9:30 AM, Staff 1 (Administrator) was informed of residents' concerns regarding not receiving mail on Saturdays. Staff 1 acknowledged the facility did not have a system in place to ensure residents received timely written communication.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident with a history of trauma received trauma informed care for 1 of 1 sampled resident (#6) reviewed for mood and behavior. This placed residents at risk for re-traumatization. Findings include:The facility's Trauma Informed Care Policy dated 1/1/26 indicated:-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social/history assessment, and others.-The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plans. Resident 6 was admitted to the facility in 8/2024 with diagnoses including PTSD (Post-Traumatic Stress Disorder) and depression.Resident 6's 11/6/25 Quarterly MDS indicated the resident was cognitively intact.Resident 6's 8/5/24 Social Services & Initial Assessment indicated Resident 6 had a diagnosis of depression; however, there was no mention of the resident's documented PTSD or related triggers.No evidence was found in Resident 6's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers. Record review revealed Resident 6 had an open PTSD claim with the Veterans Administration (disability compensation application in review process), which was discussed during the care conference on 8/7/25.On 1/28/26 at 8:57 AM Resident 6 was observed in her/his room. Resident 6 stated the facility had not asked her/him about any triggers she/he had. Resident 6 stated she/he had experienced nightmares in the past and seeing news coverage related to the U.S. Coast Guard triggered distressing memories. Resident 6 further stated the facility had not discussed or assessed these triggers with her/him.On 1/29/26 at 9:47 AM Staff 7 (CNA) stated she did not know if Resident 6 had a diagnosis of PTSD. Staff 7 reviewed the resident's Kardex (quick-reference bedside care plan), PTSD or trauma-related triggers were not listed. Staff 7 further stated Resident 6 would become upset when her/his requests were not met, would refuse cares and would yell at staff. Staff 7 was unable to identify any trauma-related triggers or interventions in place to address these behaviors.On 1/29/26 at 9:55 AM Staff 8 (CNA) stated she did not know Resident 6 had a diagnosis of PTSD. Staff 8 reviewed the resident's Kardex, PTSD or trauma-related triggers were not addressed. Staff 8 stated when Resident 6 became upset she/he would yell at staff. Staff 8 was unable to identify any trauma-related triggers or interventions in place.On 1/29/26 at 10:04 AM Staff 5 (LPN Resident Care Manager) stated she was unaware Resident 6 had a diagnosis of PTSD and could not identify any triggers. Staff 5 confirmed the resident's care plan did not include interventions or approaches related to PTSD or known triggers.On 1/29/26 at 10:26 AM Staff 6 (Social Services) stated resident trauma screenings were to be completed at the time of admission. Staff 6 stated a care plan had not been developed related to Resident 6's history of trauma or potential triggers. Staff 6 stated she was unaware if Resident 6 had any triggers.On 1/29/26 at 10:53 AM Staff 2 (DNS) and Staff 3 (Nurse Consultant) acknowledged Resident 6 had a diagnosis of PTSD and no interventions were implemented to address the resident's trauma or trauma triggers. Staff 2 stated she expected a care plan to be developed to address Resident 6's potential PTSD triggers and staff were responsible to implement the care plan.

Based on observation, interview and record review, it was determined the facility failed to ensure a medication error rate of less than five percent. There were 2 errors out of 25 medication administration opportunities resulting in an 8% error rate. This placed residents at risk of receiving a sub-therapeutic medication dose and reduced medication efficacy. Findings include:The facility's Insulin Pen Policy dated 1/1/26 specified insulin pens were to be primed with two units of insulin prior to each use to avoid the collection of air in the reservoir. Resident 18 was admitted to the facility in 10/2020 with diagnoses including type 2 diabetes mellitus (a chronic condition affecting the body's ability to control blood sugar levels).Resident 18's Physician Orders included the following:- insulin glargine (a long-acting mediation for diabetes) 100 units/ml inject 25 units two times daily- insulin lispro (a rapid-acting medication for diabetes) 100 units/ml inject 10 units before mealsOn 1/28/26 at 7:19 AM Staff 10 (LPN) administered insulin glargine and insulin lispro to Resident 18 and did not prime the insulin pens prior to administration. On 1/28/26 at 7:19 AM Staff 10 acknowledged they did not prime the insulin pens prior to administration and expressed they were not aware priming was required.On 1/28/26 at 10:39 AM Staff 2 (DNS) stated she expected all nursing staff to prime the insulin pens prior to administering insulin. Staff 2 acknowledged Resident 18's insulin pens had not been primed before insulin administration.

Based on observation and interview it was determined the facility failed to maintain a homelike environment with window cleanliness for 1 of 1 facility reviewed for a homelike environment. This placed residents at risk for an unclean homelike environment. Findings include: On 9/9/24 at 3:38 PM Resident 22 stated her/his windows were all very dirty and she/he would like them cleaned. Observation of Resident 22's windows and windows throughout the facility determined the majority of windows were dirty and unhomelike. On 9/13/24 at 9:06 AM Staff 8 (Maintenance Director) stated the outside windows in the facility had been cleaned only twice in the last eight years. Staff 8 confirmed the outside windows needed to be cleaned.

Based on interview and record review it was determined the facility failed to comprehensively assess 3 of 7 sampled residents (#s 8, 25 and 83) reviewed for medications, behavior and mood. This placed residents at risk for inaccurate or incomplete assessments and unmet care needs. Findings include: 1. Resident 83 was admitted to the facility in 8/2024 with diagnoses including recent stroke and delirium. Resident 83's physician orders included the use of scheduled and PRN antipsychotic medication. The 8/29/24 psychotropic CAA did not include a description of the specific behavior necessitating the use of the antipsychotic; causes and contributing factors; or risk factors related to the care area such as increased drowsiness, lethargy or increased risk for falls. On 9/13/24 at approximately 9:50 AM Staff 2 (DNS) confirmed the CAAs lacked an analysis of findings. 36494 2. Resident 8 was admitted to the facility on ,d+[DATE] with diagnoses including dementia and depression. A review of the 2/12/24 Cognitive Loss/Dementia CAA revealed Resident 8 had dementia. The family was aware and content with care and the plan moving forward. Communicate with Resident 8 and her/his family regarding capabilities and needs. The CAA failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident, or a rational for the care planning decision. A review of the 2/15/24 Psychotropic Drug Use CAA revealed Resident 8 was on venlafaxine (an antidepressant) for major depressive disorder, which was effective with no adverse effects noted. The CAA failed to indicate specifically how depression was a problem for the resident, how the resident's depression impacted Resident 8, or a rationale for the care planning decision. On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility. On 9/12/24 at 4:19 PM Staff 3 (Social Service Director) stated she completed the Cognitive Loss/Dementia CAA for Resident 8. Staff 3 stated she was learning how to better complete the CAAs and acknowledged there was not sufficient information in the CAA section. On 9/12/24 at 6:41 PM Staff 4 (LPN) stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 8's CAA but confirmed there was not enough meat and potatoes in Resident 8's Cognitive Loss/Dementia and Psychotropic CAA. Staff 4 stated The CAAs were important because they helped drive the care plan for each resident. 3. Resident 25 was admitted to the facility on ,d+[DATE] with diagnoses including schizophrenia and cancer of the lung. A review of the 7/2/24 Psychotropic Drug Use CAA revealed the resident received aripiprazole (an antipsychotic) for her/his schizophrenia which had been effective with no adverse effects noted. Medicate the resident per physician order and assess effectiveness of the medication for adverse effects. The CAA failed to include information regarding Resident 25's potential problems, manifested behaviors, precipitating factors, alleviating factors or non-pharmacological interventions. On 9/12/24 at 1:26 PM PM Staff 1 (Administrator) stated Staff 4 (LPN) completed the MDS and CAAs for the facility. On 9/12/24 at 6:41 PM Staff 4 stated she was training staff to complete the MDS and triggered CAAs. Staff 4 stated she did not complete Resident 25's CAA but confirmed there was not enough meat and potatoes in Resident 25's Psychotropic CAA. Staff 4 stated the CAAs were important because they helped drive the care plan for each resident.

Based on interview and record review it was determined the facility failed to follow physician orders for medication administration and implement bowel care timely for (1 of 5) sampled residents (# 17) reviewed for medications. This placed residents at risk for adverse side effects and constipation. Findings include: Resident 17 was admitted to the facility in 10/2020 with diagnoses including hypothyroidism (deficiency of hormones used to regulate heart rate, body temperature and digestion) and constipation. a. A physician order from 12/5/23 stated levothyroxine 50 mg was to be given once a day at 8:00 AM to Resident 17 for hypothyroidism. On 9/6/24 the orders for levothyroxine were modified for the medication to be given at 5:00 AM. Review of the 9/2023 MAR revealed Resident 17 did not receive levothyroxine from 9/6/24 through 9/11/24. On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed Resident 17 did not receive levothyroxine on the dates listed and did not provide any additional information as to why the medication was not administered. b. A physician order from 4/15/23 stated bisocodyl was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement A physician order from 4/15/23 stated fleet enema was to be administered as needed for constipation to Resident 17 on the fourth day of no bowel movement. A physician order from 4/28/23 stated milk of magnesia was to be administered as needed for constipation to Resident 17 on the third day of no bowel movement. Review of 8/2024 and 9/2024 bowel care records revealed the following: - Resident 17 had no bowel movements from 8/29/24 through 9/1/24, a total of four days. Review of medication administration records revealed none of the medications listed above were attempted to be administered on day three or day four. - Resident 17 had no bowel movements from 9/3/24 through 9/6/24, a total of four days. Review of medication administration records revealed none of the medications listed above were administered on day three or day four. - Resident 17 had no bowel movements from 9/9/24 through 9/11/24, a total of three days. Review of medication administration records revealed milk of magnesia was not administered on day three. On 9/12/24 at 1:29 PM Staff 2 (DNS) confirmed that based on the 8/2024 and 9/2024 bowel care records, medications used for constipation were not administered as ordered to Resident 17.

Based on observation and interview it was determined the facility failed to ensure medications were labeled with administration instructions for 1 of 5 residents (#11) for whom medication administration was observed. This placed residents at risk for decreased medication efficacy. Findings include: On 9/11/24 at 8:43 AM Staff 6 (CMA) was observed to crush the medication pantoprazole 40 mg DR (delayed release) prior to administration to Resident 11. According to the manufacturer's instruction, this medication is enteric coated to pass through the stomach and should not be crushed. The medication was labled as pantoprazole 40 mg without the DR. There were no instructions on the MAR or the medication bubble pack from the pharmacy to indicate the medication should not be crushed prior to administration. On 9/12/24 at 10:48 AM Staff 7 (Consultant Pharmacist) confirmed pantoprazole 40 mg should not be crushed and was not labeled with instructions not to crush.

Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 1 of 5 residents (#8) reviewed for medications. This placed residents at risk for inaccurate medical records. Findings include: Resident 8 was admitted to the facility in 2/2024 with diagnoses including dementia and depression. A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/15/24, discontinued on 8/16/24, for mirtazapine (an appetite stimulant) 7.5 mg, one tablet for appetite stimulation for three days. The medication was administered on 8/15/24. A review of Resident 8's Physician Orders dated 8/2024, revealed an order dated 8/16/24, for mirtazapine 7.5 mg, one tablet for appetite stimulation for 30 days. A review of Resident 8's clinical record revealed no evidence the resident received her/his mirtazapine from 8/16/24 through 8/25/24. In an interview on 9/12/24 at 1:42 PM, Staff 1 (Administrator) and Staff 5 (RNCM) stated both physician orders for the mirtazapine were incorrectly transcribed. Staff 1 stated facility staff clarified the mirtazapine order with the physician, and the physician clarified the mirtazapine with a new start date of 8/26/24. Staff 1 acknowledged the 8/2024 MARs were incorrectly transcribed.

Based on interview and record review it was determined the facility failed to properly administer anticoagulant medication to 1 of 2 sampled residents (#2) reviewed for medications. As a result, Resident 2 was hospitalized and required Vitamin K infusion (used as reverse the effects of blood thinning medications). Findings include: Resident 2 was admitted to the facility in 5/2021, with diagnosis including paroxysmal atrial fibrillation (irregular heart beat caused by poor blood flow). Resident 2's 5/20/22 Care Plan noted the resident received Coumadin (an anticoagulant medication) related to atrial fibrillation. Resident 2's 5/2022 physician orders indicated Resident 2 was to be administered Coumadin 5 mg daily every Tuesday, Friday, and Sunday at 4:00 PM. A review of Resident 2's 11/2023 MAR revealed the following dates and times the resident's Coumadin was administered: - 5 mg on 11/3/23 at 8:00 AM - 5 mg on 11/3/23 at 4:00 PM - 5 mg on 11/5/23 at 8:00 AM - 5 mg on 11/5/23 at 4:00 PM - 5 mg on 11/7/23 at 8:00 AM - 5 mg on 11/7/23 at 4:00 PM - 5 mg on 11/10/23 at 8:00 AM - 5 mg on 11/10/23 at 4:00 PM - 5 mg on 11/12/23 at 8:00 AM - 5 mg on 11/12/23 at 4:00 PM An 11/14/23 facility investigation revealed Staff 4 (LPN) inputted a duplicate order of Coumadin, which resulted in Resident 2 receiving two doses of Coumadin for six days. The investigation noted Resident 2 was sent to the emergency department after lab test revealed critical lab results. Resident 2's 11/15/23 Progress Note indicated the resident received a Vitamin K infusion while at the hospital. On 7/15/24 at 11:58 AM, Staff 4 (LPN) stated he ordered a duplicate medication of Coumadin, which resulted in Resident 2 receiving extra Coumadin for six days. On 7/11/24 at 12:56 PM, Staff 1 (Administrator) confirmed findings and indicated Resident 2 received a Vitamin K infusion while at the hospital as a result of the medication error. On 11/20/23, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was medication error. The Plan of Correction included: 1. The effected resident was assessed and sent the emergency department for Vitamin K infusion. 2. An audit of all anticoagulant orders were reviewed for accuracy. 3. All nursing staff were provided education related to administration of Coumadin including warning systems to prevent duplicate orders. 4. Education was received by consultant pharmacist on avoiding medication errors. 5. Anticoagulation orders for residents continued to be monitored and triple checked for accuracy.

Based on interview and record review it was determined the facility failed to ensure nursing professional standards of practice were followed for 1 of 1 sampled resident (#33) reviewed for hospitalization . This resulted in Resident 33 being transported to the hospital and placed in the ICU on a ventilator. This also placed other residents at risk for hospitalization . Findings include: The Oregon Nurse Practice Act included the following: Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Licensed Practical Nurses - Standards related to the LPN's responsibility for nursing practice. Applying practical nursing knowledge, at the clinical direction and under the clinical supervision of the RN or LIP (Licensed Independent Practitioner), the LPN shall: - Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data discrepancies to the supervising RN or supervising LIP; - Evaluate client responses to nursing interventions, progress toward measurable outcomes, and communicate such to appropriate members of the health care team. Resident 33 was admitted to the facility in 2023 with diagnoses including hip fracture. The facility's Bowel Management Policy and Procedure dated 9/2020 included the following interventions for when a resident did not have a bowel movement: - On day three administer Milk of Magnesia in the evening. - On day four administer a laxative suppository in the evening. - On day five if the resident has not had a bowel movement by after breakfast the nurse will check for impaction, check the abdomen and administer an enema per physician's orders. If the resident has not had a bowel movement by 3:00 PM the nurse will again check for impaction and check the abdomen. If there is no stool in the rectal vault the physician will be called for further orders and alert charting will begin. Resident 33's Care Plan initiated on 3/17/23 included the following interventions related to constipation and pain: - Follow facility bowel protocol for bowel management. - Monitor medications for side effects of constipation. Keep physician informed of any problems. - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Resident 33's 3/2023 Order Summary report included a physician's order for an enema as needed for constipation after five days of no bowel movement. Administer after a bowel assessment. If no results by the afternoon notify the physician for further orders. Resident 33's 3/2023 MAR and Progress Notes revealed the following: - On 3/20/23 at 6:58 PM a Progress Note by Staff 5 (LPN) indicated the resident had not had a bowel movement and an enema was administered (no enema administration was documented on the MAR) after lunch with no bowel movement by the end of the shift. The resident continued with nausea (no nausea was documented prior to this note) and vomited once. The resident's abdomen was hard and bowel tones were sluggish. The note did not indicate Staff 5 contacted an RN or the physician for further instructions. The note indicated will continue to monitor. - On 3/21/23 at 4:39 AM a Progress Note indicated Resident 33 was transported to the hospital by ambulance at 4:00 AM. The resident woke from her/his sleep with multiple episodes of vomiting which was dark brown in color and appeared to be fecal matter. The resident had not had a bowel movement for several days despite being administered Milk of Magnesia and an enema. - On 3/22/23 at 2:50 AM a Progress Note indicated the resident was in the ICU, intubated and on a ventilator. On 6/14/23 at 9:16 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 5 (LPN). Staff 5 stated she recalled Resident 33 and the incident on 3/20/23. Staff 5 stated she did not remember notifying anyone, such as Staff 2 (DNS) or the physician on 3/20/23. Staff 5 stated she usually did not contact Staff 2 for bowel issues and faxes were the normal method to contact the physician. Staff 5 stated she did not know how to contact the on-call provider. On 6/13/23 at 2:37 PM and 6/14/23 at 11:04 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 2. Staff 2 stated the physician should have been informed of the resident's condition on 3/20/23. Staff 2 stated the nurses were aware they could call her to evaluate any questions they had. Staff 2 stated the on-call provider was available by fax, text or phone and the charge nurse had the authority to send resident's out to the hospital based on their nursing judgement. Staff 2 verified the physician was not notified on 3/20/23 about Resident 33's condition. Refer to F684.

Based on interview and record review it was determined the facility failed to follow physician's orders and the plan of care for 3 of 8 sampled residents (#s 16, 20 and 33) reviewed for hospitalization , dialysis and medications. This resulted in Resident 33 being transported to the hospital where the resident was placed in the ICU on a ventilator and died three days later. This also placed other residents at risk for hospitalization and unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2023 with diagnoses including hip fracture. The facility's Bowel Management Policy and Procedure dated ,d+[DATE] included the following interventions for when a resident did not have a bowel movement: - On day three administer Milk of Magnesia in the evening. - On day four administer a laxative suppository in the evening. - On day five if the resident has not had a bowel movement by after breakfast the nurse will check for impaction, check the abdomen and administer an enema per physician's orders. If the resident has not had a bowel movement by 3:00 PM the nurse will again check for impaction and check the abdomen. If there is no stool in the rectal vault the physician will be called for further orders and alert charting will begin. Resident 33's Care Plan initiated on [DATE] included the following interventions related to constipation and pain: - Follow facility bowel protocol for bowel management. - Monitor medications for side effects of constipation. Keep physician informed of any problems. - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Resident 33's ,d+[DATE] Order Summary report included the following physician's orders: - Milk of Magnesia as needed for constipation after three days of no bowel movement. - Bisacodyl suppository as needed for constipation after four days of no bowel movement. - Enema as needed for constipation after five days of no bowel movement. Administer after a bowel assessment. If no results by the afternoon notify the physician for further orders. - Hydrocodone(opioid pain medication which may cause constipation)-acetaminophen every four hours PRN for pain. Resident 33's ,d+[DATE] Progress Notes and MAR revealed the following: - hydrocodone-acetaminophen was administered five times from [DATE] through [DATE]. - On [DATE] a Progress Note indicated a bisacodyl (laxative) suppository was administered because the resident had not had a bowel movement for four days after Milk of Magnesia (laxative) was administered. - No administration of Milk of Magnesia was charted as being administered on or prior to [DATE] either in Progress Notes or the MAR. - On [DATE] a Progress Note indicated the resident did not have a bowel movement after the medication was administered. - On [DATE] at 3:59 PM a Progress Note indicated Milk of Magnesia was administered for third day with no bowel movement. (Being the third day with no bowel movement is not consistent with charting on [DATE] and [DATE] which indicated the resident had not had a bowel movement by those dates.) - On [DATE] at 6:58 PM a Progress Note by Staff 5 (LPN) indicated the resident had not had a bowel movement and an enema was administered (no enema administration was documented on the MAR) after lunch with no bowel movement by the end of the shift. The resident continued with nausea (no nausea was documented prior to this note) and vomited once. The resident's abdomen was hard and bowel tones were sluggish. The note did not indicate Staff 5 contacted an RN or the physician for further instructions. The note indicated will continue to monitor. - On [DATE] at 4:39 AM a Progress Note indicated Resident 33 was transported to the hospital by ambulance at 4:00 AM. The resident woke for her/his sleep with multiple episodes of vomiting which was dark brown in color and appeared to be fecal matter. The resident had not had a bowel movement for several days despite being administered Milk of Magnesia and an enema. - On [DATE] at 2:50 AM a Progress Note indicated the resident was in the ICU, intubated and on a ventilator. Resident 33's Hospital History and Physical dated [DATE] revealed the resident was diagnosed with a small bowel obstruction (blockage of the small intestine), aspiration pneumonia (infection of the lungs related to food or liquids breathed into the lungs) and pulmonary emboli (blockage of arteries in the lungs). The resident died on [DATE]. On [DATE] at 9:16 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 5 (LPN). Staff 5 stated she recalled Resident 33 and the incident on [DATE]. Staff 5 stated she did not remember notifying anyone, such as Staff 2 (DNS) or the physician on [DATE]. Staff 5 stated she usually did not contact Staff 2 for bowel issues and faxes were the normal method to contact the physician. Staff 5 stated she did not know how to contact the on-call provider. On [DATE] at 2:37 PM and [DATE] at 11:04 AM Resident 33's Care Plan, physician's orders and Progress Notes were reviewed with Staff 2. Staff 2 stated the physician should have been informed of the resident's condition on [DATE]. Staff 2 stated the nurses were aware they could call her to evaluate any questions they had. Staff 2 stated the on-call provider was available by fax, text or phone and the charge nurse had the authority to send resident's out to the hospital based on their nursing judgement. Staff 2 verified the physician was not notified on [DATE] about Resident 33's condition. 41458 2. Resident 16 was admitted to the facility in 2020 with diagnoses including diabetes. a. An [DATE] physician order indicated Resident 16 was prescribed Lantus (a drug used to control the amount of sugar in the blood) two times a day for diabetes. Hold for CBG less than 90. A review of Resident 16's [DATE] through [DATE] DAR (Diabetic Administration Record) indicated the resident's Lantus was not given according to physician orders on the following days: -,d+[DATE] evening dose with no rationale provided; -,d+[DATE] morning dose with a progress note indicating the resident was in shower/activity; -,d+[DATE] evening dose with a progress note indicating insulin was given by the day nurse. On [DATE] at 9:54 AM Staff 2 (DNS) reviewed Resident 16's Lantus DARs and stated the resident's Lantus should have been given on the dates identified and if a resident was in an activity or shower, the nurse should find the resident and administer the insulin or administer the insulin as soon as the resident was available. Staff 2 stated if the day nurse administered insulin, the day nurse should document. b. A [DATE] physician order indicated Resident 16 was prescribed Insulin lispro (a short acting type of insulin) after meals. Hold if intake was less than 25%. Notify the physician of CBG's greater than 500. A review of Resident 16's [DATE] through [DATE] DAR (Diabetic Administration Record) indicated the resident's lispro was not given according to physician orders on the following days: -,d+[DATE] dinner dose with no rationale provided; -,d+[DATE] dinner dose with no rationale provided; -,d+[DATE] dinner dose with no rationale provided; -,d+[DATE] lunch dose with a progress note which indicated the resident was in an activity; -,d+[DATE] breakfast dose with a progress note which indicated the resident was in the shower or activity; -,d+[DATE] dinner dose with a progress note which indicated the insulin was given by the day nurse; -,d+[DATE] breakfast dose with a progress note which indicated the resident was in an activity; -,d+[DATE] breakfast with no rationale provided; -,d+[DATE] dinner dose with a progress note which indicated the insulin was given by the day nurse; -,d+[DATE] lunch dose with no rational provided; -,d+[DATE] lunch dose with a progress note which indicated the resident was in an activity; -,d+[DATE] dinner dose with a progress note which indicated the insulin was held due to the resident's blood sugar being 132; -,d+[DATE] lunch dose with a progress note which indicated the resident was in an activity. On [DATE] at 9:54 AM Staff 2 (DNS) reviewed Resident 16's lispro DARs and stated the resident's lispro should have been given on the dates identified and if a resident was in an activity or shower, the nurse should find the resident and administer the insulin or administer the insulin as soon as the resident was available. Staff 2 stated if the day nurse administered insulin, the day nurse should document. 3. Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. A [DATE] physician order indicated Resident 20 was prescribed Nova Source (a nutritional supplement which provides protein, vitamins and minerals specifically for people with chronic kidney disease on dialysis) one time a day for end stage kidney disease. A review of Resident 20's [DATE] through [DATE] TARs indicated the resident's Nova Source was not given according to physician orders on the following days: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE]. On [DATE] at 11:05 AM Resident 20 stated she/he was supposed to receive Nova Source every day but had not received it for at least the past three weeks. Resident 20 stated every time she/he asked about it, she/he was told it was on order. On [DATE] at 10:32 AM Staff 11 (LPN) stated Resident 20 was supposed to receive Nova Source once a day and thought it was being ordered. On [DATE] at 11:24 AM and [DATE] at 12:32 PM Staff 2 (DNS) stated the facility was currently out of Nova Source. Staff 2 stated she was notified by text that more Nova Source needed to be ordered but she did not see the text so none was ordered.

