Every finding on record at Corvallis Manor Nursing & Rehabilitation Center

Based on interview, observation, and record review it was determined the facility failed to ensure medications were safely stored with proper temperature monitoring for 1 of 2 refrigerators reviewed for medication storage. This placed all residents with refrigerated medications at risk for receiving ineffective or unstable medications, including insulin. Findings include: According to the American Diabetes Association, insulin stored too cold does not work as intended and has reduced effectiveness, which may cause hyperglycemia (high blood sugar) and left untreated, result in ketoacidosis (a life-threatening emergency where a high level of acids build up in the blood). Insulin stored below 36 degrees F should be discarded and replaced.On 5/5/26 at 1:37 PM, Staff 1 (Administrator) stated refrigerator temperatures were monitored with digital temperatures sent to an electronic application every hour. Staff 1 stated the system did not send out an alert if the temperature was an abnormal temperature, but he checked the application weekly.On 5/7/26 at 4:40 PM, Staff 1 provided the digital refrigerator temperature logs for the New Wing medication refrigerator. A review of the temperature logs indicated the New Wing medication refrigerator serviced rooms 208 through 316 and had temperatures below 36 degrees Fahrenheit for 19 of 30 days reviewed. Temperatures below 36 degrees were as follows:-4/13/26 one hour at 34.6 degrees F-4/19/26 three hours with the low of 25.7 degrees F-4/20/26 16 hours with a low of 19.6 degrees F-4/21/26 21 hours with a low of 20.5 degrees F-4/22/26 14 hours with a low of 21 degrees F-4/23/26 10 hours with a low of 22.9 degrees F-4/24/26 14 hours with a low of 23.3 degrees F-4/25/26 six hours with a low of 28.2 degrees F-4/26/26 eight hours with a low of 26.8 degrees F-4/27/26 four hours with a low of 28.4 degrees F-4/28/26 eight hours with a low of 27.5 degrees F-4/29/26 nine hours with a low of 27.8 degrees F-4/30/25 21 hours with a low of 24.9 degrees F-5/1/26 four hours with a low of 28.9 degrees F-5/2/26 nine hours with a low of 21.4 degrees F-5/3/26 24 hours with a low of 17.5 degrees F-5/4/26 24 hours with a low of 19.3 degrees F-5/5/26 four hours with a low of 25.6 degrees F-5/6/26 three hours with a low of 24.9 degrees F-5/7/26 seven hours with a low of 26.2 degrees F On 5/7/26 at 2:45 PM, Staff 2 (DNS) stated Staff 1 monitored the refrigerator temperatures. Staff 2 stated if the refrigerated medications were exposed to temperatures outside the safe range, the medication needed to be disposed of. On 5/8/26 at 8:15 AM the New Wing medication refrigerator was observed with Staff 15 (LPN). It held nine GLP injections (a medication used to treat diabetes and help with weight loss), 29 glargine insulin pens (long-acting insulin), one glargine insulin vial, 10 insulin aspart pens (short acting insulin), one insulin aspart vial, and one shingles vaccine. The glargine insulin vial was in a plastic bag against the back of the refrigerator and ice crystals were observed on the bag. On 5/8/26 at 2:17 PM, the information from the temperature logs was shared with Staff 16 (Pharmacist) who stated with that many hours under freezing, the insulin, GLP, and vaccine were no good and needed to be discarded.

Based on interview and record review it was determined the facility failed to ensure residents were offered pneumococcal vaccines for 4 of 5 sampled residents (#s 7, 13, 18, and 34) reviewed for vaccines. This placed residents at risk for pneumonia. Findings include:A review of the facility's revised 8/2024 Infection Prevention and Control-Influenza and Pneumococcal Immunizations policy revealed the following:-Residents [AGE] years of age and those aged 19-64 with chronic medical conditions or other risk factors, who have not previously received PCV, or whose previous vaccination history is unknown are offered pneumococcal vaccination per current CDC recommendations.-The resident record will reflect the provision of education and the administration or refusal of the immunization, or non-administration due to medical contraindication. 1. Resident 7 was admitted to the facility in 2021 with a diagnosis of heart failure.Resident 7's clinical record revealed she/he was eligible for, but was not offered, a pneumococcal vaccine.On 5/7/26 at 10:12 AM Staff 12 (Infection Preventionist LPN) stated a couple weeks ago she identified Resident 7 was eligible but was not offered pneumococcal vaccine yet.On 5/7/26 at 10:16 AM Staff 6 (LPN Resident Care Manager) stated she was the previous Infection Preventionist from November 2025 to March 2026 and never had the chance to offer the pneumococcal vaccination to eligible residents.On 5/7/26 at 1:46 PM Staff 2 (DNS) stated she was unsure what the regulation was to offer residents the pneumococcal vaccination. 2. Resident 13 was admitted to the facility in 2024 with a diagnosis of heart failure.Resident 13's clinical record revealed she/he was eligible for, but was not offered, a pneumococcal vaccine.On 5/7/26 at 10:12 AM Staff 12 (Infection Preventionist LPN) stated she a couple weeks ago she identified Resident 13 was eligible but was not offered pneumococcal vaccine yet.On 5/7/26 at 10:16 AM Staff 6 (LPN Resident Care Manager) stated she was the previous Infection Preventionist from November 2025 to March 2026 and never had the chance to offer the pneumococcal vaccination to eligible residents.On 5/7/26 at 1:46 PM Staff 2 (DNS) stated she was unsure what the regulation was to offer residents the pneumococcal vaccination. 3. Resident 18 was admitted to the facility in 2021 with a diagnosis of diabetes.Resident 18's clinical record revealed she/he was eligible for, but was not offered, a pneumococcal vaccine.On 5/7/26 at 10:12 AM Staff 12 (Infection Preventionist LPN) stated a couple weeks ago she identified Resident 18 was eligible but was not offered pneumococcal vaccine yet.On 5/7/26 at 10:16 AM Staff 6 (LPN Resident Care Manager) stated she was the previous Infection Preventionist from November 2025 to March 2026 and never had the chance to offer the pneumococcal vaccination to eligible residents.On 5/7/26 at 1:46 PM Staff 2 (DNS) stated she was unsure what the regulation was to offer residents the pneumococcal vaccination. 4. Resident 34 was admitted to the facility in 2024 with a diagnosis of dementia.Resident 34's clinical record revealed she/he was eligible for, but was not offered, a pneumococcal vaccine.On 5/7/26 at 10:12 AM Staff 12 (Infection Preventionist LPN) stated a couple weeks ago she identified Resident 34 was eligible but was not offered pneumococcal vaccine yet.On 5/7/26 at 10:16 AM Staff 6 (LPN Resident Care Manager) stated she was the previous Infection Preventionist from November 2025 to March 2026 and never had the chance to offer the pneumococcal vaccination to eligible residents.On 5/7/26 at 1:46 PM Staff 2 (DNS) stated she was unsure what the regulation was to offer residents the pneumococcal vaccination.

Based on interview and record review it was determined the facility failed to develop and implement an effective water management plan to identify potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.A review of the facility's 3/2023 Infection Prevention and Control- Legionnaire's Disease Policy revealed the following:-Legionnaires' Disease is caused by the organism Legionella pneumophila. Although rare in long term care facilities, Legionnaires' Disease may occur and could be either facility or community acquired. Specific actions should be taken for prevention of Legionella and for investigation should a case occur.A review of the 12/30/25 Facility Assessment revealed no evidence a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the facility's main water system.A review of the facility's 1/22/26 Risk Management plan for Legionella Control revealed no facility water system assessment identifying potential areas of growth and spread of water-borne pathogens and no risk analysis assessment with control measures to prevent opportunistic waterborne pathogens. The plan also contained another facility's name throughout the document.On 5/11/26 at 11:08 AM and at 11:30 AM Staff 9 (Maintenance Director) and Staff 1 (Administrator) stated they were provided the template Risk Management Plan for Legionella Control from another facility and could not remove the other facility's name within the plan, however Staff 1 stated he updated the information to reflect their facility. Staff 1 was asked if the facility developed and implemented a water management plan and Staff 1 stated facility staff identified there was nowhere water-borne pathogens could grow as the water was always in use and the facility never had an empty resident room. Staff 1 was asked for documentation of that assessment, and none was provided. Staff 1 stated Legionella control was not part of their Risk Management plan.