Based on interview and record review it was determined the facility failed to promptly intervene when a resident experienced severe weight loss for 1 of 3 sampled residents (#30) reviewed for nutrition. This resulted in an unplanned severe weight loss for Resident 30 and placed residents at risk for unplanned weight loss. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's diet order dated 5/4/23 included a general diet with regular texture and thin consistency (for fluids). Resident 30's Nutritional Status CAA dated 5/11/23 did not indicate a nutritional problem, a comprehensive assessment of the resident's nutritional status or the impact on the resident. Resident 30's Care Plan initiated on 5/4/23 for ADLs and nutrition included the following interventions: - Set-up assistance for eating. - Explain and reinforce to [the resident] the importance of maintaining the diet ordered. Encourage [her/him] to comply. Explain consequences of refusal, obesity/malnutrition risk factors. (The resident was ordered a regular diet therefore it was not evident why this intervention was pertinent.) - Provide and serve the diet as ordered. Monitor and record the resident's intake at each meal. - The RD will evaluate [the resident] and make diet change recommendations as needed. - Weigh the resident weekly. Resident 30's weight record from 5/4/23 through 6/8/23 revealed the resident lost 18 pounds or 6.7% body weight over 35 days. Resident 30's meal intake record from 5/14/23 through 6/11/23, (29 days or 87 meals) revealed 54% of meals were documented as 76-100% eaten and 31% were 51-75% eaten. Resident 30's Nutritional assessment dated [DATE] indicated the resident received a general diet which was appropriate at that time. The resident's meal acceptance was around 75%. The resident was at increased nutritional risk due to an elevated BMI (body mass index). The resident's overall health would likely benefit from a gradual weight decrease. Goals included stable weight with gradual weight decrease okay and to notify the RD as needed. (The assessment did not indicate what specific risks Resident 30 was at risk for due to the elevated BMI. The assessment also did not specify what a gradual weight loss would be or a specific plan to achieve a gradual weight loss.) Resident 30's Progress Notes from 5/4/23 through 6/9/23 revealed no documentation to indicate the resident was reassessed for weight loss, new interventions implemented, referral to the RD, notification to the resident's family or notification to the physician regarding the resident's severe weight loss. On 6/12/23 at 11:04 AM Resident 30's weight loss was reviewed with Staff 2 (DNS). Staff 2 stated the resident was reviewed at the facility's monthly dietary meeting and the RD should have made a progress note and put updated dietary recommendations in her in-box. Staff 2 checked her in-box and reviewed the progress notes. She stated there was no progress note or new dietary recommendations. Staff 2 verified Resident 30's Nutritional Status CAA was not comprehensive, the resident lost 18 pounds over 35 days, the weight loss was not planned and the resident's family and physician were not immediately notified. Staff 2 confirmed there was no evidence of a reassessment of the resident's nutritional status or rationale for no new interventions after the resident lost 18 pounds.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 6/11/23 the facility provided a list of residents who: -Required one or two person assistance with bathing: 17; -Were fully dependent for bathing: 17; -Required one or two person assistance for eating: 5; -Were fully dependent on staff for eating: 6; -Required one or two person assistance for toileting: 9; -Were fully dependent on staff for toileting: 25; -Required one or two person assistance with transfers: 12; -Were fully dependent on staff for transfers: 20; -Required one or two person assistance with dressing: 19; -Were fully dependent on staff for dressing: 12. Random observations revealed the following: On 6/12/23 at 8:18 AM seven residents in the 300 dining room for breakfast. Three residents were waiting to be assisted with eating and four residents were eating on their own. There was only one CNA in the dining room to assist residents with eating their breakfast until 8:35 AM when a second CNA arrived after passing trays to residents in the hallway. On 6/12/23 at 8:48 AM a resident was heard frequently yelling for help in the 300 hallway. Several staff passed by the resident's room and at 8:57 AM a CNA entered the room. On 6/13/23 at 8:43 AM there were seven residents in the 300 dining room for breakfast. One resident sat with untouched food in front of her/him. Staff 8 (CNA) was assisting another resident with eating. At 8:48 AM a second CNA arrived to assist residents with eating. Staff 8 reported trays arrived at 8:00 AM, the CNAs passed the hall trays and then assisted residents in the dining room. On 6/11/23 at 10:58 AM Resident 20 stated the facility utilized many staff from different agencies and those staff were unfamiliar with her/his needs or how to provide care for her/him. On 6/12/23 at 2:54 PM Witness 1 (Family) stated there were several times the CNA staff were unable to get her family member up for meals because the facility did not have enough CNA staff. Witness 1 stated the previous week she was visiting her family member and asked CNA staff to get her/him up for dinner. She reported the CNA staff were unable to get her family member up as requested because there were only two CNAs working on the hallway; one CNA was giving a shower and the other CNA had to pass dinner trays. Witness 1 stated this happened many other times, too. On 6/12/23 at 2:08 PM Staff 15 (CNA) stated there were many residents who required assistance with eating and there were not enough CNAs to provide timely eating assistance so it took a long time to get through meal service. Staff 15 stated residents often complained about the length of time it took staff to respond to call lights. Staff 15 reported CNA staff often did not get to take their breaks or lunches and they sometimes worked after their shift ended in order to get care completed. Staff 15 stated there were at least eight residents on the 300 hallway that required two person assistance to get them out of bed so many times they could not get all the residents up who wanted to get up for meals. On 6/12/23 at 3:38 PM Staff 19 (CNA) stated there were times when there was not enough CNA staff to get residents up for the dinner meal. On 6/12/23 at 10:24 AM Staff 14 (RN) stated the 300 hallway had high acuity residents and many of them required two person assistance to get out of bed. Staff 14 stated sometimes showers got bumped, CNAs were unable to get all the residents up that needed to be up for meals and residents were not always repositioned every two hours. On 6/13/23 at 10:57 AM Staff 8 (CNA) reported she often did not get breaks or lunches and sometimes worked over her shift to get resident care completed. Staff 8 stated many of the residents in the facility required a lot of assistance and she often could not complete all of her assigned showers or reposition and turn residents as frequently as required. On 6/14/23 at 9:47 AM staffing concerns were reviewed with Staff 2 (DNS). Staff 2 stated she was aware there were residents who expressed concerns with staffing and the facility had many residents with high acuity needs. Staff 2 acknowledged staffing was challenging and it was difficult to get staff hired because of being in a rural area.

Based on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 14 out of 103 days reviewed for staffing. This placed all residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports dated 1/1/23 through 2/28/23 and 5/1/23 through 6/14/23 revealed the facility had no RN coverage for eight consecutive hours on the following days: 1/4, 1/5, 1/6, 1/18, 1/22, 2/13, 5/15, 5/22, 5/23, 5/27, 5/28, 5/29, 6/2 and 6/10. On 6/14/23 at 9:47 AM Staff 2 (DNS) confirmed the facility lacked RN coverage on the identified days.

Based on interview and record review it was determined the facility failed to immediately notify a resident's physician of a severe unplanned weight loss for 1 of 3 sampled residents (#30) reviewed for nutrition. This placed residents at risk for unmanaged weight loss. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's weight record from 5/4/23 through 6/8/23 revealed the resident lost 18 pounds or 6.7% body weight in 35 days. Resident 30's Progress Notes from 5/4/23 through 6/9/23 revealed no evidence to indicate the resident's family and physician were notified regarding the resident's severe weight loss. On 6/12/23 at 11:04 AM Staff 2 (DNS) stated the resident's family and physician were not immediately notified after the resident lost 18 pounds. Refer to F692.