Based on interview and record review it was determined the facility failed to obtain consent from residents with dosage changes to their psychotropic medications for 2 of 5 sampled residents (#s 4 and 7) reviewed for unnecessary medications. This placed residents at risk for being uninformed of their medication dosages. Findings include: A review of the 4/28/25 revised facility Use of Psychotropic Medication(s) policy revealed the following: -The facility will document the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). 1. Resident 4 was admitted to the facility in 6/2025 with diagnoses including depression and heart failure. The 6/23/25 admission MDS revealed Resident 4 had a BIMS of 15 indicating she/he was cognitively intact. A review of the 3/12/26 Consent for use of Psychotropic Medication revealed Resident 4 consented to the use of duloxetine (an antidepressant) 60 MG bid. A 3/20/26 Pharmacy Recommendation revealed Resident 4 was due for a gradual dose reduction (GDR) for duloxetine 60 MG bid. On 3/27/26 Resident 4's provider responded to the pharmacy recommendation stating to complete a GDR for duloxetine to 90 MG once a day. A 4/13/26 signed physician order revealed an order for duloxetine 90 MG once a day with a start date of 3/28/26. A review of the 3/2026 MAR revealed Resident 4 was administered duloxetine 90 MG once a day starting on 3/29/26. A review of Resident 4's medical record revealed no updated consent for duloxetine 90 MG once daily prior to Resident 4 receiving the medication. On 5/11/26 at 8:55 AM Resident 4 stated the facility did not talk to her/him about the decrease in her/his antidepressant medication. On 5/11/26 at 11:56 AM Staff 6 (LPN Resident Care Manager) stated the facility did not speak to the residents when a GDR occurred, only the provider did. On 5/11/26 at 1:30 PM Staff 2 (DNS) confirmed Resident 4 did not consent to the decrease in duloxetine medication that started on 3/28/26. Staff 2 stated the facility did not have a good process in place for residents to consent to GDR's and only the provider spoke to the resident. 2. Resident 7 was admitted to the facility in 7/2021 with diagnoses including bipolar disorder and post-traumatic stress disorder (PTSD). A 3/20/26 Optum Progress Note indicated Resident 7 was seen by Staff 13 (APRN-BC) on 3/19/26. A 3/20/26 pharmacy recommendation indicated a gradual dose reduction (GDR) for Resident 7's trazodone order which was signed on 3/25/26 by Staff 13. On 5/7/26 at 10:22 AM, Resident 7 stated she/he was not aware she/he took trazodone. On 5/7/25 at 1:14 PM, Staff 6 (LPN Resident Care Manager) stated she was not sure when or who reviewed the GDR for trazodone with Resident 7. On 5/7/26 at 1:50 PM, Staff 6 provided a progress note written by Staff 13 with an addendum written on 5/7/26 at 1:40 PM indicating Staff 13 discussed the GDR with Resident 7 during the 3/19/26 visit. On 5/7/26 at 2:14 PM, Staff 13 stated she was not sure when she received the pharmacy recommendation for Resident 7. Staff 13 stated she discussed the GDR with Resident 7 during the 3/19/26 visit. Staff 13 stated she signed the order on 3/25/26. A review of the medical record revealed no evidence of an updated consent form after the GDR. On 5/8/26 at 8:36 AM Staff 2 (DNS) stated the pharmacy recommendations were written on 3/20/26 and she received the recommendations via email on 3/24/26. Staff 2 also stated staff were expected to discuss GDRs with the residents or the resident representative prior to initiating a GDR and resident consent was only obtained when psychotropic medication doses were increased, not decreased.

Based on interview and record review it was determined the facility failed to implement a baseline care plan for required care and interventions for 1 of 4 sampled residents (#105) reviewed for ADLs. This placed residents at risk for unmet needs and unnecessary pain. Findings include:Resident 105 was admitted to the facility in 4/2026 with diagnoses including compression fracture of the spine and muscle weakness.The 4/13/26 Admit Visit Progress Note revealed Resident 105's chief complaint was her/his compression fracture of the spine and generalized weakness. The 4/14/26 admission MDS and associated CAA indicated Resident 105 reported frequent severe pain, sustained a compression fracture of the spine from a fall, and had a BIMS assessment score of 13 (cognitively intact). The resident was at risk for unrelieved pain.The 4/17/26 baseline Care Plan indicated Resident 105 required staff assistance for toileting and hygiene. The resident was also at risk for pain related to chronic pain and had limited physical mobility. Staff were to respond to any complaints of pain and report any decreases in functional abilities. No reference to the prevention of pain or care associated with Resident 105's compression spine fracture was identified in the care plan. A 4/23/26 typed and signed note by Staff 4 (Unit Manger-LPN) revealed Resident 105 had an incident on 4/22/26 with Staff 25 (CNA). Resident 105 indicated Staff 25 moved her/him quickly while the resident was in bed and caused pain in her/his back. The note further revealed Resident 105 indicated it was painful to move, Staff 25 did not follow the resident's verbal direction for care, and the resident requested education for Staff 25.On 5/5/26 at 8:46 AM, Resident 105 stated she/he had back pain when moved and requested a slight adjustment of her/his position in bed from Staff 25 on 4/22/26. Resident 105 stated Staff 25 used a draw sheet (cloth placed under the resident to assist with movement) and jerked her/his back which caused the resident to yell out. On 5/6/26 at 12:37 PM, Staff 4 stated she was informed of the incident with Staff 25 and acknowledged Resident 105 experienced pain because of the care provided by Staff 25. Staff 4 stated Resident 105 declined to file a complaint and Staff 4 believed no further action was necessary.On 5/10/26 at 7:57 PM, Staff 25 stated she was aware Resident 105 had a bad back based on information shared by other CNAs and followed the care plan as written. On 5/11/26 at 10:58 AM, Staff 4 acknowledged Resident 105's care plan did not address the resident's back fracture and associated pain prevention. On 5/11/26 at 12:32 PM, Staff 2 (DNS) acknowledged the care needed to address Resident 105's fractured back and associated pain was not in the care plan and a correction to the care plan was needed.