Based on interview and record review it was determined the facility failed to ensure a resident's missing personal property was addressed for 1 of 1 sampled resident (#17) reviewed for personal property. This placed residents at risk for loss of personal items. Findings include: The facility's Grievance policy and procedure dated 3/9/16 indicated the following: -Prompt Resolution of Complaint: The staff member who receives the complaint should determine if they can immediately resolve the resident/representative's concern. If they cannot, they must alert their supervisor/charge nurse and a concern/comment form will be completed by staff if it occurs outside of Social Service business hours. During Social Service business hours, staff will contact them directly to aid in completing the form. -The timeframe for follow-up of concern is three days. Resident 17 was admitted to the facility in 2022 with diagnoses including Alzheimer's dementia. 6/11/23 12:41 PM Witness 4 (Family) and Witness 5 (Family) reported Resident 17 was missing a digital picture frame/pictures and hearing aids. Witness 4 and Witness 5 reported Resident 17 had a digital picture frame that displayed numerous pictures of the her/his life over many years which was missing since the resident moved rooms a while ago. They stated they reported the missing items to staff and staff looked for the items but were unable to locate them. A review of the facility's 2023 Grievance notebook revealed no evidence that a grievance form was completed for Resident 17's missing items. On 6/12/23 at 2:05 PM Staff 15 (CNA) reported she recalled seeing Resident 17's digital picture frame/pictures in the resident's previous room but had not seen the digital picture frame/pictures since. Staff 15 stated she did not know if Resident 17 had hearing aids. On 6/13/23 at 10:11 AM Staff 14 (RN) stated approximately one month ago she was informed by Resident 17's family members that the resident's digital picture frame/pictures and hearing aids were missing. Staff 14 stated she looked through the resident's room but was unable to locate the missing items. Staff 14 stated she passed the information to the night shift nurse. On 6/13/23 at 11:41 AM Staff 12 (Social Services Director) stated she was not notified that Resident 17 had any missing items. On 6/13/23 at 12:18 PM Staff 2 (DNS) stated she expected staff to complete a grievance form when residents had missing items and either the items would be located or replaced if they were unable to be located.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident's nutritional status for 1 of 3 sampled residents (#30) reviewed for nutrition. This placed residents at risk for unassessed needs. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's diet order dated 5/4/23 included a general diet with regular texture and thin consistency (for fluids). Resident 30's Nutritional Status CAA dated 5/11/23 did not indicate a nutritional problem, a comprehensive assessment of the resident's nutritional status or the impact on the resident. On 6/12/23 at 11:04 AM Staff 2 (DNS) verified Resident 30's Nutritional Status CAA was not comprehensive and the resident lost 18 pounds over 35 days. Refer to F692.

Based on interview and record review it was determined the facility failed to provide scheduled showers for 1 of 5 sampled residents (#20) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. Resident 20's 4/28/21 ADL Care Plan indicated Resident 20 required physical assistance of one staff for showering three times a week and as necessary. Resident 20's 5/17/23 Quarterly MDS indicated the resident was cognitively intact and totally dependent with one person physical assistance for bathing. Resident 20's 4/30/23 through 6/13/23 bathing task logs indicated the following: -5/5: not applicable; -5/9: shower received; -5/11: not applicable; -5/13: not applicable; -5/16: shower received; -5/20: resident refused; -5/23: shower received; -5/25: shower received; -5/27: not applicable; -5/30: not applicable; -6/3: not applicable; -6/8: shower received and -6/10: shower received. A review of Resident 20's Progress Notes from 4/30/23 through 6/13/23 revealed no documentation indicating Resident 20 was provided with additional bathing opportunities if bathing was refused or not provided. On 6/11/23 at 10:52 AM Resident 20 stated she/he was supposed to receive showers three times a week but only received them sporadically. On 6/12/23 at 1:54 PM and 2:22 PM Staff 15 (CNA) and Staff 16 (CNA) stated Resident 20 was supposed to receive showers three times a week and never refused. On 6/13/23 at 12:32 PM Staff 2 (DNS) reviewed Resident 20's bathing task logs and confirmed the resident did not receive showers three times a week and Resident 20 never refused showers unless she/he was ill.

Based on observation and interview it was determined the facility failed to ensure the residents' environment was free from hazards for 1 of 1 facility randomly observed. This placed residents at risk for injury and blood borne infection. Findings include: On 6/12/23 at 7:29 AM a large sharps container was observed attached to the right side of the medication cart on the third floor. The sharps container did not have a safety flap and was full of used needles and lancets. On 6/12/23 at 7:40 AM Staff 11 (LPN) stated he had not noticed the sharps container was full and had no safety flap. He reported the concern to Staff 2 (DNS) and got a new sharps container but could not find the key to unlock the retaining device which kept the full sharps container secured to the medication cart. Staff 11 stated when the next shift came to work they might know where the key was. On 6/13/23 at 8:15 AM and 6/13/23 at 10:32 AM the sharps container was observed still attached to the medication cart full of needles and lancets with no safety flap. On 6/13/23 at 11:01 AM Staff 2 was shown the sharps container, she acknowledged the sharps container was full of needles and lancets and the container should have a safety flap.

Based on observation, interview and record review it was determined the facility failed to conduct post dialysis assessments of resident's condition for 2 of 2 sampled residents (#s 20 and 27) reviewed for dialysis. This placed residents at risk for potential unmet care needs upon return from dialysis. Findings include: The facility's Hemodialysis Access Care policy and procedure dated 9/2010 indicated the Care Immediately Following Dialysis Treatment was as follows: -Mild bleeding from site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. -If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrive. 1. Resident 20 was admitted to the facility in 2020 with diagnoses including end stage renal disease. Resident 20's 4/28/21 Dialysis Care Plan indicated the resident received dialysis on Monday, Wednesday and Friday. A review of Resident 20's health care record and dialysis communication notebook revealed no evidence of any post-dialysis assessments. On 6/12/23 at 10:22 AM Resident 20 was observed leaving for dialysis. Resident 20 returned from dialysis at 4:16 PM. On 6/11/23 at 11:22 AM Resident 20 stated she/he went to dialysis three times a week. Resident 20 reported the nurses never assessed her/him upon returning from dialysis and she/he usually removed the pressure bandages sometime the next day. On 6/12/23 at 5:00 PM Resident 20 stated no nurse completed a post-dialysis assessment since she/he returned from dialysis. On 6/12/23 at 5:05 PM Staff 11 (LPN) stated he did not complete post-dialysis assessments on residents but if the CNAs noticed any issues they would tell the nurse. On 6/13/23 at 8:05 AM Resident 20 was observed to still have two pressure bandages on her/his left arm from dialysis on 6/12/23. Resident 20 stated no staff assessed her/his arm or removed the bandages. Resident 20 then removed the bandages and placed them on her/his bedside table. On 6/13/23 at 12:32 PM Staff 2 (DNS) stated she expected nursing staff to complete a post-dialysis assessment when a resident returned from dialysis. Staff 2 stated she expected staff to check the access site, palpate trill (feel for a vibration), look for any bleeding and remove the pressure bandage at some point. 43690 2. Resident 27 was admitted to the facility in 4/2023 with diagnoses including end state renal disease and diabetes. Resident 27's Care Plan identified she/he needed dialysis due to end stage renal disease, which was scheduled every Tuesday, Thursday and Saturday. Interventions included to monitor and report any problems with the resident's access site to the dialysis clinic. There was no documentation in the resident's Progress Notes since her/his admission of a post dialysis evaluation. On 6/11/23 at 1:30 PM Resident 27 was observed in her/his room sitting on her/his bed with the TV on. Resident 27 stated she/he was on dialysis and showed this surveyor her/his fistula site located on the upper left arm. Resident 27 stated on her/his dialysis days she/he removed the pressure dressing herself/himself after four hours and stated she/he was not assessed after returning from dialysis appointments. On 6/13/23 at 2:52 PM Resident 27 was observed to return from her/his dialysis appointment. On 6/13/23 at 3:50 PM Staff 4 (RN) stated she was unaware what type of dialysis site Resident 27 had, missed giving Resident 27 her/his morning medications because she was running late and had not observed or assessed Resident 27 since she/he had returned from the dialysis clinic. On 6/13/23 at 4:06 PM Resident 27 was observed in bed and had not yet been assessed from her/his return from the dialysis clinic. On 6/14/23 at 11:44 AM Staff 2 (DNS) stated there were no post dialysis assessments in Resident 27's chart because they had not been completed. Staff 3 (RNCM) stated it was her expectation residents on dialysis were assessed within 15 minutes of their return to the facility and all vital signs were completed.

Based on observation, interview, and record review it was determined the facility failed to monitor weights for a resident identified at nutritional risk and failed to implement new interventions to prevent weight loss for 1 of 2 sampled residents (#17) reviewed for nutrition. This resulted in a severe unintended weight loss of 14% over two months. Findings include: Resident 17 was admitted in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] identified the resident to have mild cognitive impairment, several indicators of depression, but no appetite problems. The resident required extensive assistance from staff for most ADLs but only supervision for eating. Resident 17's admission weight was documented as 133 lbs. The Admission MDS indicated no history of weight loss. The hospital dietician assessment dated [DATE] included information about significant recent weight loss and the resident was identified to have severe protein calorie malnutrition. According to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dietician assessment dated [DATE] identified the resident's appetite was fair, she/he had no food complaints, special diet or preferences. The dietician noted the hospital dietary assessment identified a history of significant weight loss and the resident was noted to be at the low index of healthful weight for an older individual with increased energy needs related to the progressive nature of [CONDITION(S)]. Resident 17 was considered to be at increased nutritional risk due to the mechanically altered texture diet and history of weight loss. The dietician recommended the facility clarify the diet as NEM/dysphagia level 3 (advanced)/thin [liquids] with supplement plus BID to increase calories and protein provided; monitor weights weekly and notify RD PRN. The stated goal was adequate nutrition to support recovery and avoid significant weight changes. The facility was advised to monitor the resident's weight and intake. No evidence was found to indicate the dietician's recommended interventions were considered or implemented. Resident 17's Care Plan dated 12/23/20, included a problem statement of, requires a mechanically altered diet R/T dysphagia. Interventions consisted of encouraging intake, monitoring and recording amount of food and fluid consumed and to monitor, record and report to MD signs/symptoms of malnutrition or significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. According to the 3/9/21 Quarterly Nutrition review, Resident 17's intake averaged 25-51% of most meals. Resident 17 was identified to have a poor appetite on the quarterly MDS dated [DATE], however, the resident's weight was considered stable at 129 lbs. On 3/12/21 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to receive the originally ordered diet of Dysphagia - Dental Soft Texture, Extra Gravy, thin liquids. The resident was not receiving NEM or the upgraded diet as recommended by the Dietician. Review of the intake records for March, April and May, 2021, indicated Resident 17 did not consistently consume the entire supplement when offered. On 3/23/21, the resident weighed 133 lbs according to facility weight records. The resident was hospitalized from 3/29/21 to 3/31/21 with a urinary tract infection and [CONDITION(S)] and was sent to the hospital again on the evening of 5/21/21 for an actute mental status change, returning 5/24/21. There was no documented evidence in the record that the resident's weight was monitored during the month of April 2021. The resident had one recorded weight of 151 lbs on 4/23/21 that was later struck out as on error, with no documented evidence a re-weight was done. The next documented weight was 125 lbs on 5/4/21. The resident was weighed 13 days later on 5/17/21 at 115 lbs and on 5/20/21 at 114 lbs, which represented a 14% severe weight loss since 5/4/21. On 5/26/21 at 8:48 AM Staff 9 (CNA) was observed assisting Resident 17 to eat breakfast. Staff 9 tried multiple times to engage the resident in eating, however, the resident was unwilling or unable to eat. Staff 9 left the resident's beverages on her/his bedside table and removed the resident's tray. On 5/26/21 at 12:28 PM Resident 17 was observed to be assisted by Staff 6 (RN) to eat lunch. The resident was dependent on Staff 6 for assistance to eat and drink but did consume approximately 50% of the meal over the course of an hour. On 5/26/21 at 2:51 PM Staff 6 (RN) stated the resident experienced a steady overall decline for the last couple of months and the facility requested a neurological consult. Regarding the lack of recorded weights between March and April, 2021, Staff 6 stated weights were usually done on shower days and recorded on the same document as the skin checks. Staff 6 stated the norm was to weigh the resident at least the day after admit or re-admit from the hospital. The resident currently required the Hoyer lift scale and she did not know why no weights were obtained after the resident returned from the hospital. According to documentation from a Dietician Review on 5/26/21 Resident 17's intake records indicated generally poor to fair acceptance of meals. The dietician identified a severe weight loss over two months with a general decline in condition. The RD again recommended adding NEM to meals and increased the health shake to TID with meals to increase calories and protein provided. The dietician asked that the resident's weights be monitored weekly for changes and notify the RD as needed. On 5/27/21 at 9:01 AM Staff 2 (DNS) stated she expected all residents to have weekly weights, since the first of April 2020 when the facility changed to a different type of EHR (electronic health record). She reviewed weights about once a week. Staff 2 confirmed the facility was aware the resident was not eating and confirmed weight loss was not identified and poor intake was not communicated to the dietician. On 5/27/21 at 2:34 PM Staff 8 (RD) stated she visited the facility twice a month. She was not informed by the facility of Resident 17's decline, poor appetite or subsequent weight loss. She reviewed the resident because the resident was on a list of residents who were recently hospitalized . She stated the facility did not have an interdisciplinary team meeting - usually referred to as a Nutrition at Risk (NAR) meeting to discuss residents at risk for weight loss. Staff 8 confirmed no interventions were in place other than dining assistance and BID health shakes prior to the 5/27/21 evaluation.

Based on interview and record review it was determined the facility failed to follow care planned fall risk interventions for 2 of 3 sampled residents (#s 1 and 2) reviewed for abuse and not following the care plan. This failure resulted in Resident 2 obtaining a fractured leg due to staff's failure to follow the care plan. This placed other residents at risk for falls. Findings include: 1. Resident 2 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. A Care Plan initiated on 5/16/18 indicated Resident 2 was a fall risk due to decreased sitting balance and lack of left sided awareness. Staff were to block her/his left foot when standing or the resident's foot would go out from under her/him. Resident 2 was a two-person limited assist from the wheelchair, standing at the transfer pole to the bed or bed to the wheelchair. The Quarterly MDS dated [DATE] indicated Resident 2 was an extensive two person assist with transfers and bed mobility. Resident 2 was dependent for bathing with two-person assist and was not steady on her/his feet. An Occurrence Investigation Final Summary initiated by Staff 5 (DNS) on 8/3/20 revealed the following: -Attached to the investigation was a Safety Events form dated 8/3/20 completed by Staff 4 (RN). -Staff 6 (CNA) transferred Resident 2 on 8/2/20 at approximately 7:00 PM from her/his wheelchair to her/his bed on her own. -Staff 6 stated she transferred Resident 2 on her own from the wheelchair to the bed and indicated she blocked Resident 2's left leg. Staff 6 stated the resident never complained of any pain or discomfort once in her/his bed or later when Staff 6 changed her/him later in the shift. -On 8/3/20 Resident 2 reported to Staff 3 (CNA) she/he did not sleep well during the night because her left leg hurt, and Staff 3 reported the concern to Staff 4 (RN). -Resident 2 reported to Staff 4 her/his knee hurt after being transferred on 8/2/20. -Staff 4 assessed the residents left knee and it was red with a large focal effusion (a collection of fluid between tissues of the body) to the medial side of the left knee, it was soft and boggy. The left knee was tender to touch and tender with movement. -Resident 2 was sent to the hospital for further evaluation and an x-ray revealed a non-displaced fracture across the distal (end of) femoral (femur bone) metaphysis (the neck of the long femur bone). -Resident 2 returned to the facility later in the afternoon on 8/3/20. -Resident 2's care plan indicated she/he was a two-person extensive assist for all transfers using a transfer pole when moving the resident from wheelchair to bed and from bed to wheelchair. -Abuse and neglect were ruled out, however Staff 6 did not follow the care plan when transferring the resident from her/his wheelchair to bed. On 8/13/20 a public complaint was received that alleged Staff 6 transferred Resident 2 by herself even though the resident was care planned to be a two person assist. The resident sustained [REDACTED]. On 2/19/21 at 8:13 AM Witness 10 (Complainant) verified the above information. Multiple attempts to reach Staff 6 from 2/18/21 through 2/22/21 were made and were unsuccessful. On 2/18/21 at 8:06 PM Staff 3 (CNA) stated Resident 2 was a two-person extensive assist with transfers, utilized a transfer pole and two staff were needed to transfer Resident 2 from her/his wheelchair to her/his bed and vice versa. Staff 3 stated Resident 2 was weak and was unable to use her/his left side very well. Staff 3 stated on the morning of 8/3/20 when he was assisting the resident in bed, he noticed Resident 2's left leg and the resident stated this happened when she/he was transferred from her/his wheelchair the night before. Staff 3 stated the resident told him her/his knee was tender and sore. Staff 3 stated he told Staff 4 (RN) who assessed Resident 2 and she/he was sent out to the hospital. On 2/22/21 at 10:15 AM Staff 4 (RN) stated Resident 2 had a history of [REDACTED]. Staff 4 stated she remembered on 8/3/20 Staff 3 reported to her that Resident 2's left knee did not look right. Staff 4 immediately assessed the resident's left knee and was obvious there was an effusion on the medial portion of the left knee. Staff 4 stated Resident 2 was asked if the left knee hurt and the resident nodded yes, and the resident stated this happened the night before when being transferred to her/his bed. Staff 4 stated she sent the resident out to the hospital on [DATE] and an x-ray revealed the resident's left leg was fractured. Staff 4 stated Resident 2 returned later in the shift on 8/3/20. On 2/23/21 at 11:34 AM Staff 5 (DNS) stated she recalled the incident, which occurred 8/2/20 on evening shift and was reported to her on 8/3/20 by Staff 4 (RN). Staff 5 stated on 8/3/20 the resident complained of left leg discomfort to Staff 3 and he reported this information to Staff 4. Staff 5 stated the resident's leg was sore and swollen and Staff 4 sent Resident 2 to the hospital, an x-ray revealed a fractured left leg. Staff 5 stated she initiated the investigation and Staff 6 told her she transferred Resident 2 on her own to bed because that was how she was trained. Staff 5 stated Resident 2 had left sided weakness and when staff transferred her/him staff were to place a foot on the outside of Resident 2's weak leg to stabilize her/him and Staff 5 indicated Staff 6 had placed her foot on the left side prior to the transfer. Staff 5 stated she could not verify if the fracture occurred during the transfer, however stated again Staff 6 did not follow the care plan. On 2/24/21 at 10:06 AM Staff 7 (Administrator) stated Staff 5 completed investigations for Resident 2 and Staff 5 was no longer with the facility. Staff 7 stated she would expect all CNAs to follow the care plan for transfer status. 2. Resident 1 was admitted to the facility in 10/2020 with [DIAGNOSES REDACTED]. A Care Plan initiated on 7/20/20 indicated Resident 1 was a fall risk due a history of falls with injury. Resident 1 was a two-person extensive assist with a front wheel walker for all transfers. An Admission MDS dated [DATE] indicated Resident 1 had a BIMs score of 14/15 which indicated she/he was cognitively intact. An Occurrence Investigation Final Summary initiated by Staff 5 (DNS) on 8/15/20 revealed the following: -Attached to the investigation was a Safety Events form dated 8/11/20 completed by Staff 4 (RN). -On 6/11/20 Staff 8 (CNA) attempted to transfer Resident 1 from the shower chair to her/his bed when the residents left knee buckled and Staff 8 guided the resident down to the floor. The resident's walker was in front of the resident and she/he had a gait belt on. -Staff 8 called for assistance and Staff 4 entered the room and assisted Staff 8 with getting Resident 1 into her/his bed. -Resident 1 reported Staff 8 transferred her/him after her/his shower and Resident 1 stated she/he started to go down. Staff 8 tried to ease the resident down when her/his left knee buckled. -The resident did not complain of knee pain directly after the fall but later that night and the next day complained of discomfort, an x-ray was obtained which ruled out any fracture or injury. The residents swelling in the left knee did not change before the lowering to the floor per Staff 4 who reported the fall. -Abuse and neglect were ruled out, however Staff 8 did not follow the care plan when transferring the resident from her/his wheelchair to bed. On 8/11/20 a public complaint was received that alleged Staff 8 transferred Resident 1 by herself even though the resident was care planned to be a two person assist. On 2/19/21 at 1:43 PM Witness 10 (Complainant) verified the above information. On 2/18/21 at 1:33 PM Staff 8 (CNA) stated Resident 1 was alert and oriented and able to state her/his needs. Staff 8 stated the resident was a two-person transfer and she should not have transferred the resident on her own on 8/11/20. Staff 8 stated Resident 1 had a gait belt and when the resident stood up and tried to grab the grab bar on the right side of the bed, she/he missed, and Staff 8 guided the resident down onto the floor. Staff 8 stated she called for assistance and Staff 4 entered the room, assessed the resident and helped Resident 1 into bed. Staff 8 stated the resident did not complain of pain or discomfort after the fall. On 2/22/21 at 9:59 AM Staff 4 stated she remembered the incident on 8/11/20 and stated Staff 8 transferred Resident 1 by herself when the resident was care planned as a two-person assist with transfers. Staff 4 stated at the time of the fall Resident 1 was alert and oriented able to state her needs. Staff 4 stated Staff 8 called for assistance around the lunch time hour, when she entered the room Resident 1 was on her/his knees. Staff 4 indicated they lowered the resident's bed and utilized the gait belt on the resident to assist her/him into bed. Staff 4 stated she recalled an x-ray was obtained and no signs of a fracture was indicated. Staff 4 further stated she did not recall the resident complaining of pain or discomfort after the fall and the resident had chronic swelling to the left leg at baseline and thought it was due to Resident 1's [MEDICAL CONDITION]. On 2/22/21 at 11:26 AM Staff 5 (DNS) stated she was not aware of the fall that occurred on 8/11/20 until 8/15/20 when she initiated her investigation. Staff 5 stated Resident 1 was a two-person assist with all transfers and Staff 8 transferred the resident on her own. Staff 5 stated Resident 1 had a gait belt on and during the transfer her/his left knee buckled, and Staff 8 assisted the resident to the floor. Staff 5 stated she did not recall the resident having pain or discomfort and an x-ray was obtained and ruled out a fracture. Staff 8 stated Resident 1 had baseline swelling to the left leg due to her/[MEDICAL CONDITION] and there was no increase to the left knee area. On 2/24/21 at 10:06 AM Staff 7 (Administrator) stated Staff 5 completed investigations for Resident 1 and Staff 5 was no longer with the facility. Staff 7 stated she would expect all CNAs to follow the care plan for transfer status.