Based on observation, interview, and record review it was determined the facility failed to develop and implement a comprehensive care plan for 2 of 4 sampled residents (#s 82 and 84) reviewed for ADLs. This placed residents at risk for unmet care needs related to toileting hygiene and meal tray set up for dependent residents. Findings include:1. Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and chronic pain. The 6/13/25 revised Care Plan revealed Resident 84 was dependent on staff for meeting physical needs due to physical limitations. The 11/17/25 revised Care Plan revealed Resident 84 had an ADL self-care performance deficit due to residual right-side weakness from a history of stroke. The 12/26/25 Annual MDS indicated Resident 84 had upper and lower impaired range of motion on one side and required set-up assistance for eating. The 12/30/25 revised Care Plan indicated Resident 84 required set up assistance of one staff for eating. A 4/22/26 Quarterly Care Conference note indicated Witness 4 (Family Member) expressed Resident 84's left hand was used for eating, so the utensils were to be on the resident's left side. Resident 84's Kardex indicated staff were to provide assistance with dining, such as tray set up. A review of the resident's care plans did not reveal any information related to placing food items and utensils to the resident's left side, or to ensure all food packing was opened. On 5/4/26 at 10:09 AM Resident 84 had a sign in her/his room which indicated meal trays were to be set up on the resident's left side. On 5/4/26 at 11:17 AM Witness 4 (Family Member) stated Resident 84 was only able to use her/his left hand for eating and required her/his tray set up with utensils on the left side, with all items unwrapped and opened. Witness 4 stated she put up the sign in the resident's room to remind staff where to position tray items. On 5/5/26 at 12:48 PM Resident 84's lunch tray included fruit salad in a bowl placed on the right side of the tray, out of reach of the resident. On 5/6/26 at 8:35 AM Resident 84's breakfast tray included a bowl of plain oatmeal with the lid on. In addition, the resident had butter and jelly in un-opened sealed packets on the right side of the tray, out of the resident's reach. On 5/6/26 at 5:08 PM Staff 10 (CNA) indicated Resident 84 needed all food items opened and placed on her/his left side. On 5/7/26 at 1:59 PM Staff 6 (LPN Resident Care Manager) stated Resident 84's care plan did not direct staff to set up meal trays on the resident's left side and to open all food packaging. 2. Resident 82 was admitted to the facility on [DATE] with diagnoses including bilateral lower limb reduction defects (congenital deficit where both legs fail to form completely) and weakness. The 4/9/26 admission MDS revealed Resident 82 had a BIMS score of 15 indicating she/he was cognitively intact. The 4/9/26 admission MDS Urinary Incontinence CAA revealed Resident 82 was incontinent of bowel and bladder and was dependent on staff for with perineal hygiene and brief changes. A review of the 4/3/26 care plan revealed Resident 82 required staff assistance for toileting hygiene and staff were to keep Resident 82's skin clean and dry. On 5/4/26 at 2:53 PM and on 5/7/26 at 11:18 AM Resident 82 stated she/he was unable to assist with toileting hygiene and depended on staff. Resident 82 stated a couple weeks ago her/his skin became sensitive to the wipes used during toileting hygiene care. Resident 82 stated Staff 22 (LPN) completed various treatments for her/him and implemented the use of a warm wet washcloth during toileting hygiene care to reduce any irritation. Resident 82 stated she/he had to remind staff what supplies to use and felt she/he should not have to remind staff. On 5/7/26 at 9:35 AM Staff 17 (CNA) stated recently staff started to use a warm wet washcloth to assist with toileting hygiene clean up as the wipes were irritating Resident 82's skin. On 5/7/26 at 11:23 AM Staff 29 (CNA) stated when she assisted Resident 82 with toileting hygiene, she used wipes to clean up. Staff 29 stated she was unaware Resident 82 preferred washcloths. On 5/7/26 at 11:31 AM Staff 19 (CNA) stated recently Resident 82 informed her the wipes were causing irritation and Resident 82 wanted to use washcloths during toileting hygiene care. On 5/7/26 at 2:28 PM Staff 30 (CNA) stated when Resident 82 first admitted to the facility, she/he had her/his own wipes for toileting hygiene due to sensitive skin but eventually ran out of those wipes so staff started to use the facility's wipes. Staff 30 stated the facility wipes irritated Resident 82's skin. She/he stated Staff 22 implemented the use of washcloths with baby soap. Staff 30 stated since the switch of supplies she noticed Resident 82's skin to be less irritated. On 5/11/26 at 9:23 AM Staff 22 stated she completed various treatments for Resident 82 and a couple weeks ago Resident 82 stated the facility wipes caused burning and skin irritation. Staff 22 stated she suggested the use of washcloths and baby soap during cares to reduce the irritation and Resident 82 agreed. Staff 22 stated she told Resident 82 to tell staff what her/his preferences were during cares. Staff 22 acknowledged Resident 82's preferences should be in the care plan for all staff to know. On 5/11/26 at 12:56 PM Staff 4 (LPN Resident Care Manager) stated she was not aware Staff 22 implemented the use of washcloths and baby soap for Resident 82 during toileting hygiene care and that information should be placed in the care plan. On 5/11/26 at 1:23 PM Staff 2 (DNS) acknowledged Resident 82's preferences should be in the care plan.

Based on interview and record review it was determined the facility failed to ensure a dependent resident received assistance with toileting hygiene for 1 of 1 sampled resident (#82) reviewed for bowel incontinence. This placed residents at risk for skin related issues and infections. Findings include: Resident 82 was admitted to the facility on [DATE] with diagnoses including bilateral lower limb reduction defects (congenital deficit where both legs fail to form completely) and weakness.The 4/9/26 admission MDS revealed Resident 82 had a BIMS of 15 indicating she/he was cognitively intact.The 4/9/26 admission MDS Urinary Incontinence CAA revealed Resident 82 was incontinent of bowel and bladder and was dependent on staff for perineal hygiene and brief changes.A review of the 4/3/26 care plan revealed Resident 82 required the assistance of one staff member for toileting hygiene and staff were to keep Resident 82's skin clean and dry. On 5/4/26 at 2:53 PM and on 5/7/26 at 11:18 AM Resident 82 stated she/he was unable to assist with toileting hygiene and depended on staff. Resident 82 stated some staff were not thorough when providing toileting hygiene care and she/he did not feel fully clean after an incontinent bowel episode resulting in redness to the skin. Resident 82 stated Staff 19 (CNA) and Staff 22 (LPN) observed her/him with inadequate toileting hygiene care.On 5/7/26 at 9:35 AM Staff 17 (CNA) stated she assisted Resident 82 with toileting hygiene and observed Resident 82 to have feces in her/his genital area from a prior brief change. Staff 17 stated it happened a couple times and she did not report her observations to the nurse.On 5/7/26 at 9:43 AM Staff 18 (CNA) stated she observed feces left in Resident 82's genital area during toileting hygiene. Staff 18 stated Resident 82 was compliant with cares and prior shift staff were not thoroughly cleaning the resident. Staff 18 stated she told the oncoming CNA during shift change and the charge nurse but did not recall who that was.On 5/7/26 at 11:31 AM Staff 19 stated Resident 82 was good about letting you know when she/he required toileting hygiene. Staff 19 stated about one to two weeks ago she started to notice Resident 82 to not be thoroughly cleaned when she provided toileting hygiene care. Staff 19 stated there was an occurrence when Resident 82 was incontinent of bladder and when she performed toileting hygiene, she observed feces in the genital area, left from another shift.On 5/7/26 at 12:46 PM Staff 20 (CNA) stated she had not observed Resident 82 with feces left on her/him. However, Resident 82 mentioned other staff were not providing thorough toileting hygiene care. Staff 20 stated she told Staff 21 (Agency LPN) some residents were not receiving thorough toileting hygiene care but did not state which residents.On 5/10/26 at 6:45 PM Staff 21 stated he had not observed feces left on Resident 82's genital area but heard about it from other staff members. Staff 21 stated he felt it wasn't intentional, just lack of providing thorough care. Staff 21 stated he did not report the lack of thorough toileting hygiene care reported to him to the Resident Care Manager or the DNS.On 5/11/26 at 9:23 AM Staff 22 stated she completed various treatments for Resident 82 and during a treatment a couple weeks ago she observed the resident to have smeared feces in her/his genital area. Staff 22 stated feces left in the genital area increased the risk of infections.On 5/11/26 at 12:56 PM Staff 4 (LPN Resident Care Manager) stated she was not aware staff were finding Resident 82's toileting hygiene care inadequate and Resident 82 had not mentioned this to her.On 5/11/26 at 1:23 PM Staff 2 (DNS) stated she was not aware Resident 82 was not receiving thorough toileting hygiene care. Staff 2 stated she expected staff to provide thorough ADL care for residents who required it.