Based on interviews and record review it was determined the facility failed to follow the plan of cares for 2 of 3 sampled residents (#s 1 and 3) reviewed for falls. Resident 1 sustained a left thumb fracture and a large left scalp hematoma. Findings include: The facility's 1/10/15 walkie-talkie policy and procedure indicated the purpose of the walkie-talkies was to enable all staff to stay in constant contact with each other when face to face communication was not possible. The policy indicated their use afforded the staff the ability to enhance safety, improve security and increase overall productivity. The document indicated walkie-talkie use was mandatory. It indicated if there was a problem with the device the staff were to write out a work order. 1. Resident 1 was admitted to the facility in March 2017 with [DIAGNOSES REDACTED]. The 3/16/17 Resident Profile Report (CNA Care Plan) included the directive Do not leave resident alone on toilet The 4/15/17 Progress Notes written at 1:15 am by Staff 5 (LPN) indicated she observed Resident 1 on the toilet. Staff 5 documented Resident 1 yelled at Staff 4 (CNA) and Staff 5 (LPN) to get out, get out, I don't want you here. Staff 5 documented she left the room and Staff 4 left Resident 1 alone on the toilet in order to locate Staff 6 (CNA) for assistance. When Staff 6 went into the resident's room she heard a thud and found Resident 1 on the floor. The resident sustained [REDACTED]. An undated witness statement by Staff 4 (CNA) documented she answered a call light and when she attempted to assist Resident 1 to the bathroom she/he began yelling at me saying that (she/he) didn't want me because 'I can do this by myself.' I got the other Aide (Staff 6) to assist the resident The 4/19/17 unsigned type-written interview with Staff 4 (CNA) indicated Called to room to assist resident to bathroom. Resident was yelling, I don't know you, you haven't taken care of me, get out of my room. Resident 1 was described as very confused. The interview documented Staff 6 (CNA) was just outside the door. Staff 4 indicated she left the room and the resident alone for 10-15 seconds. Staff 4 acknowledged she knew the resident was not to left alone on the toilet. Staff 4 stated she had a walkie-talkie and knew the nurse had a walkie-talkie. Staff 4 indicated she was not sure if Staff 6 (CNA) had a walkie-talkie. The 4/19/17 unsigned type-written interview with Staff 5 (LPN) indicated Staff 4 (CNA) answered the resident's call light and assisted Resident 1 to the bathroom. Staff 5 was called into the room and observed the resident's behaviors. Staff 5 told Staff 4 to step outside of the bathroom and just stand outside until resident was ready to return to bed. Staff 5 indicated the resident continued to be abusive and Staff 4 left the resident alone on the toilet to locate Staff 6. Resident 1 was unattended when she/he fell . Staff 5 indicated the CNAs had walkie-talkies. The 4/19/17 unsigned type-written interview with Staff 6 (CNA) indicated Resident 1 was alone for less than a minute when Staff 4 left the room to ask Staff 6 to assist the resident. The facility's 4/26/17 investigation documented by Staff 3 (RNCM) indicated the resident's care plan was followed until the resident's behaviors escalated to the point Staff 4 (CNA) was concerned about the resident's safety. Resident 1 voiced she/he wanted Staff 4 to leave the bathroom. Staff 3 documented Staff 5 (LPN) was aware, checked on resident and CNA while resident was on the toilet. Staff 5 advised Staff 4 to stand just outside the bathroom door to decrease resident agitation, yet remain available to assist. Staff 3 documented the resident's agitation/behaviors continued so Staff 4 felt following the instructions would continue to agitate the resident and went to get additional help from nearby CNA. Staff 3 documented the resident was left alone for 15-20 seconds and fell hurting her/his thumb. Staff 3 documented the resident's care plan was updated to include instruction to divert Resident 1's behavior by discussing familiar topics such as family and resident's past, to maintain presences with resident calling in another caregiver via walkie should resident become agitated while explaining to the resident that care giver will remain with her/him for safety until other caregiver arrives Staff 3 documented the staff was not compliant with facility's policy and procedures. Staff 3 documented Staff 4 felt following the resident's care plan would continue to agitate the resident so went to get help from nearby CNA. Periodic observations conducted on 6/1/17 from 8:20 am through 3:00 pm on the 300 hallway/floor and 400 hallway/floor revealed there was no sound from the walkie-talkies in use. On 6/1/17 at 1:35 pm Staff 15 (CNA) stated she did not have walkie-talkie and stated the devices were sometimes out of order so not functional. On 6/1/17 at 2:55 pm Staff 17 (CNA) stated the walkie-talkies were able to be used to communicate between the 300 and 400 hallways/floors. On 6/1/17 at 3:15 pm Staff 7 (LPN) stated the walkie-talkies had been in use for about three years. Staff 7 stated some CNAs had the walkie-talkies and some CNAs did not. Staff 7 stated sometimes they were not charged. Staff 7 stated the facility tried different brands of walkie-talkies and a different charging station. Staff 7 stated the staff needed to be sure they used the right frequency as the facility walkie-talkies were able to hear construction workers working outside of the facility. On 6/1/17 at 8:35 pm Staff 4 (CNA) stated Resident 1 was upset and did not want Staff 4 to be in the toilet with her/him. Staff 4 stated she heard Staff 6 (CNA) out in the hallway so Staff 4 left the resident alone in the toilet to ask for Staff 6's assistance. Staff 4 stated she knew the resident was not to be left alone in the toilet. Staff 4 stated she had her walkie-talkie though didn't think Staff 6 had her walkie-talkie with her. On 6/2/17 at 4:30 am Staff 6 (CNA) stated Staff 4 (CNA) left the resident alone on the toilet to tell her the resident needed assistance. Staff 5 stated she knew the resident was not to be left alone on the toilet. Staff 6 stated she usually carried her walkie-talkie and stated she used the call light or the walkie-talkie to obtain assistance from the other CNA. On 6/2/17 at 7:00 am and 6/20/17 at 4:57 pm Staff 5 (LPN) stated she observed Resident 1 on the toilet and knew the resident was upset with Staff 4. Staff 5 stated she was not in the resident's room when Staff 4 left Resident 1 alone on the toilet. Staff 5 stated she would expect Staff 4 to use the call light or walk-talkie to ask for assistance from Staff 6 (CNA). Staff 5 stated she did not contact Staff 6 for assistance for Resident 1. On 6/5/17 at 1:39 pm Staff 3 (RNCM) stated she was the DNS at the time of the incident. Staff 3 was asked if Staff 4 (CNA) received an inservice or counseling from the facility. Staff 3 stated the walkie-talkies were not in use when she became the DNS in August 2016. Staff 3 stated the use of the walkie-talkies were started when residents were placed on the 300 floor in April 2017 so the CNAs on the 400 and 300 floors were able to communicate with one another. On 6/5/17 Staff 3 (RNCM) provided a type-written document to indicate Staff 4 (CNA) was counseled on not following the resident's care plan which stated Resident is not to be left alone in the bathroom. Resident 1 was left alone in the bathroom while agitated and resident fell with major injury. Staff 4 acknowledged she knew the resident was not to be left alone but felt she caused the resident more agitation so left to get the CNA outside the room to replace her presence. Staff 4 was counseled her action caused injury to the resident. On 6/6/17 at 10:48 am Staff 12 ((Management Company Representative) stated he was the Interim Administrator when Resident 1 fell and broke her/his left thumb. Staff 12 stated the walkie-talkies were used more once the 300 hallway opened up. Staff 12 stated he did not know how many devices were available to the staff. Staff 12 stated it was his expectation the facility staff were to use the walkie-talkies to communicate with other staff members to ensure safety. Staff 12 stated there should always be enough devices and there should be functional walkie-talkies as a back- up. 2. Resident 3 was admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. The 1/20/17 and 5/8/17 CNA and comprehensive care plan approaches included history of urinary retention, notify nurse if resident does not void 4 hours into your shift. a. The 5/18/17 progress notes documented the resident was found kneeling on her/his hands and knees on the the floor mat along side of the bed. Resident 3's incontinent brief was wet with urine and the resident had a bowel movement. The incident investigation for 5/18/17 contained no documentation when Resident 3 was last toileted. Review of the facility's documentation of Resident 3's toileting pattern indicated she/he voided on 5/18/17 at 10:25 am and then at 9:51 pm. There was no other documentation of toileting provided. There was no documentation the nurse was informed the resident hadn't voided for four hours into the shift. On 6/7/17 at 10:05 am Staff 1 (Interim Administrator), Staff 2 (DNS) and Staff 12 (Management Company Representative) were asked to provide any documentation regarding the 5/18/17 incident to determine when the resident was last toileted and when the nurse was informed the resident hadn't voided. On 6/12/17 at 1:09 pm Staff 2 stated there was no additional information to be provided. b. The 5/19/17 incident investigation documented the incident occurred at 9:00 pm. There was no documentation when resident was toileted last. The description of the incident indicated the resident becomes restless and rolls out of bed-starts putting (her/his) legs over the edge-especially if (her/his) brief is wet or soiled Review of Resident 3's toileting pattern documented the resident voided on 5/19/17 at 3:34 am and at 2:00 pm. There was no other documentation of toileting provided and there was no documentation the nurse was informed the resident hadn't voided. On 6/5/17 at 1:39 pm Staff 3 (RNCM) was asked to provide documentation when the resident was toileted prior to the fall. No additional documentation was provided. On 6/7/17 at 10:05 am Staff 1 (Interim Administrator), Staff 2 (DNS) and Staff 12 (Management Company Representative) were asked to provide any documentation regarding the 5/19/17 incident to determine when the resident was last toileted prior to the fall and the nurse was informed the resident's hadn't voided. On 6/12/17 at 1:09 pm Staff 2 stated there was no additional information to be provided. c. The 5/20/17 progress notes documented at 11:30 pm on 5/19/17 a CNA observed the resident swing her/his legs over the side of the bed and slide to the floor. The documentation indicated the resident's bed including the sheets were wet with urine. Review of Resident 3's toileting pattern documented the resident voided on 5/19/17 at 3:34 am, 2:00 pm and then at 3:44 am on 5/20/17. The incident investigation did not include documentation when the resident was last toileted. There was no documentation the nurse was informed the resident hadn't voided. On 6/5/17 at 1:39 pm Staff 3 (RNCM) was asked to provide documentation of when the resident was toileted last. Staff 3 was asked about the documentation of the resident's toileting pattern. No documentation provided when the resident was toileted last. On 6/6/17 Staff 3 provided documentation Toileting times in (CNA computer documentation) are not real-time. A resident may void multiple times and the CNA will enter it once as voided. On 6/6/17 at 12:29 Staff 15 (CNA) stated the CNAs document when toileting was provided. Staff 15 stated she was able to enter multiple entries of toileting throughout the shift. On 6/7/17 at 10:05 am Staff 1 (Interim Administrator), Staff 2 (DNS) and Staff 12 (Management Company Representative) were asked to provide any documentation regarding the 5/19/17 incidents to determine when the resident was last toileted prior to the falls and the charge nurse was informed the resident did not void. On 6/12/17 at 1:09 pm Staff 2 (DNS) stated the CNA documentation recorded incontinent care as once per shift. Staff 2 stated the current computer system did not allow numerous entries of toileting. Staff 2 stated the facility identified a problem with the current computer system and were in the process of obtaining a new system which would provide the facility an opportunity to document all the times the resident voided.