Based on interview and record review it was determined the facility failed to follow physician orders and to document or provide necessary wound care for 2 of 6 sampled residents (#s 4 and 95) reviewed for UTIs, wound care and medications. This placed residents at risk for untreated weight gain, infections and worsening wounds. Findings include: 1. Resident 4 was admitted to the facility in 6/2025 with diagnoses including heart failure and diabetes. A 4/13/26 signed physician order revealed a start date of 3/12/26 to check Resident 4's weight daily for congestive heart failure (fluid buildup into the lungs, legs and body due to the heart muscle being too weak or stiff to pump blood efficiently) and to notify the provider of a three pound weight gain overnight or a five pound weight gain within a week. A review of the March 2026 TAR revealed the resident had a weight gain of 4.2 pounds from 3/30/26 to 3/31/26. A review of Resident 4's medical record revealed no indication the resident's provider was notified of the overnight weight gain. A review of the April 2026 TAR revealed Resident 4 had a weight gain of three pounds or more on the following days: -4/1/26 to 4/2/26, a weight gain of seven pounds. -4/13/26 to 4/14/26, a weight gain of 5.2 pounds. -4/24/26 to 4/25/26, a weight gain of 4.2 pounds. A review of Resident 4's medical record revealed no indication the resident's provider was notified of any of the overnight weight gains. On 5/11/26 at 12:09 PM Staff 6 (LPN Resident Care Manager) reviewed the dates of overnight weight gain and confirmed Resident 4's provider was not notified. On 5/11/26 at 1:26 PM Staff 2 (DNS) stated she expected staff to follow the physician's order. 2. Resident 95 was admitted to the facility in 1/2026 with diagnoses including heart failure and diabetes. a. A public complaint was received on 2/19/26 which alleged the facility failed to treat and document a skin tear for Resident 95. A 2/26/26 progress note indicated Resident 95 had an existing skin tear on her/his left arm and treatment was started. On 5/6/26 at 12:13 PM, Staff 14 (LPN Resident Care Manager) stated an agency nurse found the skin tear on Resident 95 on 2/1/3/26 but did not document it or start a treatment. Staff 14 stated another agency nurse found the existing skin tear on 2/26/26 and started treatment. On 5/6/26 at 1:32 PM, Witness 6 (Family Member) stated on 2/13/26 she noted a skin tear on Resident 95's left arm. Witness 6 stated a nurse came in and put a band aid on the skin tear. Witness 6 stated on 2/26/26 she notified the nurse on duty the same band aid, with the date 2/13/26 written on it, was still on Resident 95's skin tear. Witness 6 stated the nurse changed Resident 95's dressing. On 5/7/26 at 1:09 PM, Staff 2 (DNS) acknowledged the 2/13/26 skin tear on Resident 95's left arm was not documented or treated until 2/26/26. Staff 2 stated staff were expected to document and treat any new wounds. b. On 2/28/26 Resident 95 went to the emergency department and returned with orders for antibiotics twice a day for 10 days. The first dose was received in the emergency department. The 3/2026 MAR indicated Resident 95 received the antibiotic twice a day from 3/1/26 through 3/4/26 and one dose on 3/5/26. The 3/2026 MAR indicated Resident 95 received additional antibiotics from 3/15/26 through 3/17/26. On 5/6/26 at 1:30 PM, Staff 2 (DNS) acknowledged Resident 95 did not receive the antibiotic treatment as prescribed. Staff 2 stated the physician's order was transcribed to the medical record incorrectly as 10 doses, not 10 days, as ordered.

Based on observation, interview and record review the facility failed to provide immediate monitoring and documentation of the status of a resident's access site upon return from dialysis treatment for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for delayed treatment and dialysis complications. Findings include: A review of the facility revised 3/2023 Quality of Care- Dialysis Policy revealed the following:-The facility will assess the resident's condition and monitor for complications before and after dialysis treatments received at a certified dialysis facility.-Facility staff will monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding or other complications.Resident 6 was admitted to the facility in 5/2025 with diagnoses including end-stage renal disease and dependence on dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly).The 1/12/26 dialysis care plan revealed Resident 6 went to dialysis treatment three times a week on Monday, Wednesday, and Friday. Staff were to monitor vital signs frequently and notify the provider of any significant abnormalities. Staff were to also monitor, document, and report any signs or symptoms of infection to the dialysis access site located on her/his left chest.The 2/20/26 Quarterly MDS revealed Resident 6 had a BIMS of15 indicating she/he was cognitively intact.A review of the 5/3/26 signed physician's order revealed staff were to complete the dialysis post assessment form when the resident returned from dialysis; ensure the pre-dialysis form and communication form were also returned with the resident; and review and follow up as indicated.On 5/4/26 at 10:10 AM Resident 6 was observed to return to her/his room accompanied by Staff 27 (Restorative Aide).On 5/4/26 at 10:12 AM Resident 6 stated she/he just returned from a dialysis treatment which was three times a week on Monday, Wednesday, and Friday; left the facility around 4:20 AM and returned around 10 AM. Resident 6 stated her/his dialysis access site was a port located on her/his left chest. Resident 6 stated the nurse assessed her/him before leaving for dialysis at 4:20 AM but had not assessed her/him upon return to the facility.On 5/4/26 at 10:38 AM Staff 5 (CMA) was observed to put on PPE and enter Resident 6's room with a digital blood pressure machine and asked Resident 6 if anyone had taken her/his blood pressure since her/his return from dialysis. Resident 6 said no.On 5/4/26 from 10:10 AM through 10:55 AM (45 minutes) Resident 6's room was observed from the hallway and no nurse entered to assess her/him. On 5/6/26 at 10:08 AM Resident 6 was observed to enter the facility's main door. Resident 6 self-propelled in her/his wheelchair down the hallway when Staff 11 (CNA) offered assistance which Resident 6 accepted. Staff 11 stopped at the scale, obtained Resident 6's weight, then accompanied Resident 6 to her/his room. Staff 11 exited the resident's room, put on PPE, then re-entered Resident 6's room to check her/his vitals.On 5/6/26 at 10:16 AM Staff 11 was observed to tell Staff 5 Resident 6's vitals and weight were obtained and would be documented in the medical record.On 5/6/26 at 10:18 AM Resident 6 stated she/he just returned from dialysis and was tired from a long morning. Resident 6 stated the nurse observed her/his dialysis access site prior to leaving for dialysis. However, a nurse did not observe her/his dialysis access site upon return from dialysis on 5/4/26 until that evening or the next day. Resident 6 stated she/he had not seen a nurse today since returning from dialysis.On 5/6/26 at 10:08 AM through 11:12 AM (1 hour 4 minutes) Resident 6's room was observed from the hallway and no nurse entered Resident 6's room to assess her/him post dialysis treatment.On 5/6/26 at 12:18 PM Staff 28 (LPN) stated she was the charge nurse for Resident 6, and the resident went to dialysis on Monday, Wednesday, and Friday. Staff 28 stated it was her responsibility to complete the post dialysis assessment for Resident 6. When asked if she observed Resident 6 after her/his from dialysis today, she stated she did at 10:45 AM and the dialysis access site looked okay. Staff 28 was informed Resident 6's room was observed from the hallway at 10:45 AM and she was not seen to enter Resident 6's room. Staff 28 stated, well it was around 10:20 AM to 10:45 AM, I was bopping here and there.On 5/6/26 at 12:41 PM Staff 2 (DNS) stated she would have to look at the policy to know when nurses were expected to assess a resident post dialysis, but standard of care was a couple of hours after returning from dialysis. Staff 2 was informed of the observations on 5/4/26 and 5/6/26 and of Staff 28's statements on 5/6/26 at 12:18 PM. Staff 2 did not have anything further to add.On 5/6/26 at 12:55 PM Staff 2 stated she took Staff 28 into Resident 6's room to ask if Staff 28 assessed her/him post dialysis and Resident 6 stated Staff 28 did.On 5/6/26 at 1:24 PM Resident 6 was observed asleep in bed and was not disturbed.On 5/7/26 at 10:51 AM in a follow up interview with Resident 6, she/he stated the nurse did not assess her/him post dialysis the morning of 5/6/26 when she/he returned to the facility. Resident 6 reiterated the nurse never assessed her/him upon return to the facility on dialysis days. The nurse assessed her/him and her/his dialysis access site the evening of dialysis treatment or the next day. On 5/11/26 at 1:43 PM Staff 2 acknowledged the findings and had nothing further to add.

Based on interview and record review, it was determined the facility failed to ensure adequate monitoring and indications for use of blood pressure medication for 1 of 5 sampled residents (#84) reviewed for unnecessary medications. This placed residents at risk for receiving blood pressure medications without adequate monitoring and indications for use. Findings include:Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and hypertension (high blood pressure). Physician Orders revealed a 9/9/25 order for lisinopril 10 MG oral tablet given one time per day for hypertension. The order indicated to hold the medication if the systolic blood pressure (the top number in a blood pressure reading) was less than 120. The 3/2026 and 4/2026 MARs revealed Resident 84 received lisinopril five times in March and seven times in April with a systolic blood pressure reading under 120. All administrations were given by Staff 5 (Certified Medication Aide).A review of the resident's clinical record revealed no rationale for giving the lisinopril outside of the ordered parameters. On 5/7/26 at 9:01 AM Staff 5 acknowledged she gave Resident 84 the lisinopril outside the ordered blood pressure parameters on the identified dates, and she was unable to provide a rationale for administration of the medication. On 5/7/26 at 9:58 AM Staff 6 (LPN Resident Case Manager) confirmed the dates in 3/2026 and 4/2026 when Resident 84 was given lisinopril outside of the ordered blood pressure parameters.

Based on observation, interview, and record review it was determined the facility failed to provide cut up foods for 1 of 4 sampled residents (# 84) reviewed for food. This placed residents at risk for unmet individualized food needs. Findings include:Resident 84 was admitted to the facility in 12/2024 with diagnoses including stroke and chronic pain. The 6/13/25 revised Care Plan revealed Resident 84 was dependent on staff for meeting physical needs due to physical limitations.The 11/17/25 revised Care Plan revealed Resident 84 had an ADL self-care performance deficit due to residual right-side weakness from a history of stroke.The 12/26/25 Annual MDS indicated Resident 84 had upper and lower impaired range of motion on one side and required set-up assistance for eating.The 12/30/25 revised Care Plan indicated Resident 84 required assistance with set up for eating. A 4/22/26 Quarterly Care Conference note indicated Witness 4 (Family Member) expressed the need for Resident 84's food to be cut up due to her/his inability to cut her/his own food. Resident 84's Kardex indicated staff were to provide assistance with dining, such as cutting up food. On 5/4/26 at 11:17 AM Witness 4 (Family Member) stated Resident 84 was only able to use her/his left hand for eating and required all food items to be cut up. Witness 4 stated she put up the sign in the resident's room to remind staff to cut up food. On 5/5/26 at 12:48 PM Resident 84's lunch tray included a cut up burger patty inside a whole (uncut) bun. On 5/6/26 at 8:35 AM Resident 84's breakfast tray included full slices of bacon and a whole piece of frittata (a baked egg dish). On 5/6/26 at 12:53 PM Resident 84's lunch tray included large chunks of chicken and potato, and whole asparagus spears. On 5/6/26 at 5:08 PM Staff 10 (CNA) indicated Resident 84's food was supposed to be cut up by the kitchen staff, but she could cut it if needed. On 5/7/26 at 4:38 PM Staff 6 (LPN Resident Care Manager) stated staff were to cut Resident 84's food at bedside and acknowledged the care plan did not provide clear instruction to cut the resident's food.

Based on observation and interview, it was determined the facility failed to ensure all resident areas and equipment were in good repair for 2 of 6 sampled residents (#s 30 and 34) reviewed for environment. This placed residents at risk for not having a homelike environment. Findings include:1. Resident 30 was admitted to the facility in 7/2022 with diagnoses including hypo-osmolality (low blood tonicity) and hyponatremia (low electrolyte and sodium levels), and transient cerebral ischemic attack (mini-stroke). The 1/27/25 revised Care Plan indicated Resident 30 was bedridden and required a high level of caregiver support due to general muscle weakness and muscle atrophy.The 4/17/26 Quarterly MDS indicated Resident 30 had one-sided upper body range of motion impairment and required assistance for transfers and mobility. On 5/4/26 at 10:11 AM the resident's bed cane grips were observed to be ripped and peeling on the right and left side of the bed. Resident 30 stated she/he used the bed canes when turning in bed and could not recall a time when the grips were not ripped or peeling. On 5/6/26 at 11:01 AM Staff 7 (CNA) stated Resident 30 frequently utilized the bed canes to turn during care and to reposition in bed. Staff 7 acknowledged the bed cane grips were ripped and peeling and stated they were in that condition for a couple of months.On 5/6/26 at 1:53 PM Staff 9 (Maintenance Director) stated bed canes were checked monthly. Staff 9 acknowledged the ripped and peeling bed canes in Resident 30's room and confirmed they needed to be replaced. 2. Resident 34 admitted to the facility in 11/2024 with diagnoses including dementia and stroke. The 11/14/25 Annual MDS revealed Resident 34 received hospice care.On 5/4/26 three long gouges and scraped paint were observed in the resident's room behind the head of the bed. On 5/5/26 at 11:07 AM Staff 8 (CNA) indicated the wall damage in Resident 34's room was old and was there a very long time.On 5/6/26 at 1:53 PM Staff 9 (Maintenance Director) stated resident rooms were inspected monthly for repair needs and tasks such as painting and touch ups were done frequently. Staff 9 acknowledged the wall damage in Resident 34's room and stated it had been like that for a long time but was not repaired due to the resident's presence in the room.

Based on interview and record review it was determined the facility failed to provide residents with written bed hold notifications, including reserved bed hold payments, at the time of transfer to the hospital and failed to provide appropriate information to a provider for 2 of 4 sampled residents (#s 4 and 96) reviewed for hospitalization and discharge. This placed residents at risk for rehospitalization and a lack of knowledge regarding their choices and potential financial responsibilities. Findings include: 1. Resident 4 was admitted to the facility in 6/2025 with diagnoses including heart failure and diabetes. A review of Resident 4's clinical record revealed she/he was transferred to the hospital on the following dates: 1/2/26, 1/22/26, 2/13/26, and 3/6/26. No evidence was found in Resident 4's clinical record to indicate written notice of the facility's bed hold policy was provided to the resident or her/his representative when she/he was transferred to the hospital. On 5/11/26 at 12:25 PM Staff 6 (LPN Resident Care Manager) stated upon transfer to the hospital, the charge nurse explained the bed hold policy, including the cost, to the resident and received a signature or verbal understanding. If the resident was not alert and oriented at the time of transfer to the hospital, the resident's representative was notified of the bed hold policy. Staff 6 stated the discussion would be documented in the resident's medical record. On 5/11/26 at 1:35 PM Staff 2 (DNS) confirmed a written bed hold notification was not provided to Resident 4 or her/his representative at the time of her/his transfer to the hospital on the specified dates. 2. Resident 96 was admitted to the facility in 1/2026 with diagnoses including broken bones of the right arm, right thigh and respiratory failure. A 1/13/26 BIMS Evaluation revealed a score of 15 (cognitively intact) for Resident 96. A 1/13/26 Progress Note Discharge Evaluation revealed Resident 96 made improvements in her/his functional status while in the facility and was appropriate for discharge. Home health was arranged for the resident and she/he was discharged in stable condition. A 1/13/26 Discharge Planning and Summary Plan revealed the discharge was driven by Resident 96 and the home health agency was contacted. A 1/18/26 ED (Emergency Department) Provider Note revealed Resident 96 reported pain and swelling in her/his right leg since 1/16/26 that did not allow the resident to stand. A follow up appointment was scheduled on 1/21/2026 with the resident's provider. A 1/23/26 Message Text to the home health agency from Witness 4 (NP) indicated Resident 96 was seen by appointment and a referral for home health was sent. On 5/5/26 at 7:47 PM, Witness 1 (Complainant) stated he was contacted by Resident 96 because home health services did not contact the resident after her/his discharge and the resident went to the emergency department due to swelling. Witness 1 stated Resident 96 was concerned she/he had incorrect phone numbers and gave up when she tried to contact Staff 3 (Social Worker) and home health services. On 5/6/26 at 9:12 AM, Resident 96 stated she/he saw Witness 5 (NP) to obtain a referral for home health services a month after she/he discharged from the facility. On 5/7/26 at 9:55 AM, Staff 3 (Social Worker) stated emails were sent to obtain home health services for residents who discharged and acknowledged no email for home health services was found for Resident 96. On 5/11/26 at 8:49 AM, Witness 2 (RN Clinical Manger) confirmed the home health agency did not receive a referral from the facility for Resident 96 and the resident did not receive a home health service referral until 1/23/26 when it was completed by Witness 5. On 5/11/26 at 12:32 PM, Staff 2 (DNS) acknowledged the facility was responsible and did not ensure Resident 96 received home health services after she/he discharged .