Based on observations, interview and record review, it was determined the facility failed to ensure adequate monitoring of anticoagulant use or ensure indication for use of antipsychotic medication for 2 of 8 sampled residents (#106 and 6) reviewed for unnecessary medications. This practice placed residents at risk for over-medication and resulted in Resident 106 reaching critical blood test values and [MEDICAL CONDITION] requiring hospitalization . Findings include: 1. Resident 106 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident 106's May 2015 MAR and TAR indicated the [MEDICATION NAME] was given as ordered and the PT/INR blood test was drawn on 5/22/15. Progress Notes from 5/22/15 to 5/28/15 did not include any documented attempts to contact the laboratory to obtain the results from the blood test. A 5/24/15 progress note by Staff 5, RN, documented Resident 106, .had some nose bleeding today off and on, nothing that has drained out of the nose, but detected when (she/he) blows or wipes. No follow-up was documented. Nose bleeds can indicate an excessive dose of [MEDICATION NAME]. A 5/28/15 progress note by Staff 27, RN, documented Resident 106 began to complain of shortness of breath and chest pain. Resident 106 was noted to be slightly sweaty. Staff were unable to obtain a blood pressure. When Resident 106 had a bowel movement, Staff 27 documented she, noted moderate amount of rectal bleeding. Emergency services were called and Resident 106 was transported to the emergency room . The Emergency Department Note dated 5/28/15 showed blood tests were drawn. Resident 106 was found to have critically low blood level counts and was diagnosed with [REDACTED]. The therapeutic range for INR was 3.0-4.0. Resident 106 also suffered a [MEDICAL CONDITION]. The Emergency Department Note dated 5/28/15 documented Resident 106 received Vitamin K to assist with blood clotting, two units of blood, one liter of fluids, and antibiotics due to concerns for pneumonia. Resident 106 was transferred to another hospital for further care. Resident 106 and family were advised of the critical nature of this illness and that (the resident) might not survive. Resident 106 was transferred to the intensive care unit (ICU) on 5/28/15 with [MEDICAL CONDITION] and low blood pressure with an INR exceeding therapeutic levels. An ICU note dated 5/28/15 documented the low blood pressure improved with blood [MEDICAL CONDITION], indicating likely hemorrhagic shock, a state of shock resulting from blood loss. An investigation by the facility on 5/28/15 showed they did not obtain the results of the blood test drawn on 5/22/15. When obtained, Resident 106's INR was found to be 4.02, which was identified as high and exceeded the therapeutic range of 3.0. The lab results were also not received by the attending physicians to review the appropriateness of the [MEDICATION NAME] dose. Resident 106's May 2015 MAR, TAR, and care plan did not direct staff to monitor for significant adverse side effects, such as unusual bleeding. There was no system in place to alert nurses to follow up with the laboratory, if results were not received as expected. A 6/3/15 General Medicine Progress Note documented Resident 106 received a total of five units of blood, four units of platelets, and 10 mg of Vitamin K. Resident 106 discharged from the hospital and returned to the facility. On 6/25/15 at 12:41 am, Staff 27 recalled she had sent Resident 106 to the emergency room for shortness of breath, chest pain, and rectal bleeding, which she described as a moderate amount. She compiled documentation to send with the resident to the emergency room and noticed Resident 106 was on [MEDICATION NAME]. Staff 27 reported being unaware the resident was on [MEDICATION NAME] prior to that time, since it was given earlier in the day. She stated she expected to find INR results at that time, but none could be located. Staff 27 stated it was everyone's responsibility to follow up on that. On 6/25/15 at 8:14 am, Staff 5 verified Resident 106 had a nosebleed prior to the hospital admission. He reported he didn't notify the doctor about that, because he thought Resident 106 had a dry nose. Staff 5 reported monitoring for side effects related to [MEDICATION NAME] was not typically care planned. On 6/25/15 at 9:56 am, Staff 11, LPN, reported they started to have a problem receiving blood test results when the laboratory changed computer systems. He reported they got a copy of the INR for the resident the week after the resident was sent to the hospital. He was aware of the side effects, but verified there was nothing in the care plan or on the MAR/TAR to direct staff in the monitoring of a resident on [MEDICATION NAME]. On 6/25/15 at 2:20 pm, Staff 4, RNCM, reported an ongoing issue with the lab since the lab changed their computer system. She stated the nurses didn't call to follow up when the results weren't sent to the facility and there was a breakdown in communication. When asked about a facility policy regarding lab work, Staff 4 stated they were currently working on that, because this is obviously a huge issue. We have to change what we do because of how the lab is now working. When asked if she was expected to do any additional care planning around a resident receiving [MEDICATION NAME], Staff 4 stated it was simply a part of the general nursing assessment and no additional care planning was done. On 6/25/15 at 3:42 pm, Staff 2, DNS, verified the events that transpired for Resident 106 and verified the INR results were not obtained from the laboratory after they were drawn. She stated staff are expected to call the laboratory for a copy of the results if they are missing. She stated there was no trigger for the nurses to follow up on a missing lab result. 2. Resident 6 was admitted in 1/2015 with [DIAGNOSES REDACTED]. Medication orders included [MEDICATION NAME] 0.25 mg PO qd every other day in the evening. A 1/24/15 [MEDICAL CONDITION] Medication Use CAA identified the resident was on an antipsychotic medication every other day. Contributing factors included anxiety with no behaviors observed since admission. Monthly Behavior Intervention Management Program (BIMP) meetings from February through May 2015 identified no behaviors related to the antipsychotic medication use. No referrals were pursued. During the same time period, two letters were sent from the pharmacist to the physician. On 2/19/15, a gradual dose reduction (GDR) was requested as it was felt the resident would benefit from a trial off of the medication. The lack of identified behaviors was not identified in the letter. The physician disagreed with the request on 3/2/15 with no additional information regarding the reasons for the prescribed antipsychotic medication provided. Again on 5/4/15, the pharmacist sent a letter to the physician requesting a re-evaluation of the medication. The ongoing lack of behaviors was not identified in the letter. The physician was asked to document a clinical rationale for continued use of the antipsychotic medication. The physician disagreed with a dose reduction on 6/15/15 with no additional information provided. During observations of the resident on 6/22/15 at 3:18 pm and 6/24/15 at 9:21 am and 11:27 am, the resident was neatly dressed and groomed, smiling and engaged in activities. She/he responded positively to staff and demonstrated no anxiety or negative behavior. In a 6/25/15 interview at 10:26, Staff 8, CNA, stated the resident did not have mood or behavior issues that she knew of. When Staff 8 worked at night, the resident was awake, but not disruptive. When interviewed on 6/25/15 at 2:22 pm, Staff 17, CNA, stated the resident liked to wander the hall each evening and did not like to be interrupted during her/his rounds, but did not show any mood or behavior issues. In a 6/26/15 interview at 8:14 am, Staff 4, RNCM, stated the resident was admitted with the [MEDICATION NAME] order and the request for a GDR had been declined twice by the physician. Staff 4 was uncertain if anyone had explored the resident's history of behaviors with the family or previous placement. The current plan was to approach the physician periodically and continue the monthly BIMP meetings. On 6/30/15, the facility provided information via email regarding the 6/25/15 physician visit. Resident 6 was given a [DIAGNOSES REDACTED]. Target behaviors necessitating the use of [MEDICATION NAME] were not identified.

Based on interview and record review it was determined the facility failed to ensure lab results were obtained in a timely manner for 2 of 8 sampled residents (#106 and 6) reviewed for unnecessary medication. This placed residents at risk for inadequate care and resulted in Resident 106 reaching critical blood test values and [MEDICAL CONDITION] requiring hospitalization . Findings include: 1. Resident 106 was admitted to the facility in 5/2015 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Resident 106's May 2015 MAR and TAR indicated the [MEDICATION NAME] was given as ordered and the PT/INR blood test was drawn on 5/22/15. Progress Notes from 5/22/15 to 5/28/15 did not include any documented attempts to contact the laboratory to obtain the results from the blood test. A 5/28/15 progress note documented Resident 106 was sent to the emergency room with symptoms including shortness of breath, chest pain, sweating, and rectal bleeding. The Emergency Department Note dated 5/28/15 showed blood tests were drawn. Resident 106 was found to have critically low blood level counts and was diagnosed with [REDACTED]. The therapeutic range for INR was 3.0-4.0. An investigation by the facility on 5/28/15 showed they did not obtain the results of the blood test drawn on 5/22/15. When obtained, Resident 106's INR was found to be 4.02, which was identified as high and exceeded the therapeutic range of 3.0. The lab results were also not received by the attending physicians to review the appropriateness of the [MEDICATION NAME] dose. A 6/3/15 General Medicine Progress Note documented Resident 106 received a total of five units of blood, four units of platelets, and 10 mg of Vitamin K. Resident 106 discharged from the hospital and returned to the facility. On 6/25/15 at 12:41 am, Staff 27, RN, stated she expected to find INR results when collecting documentation to send with the resident to the emergency room , but none could be located. Staff 27 stated it was everyone's responsibility to follow up on that. On 6/25/15 at 9:56 am, Staff 11, LPN, reported they started to have a problem receiving blood test results when the laboratory changed computer systems. He reported they got a copy of the INR for the resident the week after the resident was sent to the hospital. On 6/25/15 at 2:20 pm, Staff 4, RNCM, reported an ongoing issue with the lab since the lab changed their computer system. She stated the nurses didn't call to follow up when the results weren't sent to the facility and there was a breakdown in communication. When asked about a facility policy regarding lab work, Staff 4 stated they were currently working on that, because this is obviously a huge issue. We have to change what we do because of how the lab is now working. On 6/25/15 at 3:42 pm, Staff 2, DNS, verified the events that transpired for Resident 106 and verified the INR results were not obtained from the laboratory after they were drawn. She stated staff are expected to call the laboratory for a copy of the results if they are missing. She stated there was no trigger for the nurses to follow up on a missing lab in the care plan. Refer to F329. 2. Resident 6 was admitted in 1/2015 with [DIAGNOSES REDACTED]. A 5/8/15 Pharmacy Note to the Physician identified the use of the [MEDICATION NAME] with no recent lipid panel (a lab which measured the cholesterol and triglyceride levels in the blood) found in the chart. The physician responded on 5/15/15, agreeing to the blood test. No results were found in the resident's paper or electronic medical record. On 6/25/15 at 2:40 pm, Staff 2, DNS, located the lab book kept at the nurses station. It identified the lipid panel was scheduled to be drawn on 5/22/15. Staff 2 also located a copy of the pharmacy letter which indicated the lab was done and results were needed. In a 6/25/15 interview at 2:49 pm, Staff 2 stated at the time of the lab order, there was no system in place to ensure results were received in a timely manner. Although a change in their system had occurred about two weeks previously, Resident 6's lipid panel results were not received.

1. Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services related to surgical incision care and monitoring for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who were reviewed for surgical incisions. Resident 1 was transported to the hospital and required surgery for [REDACTED]. a. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 1 no longer a resided at the facility. A hospital Inpatient Physician Discharge Summary dated 2/26/13 revealed Resident 1 had lower back spinal surgery on 2/22/13. Wound care orders were: keep the incision clean and dry, do not soak the incision in water, may shower three days after surgery and monitor for any redness, swelling, drainage or increased pain at the incision site and notify the physician. A review of an Initial Admission assessment dated [DATE] revealed Resident 1 had a lower back incision with intact staples. A review of Resident 1's February and March 2013 TARs revealed the physician was to be notified of any drainage or increased pain at the incision site. A NN dated 2/26/13 revealed Resident 1 was admitted with a lower back incision and it was clean, dry and intact. The incision was open to air and the staples were intact. A review of NNs from 2/26/13 to 3/8/13 indicated Resident 1's back incision was clean, dry and intact with no sign or symptoms of infection. A 24 Hour Report note dated 3/8/13 indicated a dry dressing was applied to Resident 1's incision because it was open toward the bottom. NNs dated 3/9/13 and 3/10/13 indicated Resident 1 had a lower back dressing that was clean, dry and intact. A NN dated 3/11/13 revealed Resident 1's incision dressing was changed and there was a small amount of bloody drainage and yellow slough in the bed of the incision. (Yellow drainage from the incision can be indicative of an infectious process.) A review of Monthly Vital Sign Flow sheet revealed on 3/12/13 Resident 1 had a temperature of 100.8?F. (Normal body temperature is 98.6?F. An elevated temperature can be indicative of an infectious process.) A review of a Monthly Vital Sign Flow sheet revealed on 3/12/13 Resident 1 had a blood pressure reading of 88/52 and an oxygen saturation reading of 83% on room air. (Both of these vital signs are below normal parameters.) A review of Resident 1's March 2013 MAR indicated [REDACTED]. Prior to 3/12/13, the resident was not administered any [MEDICATION NAME]. An Occupational Therapy Treatment Encounter Note dated 3/12/13 revealed Resident 1 had increased confusion and was fatigued, complained of a burning sensation with urination, and the charge nurse reported the resident was running a fever. A Physical Therapy Treatment Encounter Note dated 3/12/13 revealed Resident 1 was in bed and was very lethargic, complained of increased right hip pain and was administered medication that "knocked (her/him) out." A NN dated 3/12/13 indicated Resident 1 was sent to the emergency room and was then transferred to an out of town hospital with a [DIAGNOSES REDACTED]. Interviews on 1/3/14 with Staff #s 3, 5 and 6 (RNs), stated they were not able to recall Resident 1 or any treatment or care they provided to the resident. A review of Resident 1's record revealed no documentation the facility notified the resident's physician or family of the resident's change in condition or the new treatment the facility provided to the resident's surgical incision site. In a fax dated 1/6/14 Staff 1(Administrator) acknowledged the facility did not notify the physician of the change in condition or treatment to Resident 1's incision. In an interview on 1/7/14 at 12:55 pm Witness 3 (Family) stated she observed the incision at an out of town hospital prior to any treatment and stated the incision was "ugly", inflamed, discolored, draining fluid, and did not look like it was healing. Witness 3 stated the facility did not contact her in the days prior to Resident 1 being sent to the hospital to inform her of any change in the resident's condition. In an interview on 1/7/14 at 1:30 pm Resident 1 stated before she/he was sent to the hospital on [DATE], she/he was too weak to stand or hold a spoon to eat and was having back pain. Resident 1 recalled staff covering the incision prior to showers, but did not recall if staff cleaned the incision. A review of Resident 1's record revealed no new orders for treatment or monitoring of the resident's surgical incision site related to the change in condition of the incision, no assessment of the condition of the incision between 3/8/13 and 3/11/13, and no indication the incision site was ever cleaned. A review of a local hospital Emergency Department Note dated 3/13/13 revealed Resident 1's back incision was covered with gauze with light brown drainage on it. The incision was 8cm long, the lower 2.5-3cm of the incision had dehisced (separated) and had cloudy light brown bloody drainage. A culture was taken of the drainage to check for infection. The note indicated the wound was infected. The resident was started on antibiotics and was transferred to an out of town hospital for further evaluation and possible surgical debridement. b. Resident 2 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. On 1/2/14 at 1:10 pm a dressing change to Resident 2's right knee was observed. There was a small amount of dry dark red drainage visible on the outside of the dressing. The resident's right knee incision started above the knee and ended below the knee. The incision was well approximated with staples in place along the entire length of the incision. No drainage was observed. The skin between the staples and around the incision was swollen with some redness along the middle and lower edges of the incision. Staff 3 (RN) cleansed the resident's incision and a new dressing was applied. On 1/2/14 at 1:10 pm Staff 3 stated Resident 2's swelling and redness had increased. Staff 3 stated she would only chart an assessment of the incision if there was a change. Staff 3 stated she would just sign off on the dressing change in the TAR because Resident 2 was assigned to the evening shift nurse for daily charting. A review of Resident 2's record found no assessments of the resident's surgical incision site since admission on 12/20/13 to 1/2/14. On 1/2/14 at 3:20 pm Staff 2 (DNS) stated it was the facility's expectation to assess the condition of surgical incisions and dressings. On 1/3/14 at 9:30 am Staff 3 stated a Nurses Note to document a surgical incision assessment was only charted if there was a change in condition or treatment. In an interview on 1/3/14 Staff 1 (Administrator) acknowledged the facility did not have a system in place for the monitoring of surgical incisions. c. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A local hospital Procedure Note dated 12/27/13 indicated Resident 4 had surgery for [REDACTED]. An observation on 1/3/14 at 1035 am revealed a dressing covering the resident's feeding tube insertion site. The dressing was clean, dry, and intact. On 1/3/14 at 1035 am Staff 4 (RN) stated she changed the dressing that morning. A review of Resident 4's record found no assessments of the feeding tube insertion site incision since admission on 1/2/14. On 1/2/14 at 3:20 pm Staff 2 (DNS) stated it was the facility's expectation to assess the condition of surgical incisions and dressings. In an interview on 1/3/14 Staff 1 (Administrator) acknowledged the facility did not have a system in place for the monitoring of surgical incisions. d. Resident 3 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. NNs dated 12/24/13 to 12/28/13 indicated the right hip incision was well approximated, had no drainage and was without signs and symptoms of infection. An observation on 01/3/14 at 10:45 am with Staff 4 (RN) present revealed Resident 3 had a right hip incision with no dressing in place. The skin was pink, with no drainage and the resident denied pain when Staff 4 touched the area. A review of Resident 3's record found no assessments of the surgical incision after 12/28/13. On 1/2/14 at 3:20 pm Staff 2 (DNS) stated it was the facility's expectation to assess the condition of surgical incisions and dressings. In an interview on 1/3/14 Staff 1 (Administrator) acknowledged the facility did not have a system in place for the monitoring of surgical incisions. 2. Based on record review and interview it was determined the facility failed to follow physician's orders [REDACTED].#1). This placed residents at risk for adverse medication reactions. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 1 was no longer a resident at the facility. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's March 2013 MAR indicated [REDACTED]. In an interview on 1/8/14 at 11:40 am Staff 1 (Administrator) and Staff 2 (DNS) acknowledged 4:00 pm was not the resident's bedtime.

Based on interviews and record review it was determined that the facility failed to develop and implement care planned interventions to prevent injury for 1 of 3 residents (# 1) who were at risk for falls. Resident 1 sustained a left knee fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 1/28/11 admission nursing assessment indicated the resident was alert and oriented and had good memory. A 1/28/11 Fall Risk Assessment indicated the resident was at high risk for falls due to a history of falls and balance problems. The Fall Risk Assessment indicated if a resident was at high risk for falls "A prevention protocol should be initiated immediately and documented on the care plan." The care plan dated 1/27/11 did not indicate the resident was at risk for falls nor were there fall interventions documented on the care plan. On 2/3/11 the resident was found on the floor in the bathroom. The incident investigation indicated the resident had been assisted to the toilet and had been told to activate the call light when finished. The resident attempted to transfer from the toilet independently and slid to the floor. The resident was not injured. The investigation indicated a "mini in-service to be written soon so that (resident) is never left on the (bathroom) unattended due to is a high fall risk." A review of the resident's care plan revealed no new fall interventions were added after the 2/3/11 fall nor was the "mini in-service" completed. According to nursing notes on 2/7/11 the resident was found on the floor in the bathroom. The resident complained of pain in her/his left leg and was sent to the hospital and diagnosed with [REDACTED]. On 2/8/11 the resident's care plan was updated to include "Do not leave (resident) in the (bathroom) unattended." On 2/18/11 the resident was readmitted to the facility. A new care plan dated 2/18/11 did not indicate the resident was at risk for falls nor were there fall interventions documented on the care plan. According to 2/19/11 day shift nursing notes the resident was "very confused, anxious, paranoid." At 8:40 pm the resident was noted to be restless and anxious and was given Ativan for anxiety. At 8:45 pm the resident was found on the floor in her/his room; blood was coming from an incision on the resident's left knee. An incident investigation indicated the resident had been left alone on the toilet when the fall occurred. On the morning of 2/20/11 the resident's left knee was noted to be swollen and a dressing on the left knee was saturated with blood. The resident's physician was notified and orders were given to send the resident to the hospital. The resident did not return to the facility. In an interview on 3/22/11 at 2:45 pm Staff 1, CNA, stated the resident did not have care planned fall interventions prior to the 2/7/11 fall. In an interview on 3/23/11 at 9:30 am Staff 2, CNA, who worked with the resident after her/his 2/18/11 readmission, stated the resident's current care plan did not indicate the resident should not to be left alone in the bathroom. In an interview on 3/21/11 at 12:00 pm Staff 3, DNS stated when a resident is identified to be a fall risk, fall interventions are developed and added to the resident's care plan. Staff 1 stated a Root Cause Analysis was in process to determine why Resident 1 did not have care planned fall interventions identified after both admissions.