Based on interview and record review, it was determined the facility failed to investigate an unwitnessed fall and misappropriation of property for 2 of 13 sampled residents (#s 11 and 14) reviewed for falls and misappropriation. This placed residents at risk for stolen property and neglect. Findings include:1. Resident 11 was admitted to the facility in 6/2025 with diagnoses including muscle weakness and unsteadiness on feet. On 10/1/25, the State Agency received a public complaint alleging that Resident 11 slept in her/his wheelchair and staff did not transfer her/him to bed. The complaint further alleged that Resident 11 slipped out of the wheelchair onto the floor. A review of the facility's 10/1/25 Unwitnessed Fall investigation indicated that at 12:20 AM, staff found Resident 11 seated on the floor with the electric wheelchair positioned behind the resident. The investigation lacked witness statements, root cause analysis and documentation confirming whether the facility ruled out abuse or neglect. On 2/9/26 at 8:48 AM, Staff 24 (RN) stated she typically completed investigations for risk management, gathered witness statements, and submitted the packet to management. Staff 24 stated she did not recall completing the 10/1/25 unwitnessed fall investigation. On 2/10/26 at 11:20 AM, Staff 1 (Administration) confirmed the investigation should have included a root cause analysis, witness statements and documentation of excluding abuse or neglect. 2. Resident 14 was admitted to the facility in 11/2025 with diagnoses including muscle weakness and diabetes. A Grievance Report dated 12/15/25 revealed Resident 14's phone had been plugged in, and around 1:00 AM on 12/12/25, the phone went missing. On 12/30/25, the State Agency received a public complaint indicating Resident 14 reported the missing phone to the police. A review of clinical records found no documentation of an investigation into the missing phone. On 2/9/26 at 12:30 PM, Staff 17 (Social Services Director) stated an investigation should have been completed, noting the grievance focused on replacing the phone rather than how the phone went missing. On 2/10/26 at 11:23 AM, Staff 1 (Administration) confirmed an investigation should have been completed regarding Resident 14's missing phone.

Based on interview and record review it was determined the facility failed to provide pain medications as ordered for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for unmanaged pain. Findings include:Resident 1 was admitted to the facility in 7/2025 with diagnoses including right hip pain and fractured thigh bone.The 7/30/25 hospital Discharge Orders directed staff to administer one tablet of hydrocodone-acetaminophen (narcotic pain medication) every eight hours as needed for pain for up to five days to Resident 1.The 8/4/25 admission MDS indicated Resident 1 received scheduled and as needed pain medication and was at risk for unrelieved pain. An 8/9/25 physician order revealed a renewed prescription for Resident 1's narcotic pain medication. An 8/14/25 provider communication revealed the facility requested a refill of Resident 1's narcotic pain medication. The 8/2025 MAR revealed Resident 1 was to receive her/his scheduled narcotic pain medication at 8:00 AM and 5:00 PM. -On 8/14/25 at 8:00 AM, the dose was NA (not available).-From 5:00 PM on 8/14/25 through 8/15/25 no medication was administered.-On 8/16/25 Resident 1's medication was NA at 5:00 PM.The 8/15/25 Order Administration Notes indicated staff were waiting for the resident's narcotic pain medication and Resident 1's pain was severe.The 8/15/25 at 3:53 PM Nursing Note revealed at approximately 12:30 PM, Staff 3 (Unit Manager-LPN) was informed by a CNA of Resident 1's pain and lack of narcotic pain medication. On 10/28/25 at 1:40 PM, Staff 7 (CMA) stated she recalled Resident 1's issue with pain and a change to the resident's narcotic pain medication administration to twice daily. Staff 7 indicated notes were provided to Unit Managers to reorder medications. On 10/28/25 at 2:15 PM, Staff 3 confirmed a communication was sent to the pharmacy on 8/13/25 and Resident 1 was without narcotic pain medication by 8/15/25. Staff 3 acknowledged there were communication issues with the provider during 8/2025.On 10/30/25 at 10:27 AM, Staff 8 (RN) stated not all nurses had access to the communication format for providers and it was the responsibility of Unit Managers to follow-up with providers for medications.On 10/31/25 at 10:01 AM, Staff 2 (DNS) stated the 8/9/25 narcotic medication order for Resident 1 did not include a refill sent to the pharmacy by the provider. Staff 2 expected staff to escalate issues with medications orders to Unit Managers or Staff 2 for improved response.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient nursing staff were available to meet the needs of residents in a timely manner for 2 of 3 sampled residents (#s 11 and 12) reviewed for staffing. This placed residents at risk for delayed care. Findings include: 1. Resident 11 was admitted to the facility in 10/2025 with diagnoses including stroke and dementia. The 10/2025 TAR revealed Resident 11 was to receive polyethylene glycol (laxative medication) as needed for constipation. A 10/22/25 revised care plan directed staff to check with Resident 11 frequently to ensure her/his needs were met. On 10/29/25 at 2:42 PM, Resident 11's call light was on. Witness 2 (Family Member) stated Resident 11 had been waiting since 2:25 PM for assistance and experienced discomfort during a recent bowel movement. On 10/29/25 at 2:48 PM, Staff 9 (Agency CNA) entered Resident 11's room and turned off the resident's call light. Staff 9 was observed talking to other CNAs in the hallway. On 10/29/25 at 2:50 PM and 5:06 PM, Staff 9 stated Resident 11 requested bowel medication for constipation when she answered the call light. Staff 9 stated she did not want to interrupt Staff 10 (CMA) with the request during the change of shift and informed Staff 10 about Resident 11's request for medication around 3:30 PM. On 10/29/25 at 4:58 PM, Staff 10 stated Resident 11 received her/his requested medication at 3:18 PM (53 minutes wait), the communication between staff in the facility was not good, and there were issues on 10/29/25 with timely medications due to low nurse staffing. On 10/30/25 at 4:26 PM and 5:45 PM, Staff 1 (Administrator) stated the facility had issues with agency staff which required additional training and hiring. Staff 1 expected nursing staff to assist with call lights, staff were to answer call lights in no more than 15 minutes. Staff 1 acknowledged deeper investigations were needed to understand why resident care needs were not met timely. 2. Resident 12 was admitted to the facility in 2022 with diagnoses including heart failure and high blood pressure. A 1/27/25 revised care plan indicated Resident 12 was bedridden and unable to provide self-care. Staff were to provide one-person extensive assistance with toileting. On 10/29/25 at 8:51 AM, Resident 12's call light was observed to be on from 8:51 AM, until 9:36 AM, a total of 45 minutes, when staff responded. Resident 12 was observed lying in bed and appeared uncomfortable, as evidenced by facial grimacing. Resident 12 confirmed she/he pressed the call light and waited for staff to assist with a brief change. Resident 12 further reported staff previously told her/him to wait until after meals for assistance with a brief change. When asked how this made her/him feel, Resident 12 displayed an unpleasant facial expression, looked down, and declined to answer. Resident 12 stated this has been an ongoing concern. On 10/29/25 at 9:56 AM, Staff 6 (CNA) confirmed Resident 12 was dependent on staff for incontinent care and she/he preferred to be changed before meals. Staff 6 reported Resident 12 informed her staff previously told the resident she/he needed to wait until after meals to be changed. Staff 6 stated the resident expressed this made her/him feel undignified. On 10/30/25 at 4:26 PM and 5:45 PM, Staff 1 (Administrator) stated he expected nursing staff to assist with call lights after no more than 15 minutes. Staff 1 acknowledged deeper investigations were needed to understand why resident care needs were not met timely.

Based on interview and record review it was determined the facility failed to ensure physician orders for eye treatments were followed for 1 of 3 sampled residents (#4) reviewed for physician orders. This placed residents at risk for eye pain and complications. Findings include:Resident 4 was admitted to the facility in 6/2025 with diagnoses including complex regional pain syndrome and anxiety.The 7/2/25 Orders at Discharge directed staff to apply one drop of Optase (Glycerin) Comfort Dry Eye Solution to Resident 4's eye twice daily. The 7/2025 MAR indicated the following:-7/2/25 through 7/10/25 Optase was unavailable or on order.A 7/7/25 OT Treatment Encounter Notes revealed Resident 4 wanted her/his eye drops which added to her/his anxiety.A 7/7/25 EpicCare Link to the facility provider identified a request to use house stock Systane to replace Resident 4's order for Optase. On 7/7/25 Resident 4's physician agreed with the request.-A 7/8/25 order for Systane Solution (dry eye drops). -Systane Solution (dry eye drops) were administered on 7/9/25.On 10/8/25 at 2:24 PM, Staff 8 (CMA) stated she contacted the facility's pharmacy each time Resident 4's Optase was not available and was not aware of a system to report issues with missing medications until recently. Staff 8 stated she was aware Staff 2 (DNS) was involved to address the need for Resident 4's Optase. On 10/9/25 at 11:53 AM, Staff 7 (LPN) stated Resident 4's call light was often on because she/he was requesting her/his eye drops. On 10/13/25 at 9:47 AM, Staff 3 (Unit Manager-LPN) acknowledged the facility had a problem obtaining eye drops for Resident 4 and Staff 3 made phone calls to address the issue. Staff 3 stated the lack of availability of eye drops for Resident 4 did not meet Staff 3's expectations. On 10/13/25 at 11:15 AM, Staff 2 (DNS) acknowledged the 7/7/25 communication to replace Resident 4's eye drop order for Optase with Systane was not implemented timely.

Based on observation, interview, and record review it was determined the facility failed to ensure a dependent resident received ADL assistance for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for unmet needs and dignity. Findings include: Resident 1 was admitted to the facility in 8/2025 with diagnoses including stroke and language deficits. The 8/7/25 admission MDS revealed Resident 1 had a BIMS assessment score of 15 (cognitively intact), was dependent on two staff for toileting assistance, and required an interpreter for communication. A 9/29/25 Grievance Report filed on behalf of Resident 1 revealed the resident was left on the commode for 30 minutes and requested staff to not leave her/him on the commode. A 9/30/25 revised care plan indicated Resident 1 preferred to have staff stay with her/him while the resident was on the commode. A 10/2/25 Grievance Report indicated Resident 1 filed a complaint related to long call lights that occurred around 1:30 PM on 10/2/25 when the resident requested commode assistance. Resident 1 indicated she/he cried and was very upset. Very frustrated. The grievance did not identify any staff who were involved.On 10/7/25 at 9:39 AM, a sign in Resident 1's room was observed on the wall that instructed staff to not leave Resident 1 alone on the commode. On 10/10/25 at 10:58 AM, Staff 10 (CNA) stated Resident 1's Kardex (care plan for CNAs) was not updated and she was unaware Resident 1 was not to be left alone on her/his commode after a 9/26/25 fall. Staff 10 explained she assisted another resident with a shower around 1:30 PM on 10/2/25 and other staff were instructed to assist Resident 1 while Staff 10 was occupied.On 10/9/25 at 4:05 PM, Staff 4 (Unit Manager-LPN) stated staff were to share resident care responsibilities especially at shift change.On 10/13/25 at 10:43 AM, Staff 2 (DNS) and Staff 12 (Regional Director of Clinical) expected an updated Kardex for Resident 1 and a thorough investigation of grievances to include statements by staff involved.

Based on interview and record review it was determined the facility failed to follow a resident's care plan to prevent falls for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for injuries from falls. Findings include:Resident 1 was admitted to the facility in 8/2025 with diagnoses including stroke and language deficits. The 8/2/25 care plan indicated Resident 1 was at risk for falls and staff were to place the resident's call light within reach.The 8/7/25 admission MDS revealed Resident 1 had a BIMS assessment score of 15 (cognitively intact), was dependent on two staff for toileting assistance, and required an interpreter to communicate. A 9/26/25 Unwitnessed Fall investigation for Resident 1 was incomplete with no information related to the cause of the fall or a conclusion to the investigation.A 9/27/25 Nursing Post Fall Risk Evaluation indicated Resident 1 stated she/he fell from the commode on 9/26/25 because her/his call light was not within reach. The fall resulted in throbbing pain to Resident 1's left ankle.A 9/29/25 Grievance Report filed on behalf of Resident 1 revealed the resident was left on the commode for 30 minutes and requested staff not to leave her/him on the commode. On 10/8/25 at 9:51 AM, Staff 9 (LPN) stated he completed a report after Resident 1's fall. Staff 9 stated he observed Resident 1's call light attached to her/his bed and not near the resident who fell off her/his commode. On 10/9/25 at 4:05 PM, Staff 4 (Unit Manager-LPN) acknowledged call lights were to be within reach of Resident 1. On 10/9/25 at 7:15 PM, Staff 13 (CNA) stated she was outside Resident 1's door on 9/26/25 when she/he was on the commode.On 10/13/25 at 10:43 AM, Staff 2 (DNS) and Staff 12 (Regional Director of Clinical) acknowledged Resident 1' s care plan was not followed and expected a thorough investigation to correctly address the root cause of the resident's fall.

Based on observation, interview and record review it was determined the facility failed to check the Hoyer (a mechanical lift device used to transfer residents) straps to prevent a fall and failed to follow care plan interventions to prevent injury for 2 of 5 (#s 10 and 11) sampled residents. As a result, Resident 11 sustained a subarachnoid hemorrhage, (bleeding in the space between the brain and the tissue covering the brain), an intraparenchymal hemorrhage (bleeding within the brain's functional tissue) a scalp hematoma (blood clot), multilevel acute compression fractures (the back bones collapse due to a forceful impact) involving the thoracic region (middle of the back) and a compression fracture of L4 vertebra (lumbar region, lower back). Findings include: 1. Resident 11 admitted to the facility 6/2021, with diagnoses including Parkinson's disease and congestive heart failure. Resident 11's 3/25/25 MDS indicated the resident was cognitively intact. Resident 11's 4/10/25 Care Plan revealed the resident required a Hoyer lift with two-person assist for transfers and the resident preferred to not have her/his feet touch the bed when transferring. On 3/18/25 at 7:25 AM, Staff 15 (CNA) and Staff 17 (CNA) prepared to transfer Resident 11 via a Hoyer from the three-foot raised bed to a shower chair when the resident fell headfirst out of the sling. On 3/18/25 at 7:30 AM, Resident 11 was transferred via ambulance to the hospital as a trauma level patient. Resident 11 was diagnosed with a subarachnoid hemorrhage, an intraparenchymal hemorrhage, a scalp hematoma and multilevel compression fractures in the thoracic and lumbar regions of the spine. Neurosurgery concluded the brain hemorrhages were not operable and would resolve on their own. Resident 11 was admitted to the hospital for observation and pain management. On 4/9/25 at 9:47 AM, Resident 11 was observed in her/his bed. The bed was elevated about three feet off the ground. Resident 11 stated she/he preferred to have the bed raised off the ground. Resident 11 recalled the fall from the Hoyer on 3/18/25. Resident 11 stated Staff 15 (CNA) and Staff 17 (CNA) brought in the Hoyer to her/his room, the sling was placed underneath her/him and attached to the Hoyer. Resident 11 stated the head hook of the sling was loose, and three of the four straps were hooked up and she/he fell to the floor headfirst. Resident 11 stated now she/he had a fear of falling. On 4/9/25 at 11:50 AM, Staff 6 (CNA) stated she was at the nurses station when Staff 17 (CNA) urgently called for Staff 4 (LPN Charge), stating Resident 11 had fallen from the Hoyer. Staff 6 stated she placed the Hoyer out in the hall and noticed one of the straps were not hooked up. On 4/9/25 at 12:45 PM, Staff 4 (RN) stated she was at the nurses station when Staff 17 (CNA) told her Resident 11 fell from the Hoyer and hit her/his head. Staff 4 immediately went to the room and saw Resident 11 on the floor under the Hoyer lift. Staff 4 provided first aide to the resident while staff called EMS. Staff 4 observed the Hoyer and sling were over Resident 11 and one of the slings straps were not attached. On 4/10/25 at 2:15 PM, Staff 15 (CNA) stated he was assisting Staff 17 (CNA) with Resident 11. Staff 15 stated they placed the sling underneath the resident and Staff 17 prepped the Hoyer lift. Staff 15 stated they hooked the four straps from the sling to the Hoyer. Staff 15 stated Resident 11 always preferred her/his bed elevated three feet off the ground. Staff 15 stated after hooking the sling straps to the Hoyer, they lifted the resident up and pulled the Hoyer out and the resident fell headfirst to the ground. On 4/11/25 at 10:31 AM, Staff 17 (CNA) stated on 3/18/25 it was Resident 11's shower day. Staff 17 stated he placed Resident 11 on the shower sling while the resident was in bed and positioned the shower sling per protocol and hooked it up. Staff 17 stated he and Staff 15 (CNA) started raising the resident up in the air off the raised bed, obtained a weight and started to move the resident in the sling off the bed. Staff 17 stated Resident 11 was in an open space, off to the side of the bed. Staff 17 lifted the resident's ankles to turn the Hoyer and he heard something snap. Staff 17 found the back right sling loop had come off the Hoyer and the resident fell headfirst to the floor, approximately four to five feet. Staff 17 stated there was no rip or tear in the sling. Staff 17 stated the sling's strap was not secured over the loop. On 4/11/25 at 3:15 PM, Staff 2 (DNS) stated the shower sling used for Resident 11 was set aside and now cannot be found. On 4/11/25 at 3:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 11's fall from a Hoyer with significant injuries. 2. Resident 10 admitted to the facility 3/2022, with diagnoses including dementia, weakness and reduced mobility. Resident 10's 2/2025 MDS revealed the resident had severe cognitive impairment. Resident 10's 4/9/25 Care Plan revealed the resident was a two-person assist with turning and repositioning and the call light was to be placed on her/his right side and clipped to the blanket. On 4/10/25 at 1:13 PM, Staff 14 (CNA) and Staff 18 (CNA) were observed to transfer Resident 10 from the wheelchair to the bed. Resident was observed to be still and did not move any extremities before, during or after transfer. Staff 14 stated Resident 10 does not assist or move her/his legs and does not move her/his legs around when staff turn the resident from side to side. On 4/10/25 at 10:10 AM, Staff 13 (CNA) stated she assisted Staff 17 (CNA) with transferring Resident 10 via the Hoyer on 3/21/25 and observed the bruising and skin tear on Resident 10's left neck. Staff 13 stated Staff 17 told her the call light, which was clipped to the resident's gown on the resident's left side, caused the bruising when he pulled the blanket, and it caught the resident on the left side of the neck. Staff 13 stated Resident 10 was crying, and the resident's neck was bleeding. Staff 13 stated the nurse was notified right away. Staff 13 stated she saw the clip for the call light was broken and really sharp. Staff 13 stated when she uncovered Resident 10 she saw a bruise on the resident's right leg and bruising on her/his chest. Staff 13 informed Staff 10 (RN) and showed her the bruise on Resident 10's chest, the bruising on the leg and the swelling of the left arm. On 4/10/25 at 10:26 AM, Staff 10 (RN) stated on 3/21/25 Staff 17 (CNA) showed her Resident 10's skin tear on her/his left neck. She stated Staff 17 showed her the clip for the call light was broken and he stated the clip had cut the resident's skin. Staff 10 stated she cleaned up the wound, put a foam dressing on the skin tear and removed the sharp clip. Staff 10 stated on 3/22/25, Staff 12 (CNA) showed her Resident 10's swelling and a purplish coloration of the skin to Resident 10's right lower leg around the shin area and some discoloration around the resident's chest. Staff 10 stated she did not know where the bruising originated. On 4/10/25 at 4:00 PM, Staff 16 (LPN-IP) stated on 3/22/25 she looked at Resident 10's left hand and stated it was concerning. Staff 17 stated he felt resistance on the blanket and possibly the call light had wrapped around Resident 10's finger, when he pulled the covers back. Staff 16 stated her biggest concern was the bruising on Resident 10's fingers. Staff 16 contacted the provider and requested an x-ray. On 4/11/25 at 10:31 AM, Staff 17 (CNA) stated on 3/21/25 he assisted Resident 10, by himself, out of bed for lunch. Staff 17 stated he pulled down the covers, met some resistance, so he tugged harder. Staff 17 stated Resident 10 was care planned as a two-person assist with dressing, but he dressed the resident himself. Staff 17 stated he turned the resident by himself towards the window. He stated Resident 10 had no muscle tone and she/he started to slip off the bed. Staff 17 stated he grabbed Resident 10's left hip where Resident 10's left hand was and reached for her/his shoulder to bring her/him back to the bed. He stated he did not see bruising on Resident 10's leg because he put the pants on quickly and did not see any bruising on her/his chest. Staff 17 stated he raised the resident's left hand and Resident 10 stated it hurt. Staff 17 stated he palpated different areas of the resident's left arm and the resident stated it hurt. On 4/11/25 at 2:11 PM, Witness 20 (MD) stated she assessed Resident 10 on 3/28/25 (one week after incident). Witness 20 stated her understanding was someone tried to provide care alone and didn't remove the call light which caused a skin tear and bruising on the chest. Witness 20 stated it seemed to her not the correct way to provide care to a resident. Records revealed an Injury of Known Cause investigation form was initiated by Staff 16 (LPN-IP) on 3/22/25. The investigation revealed a skin tear to the left lateral neck and bruising with a green and purple coloration extending from the neck to the subclavicular (collar bone) and mid chest wall. Additional injuries included green bruising on Resident 10's right lower extremity and purple bruising on her/his left index finger and thumb with mild swelling. Staff 16 wrote Resident 10 was unable to describe the injuries and how they occurred. A total body assessment was conducted. Staff 2 and the provider were notified and x-rays and labs were ordered. On 4/11/25 at 3:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the bruises on Resident 10's neck, chest, left hand and right leg. Staff 2 acknowledged the care plan was not followed.

Based on observation, interview, and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 5 sampled residents (#s 52 and 375) reviewed for nutrition. Resident 52 experienced a severe weight loss of over 13 percent in less than three months. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with diagnoses including protein malnutrition and diabetes. Resident 52 had the following weights recorded: -9/1/23 300 pounds -9/10/23 300 pounds -9/25/23 297 pounds -10/26/23 275 pounds -11/7/23 269 pounds -11/8/23 260 pounds This was a 13 percent weight loss which was severe and not gradual. The 9/1/23 care plan indicated to prevent significant weight loss and gain in the next 30 days, 90 days, and 180 days. No significant weight loss of five percent in 30 days or 10 percent in 180 days. The RD was to evaluate and make diet change recommendations as needed. A 9/7/23 Admission MDS/CAA indicated Resident 52 was at risk for malnutrition. Weight loss for this resident would be beneficial if slow and gradual. Will continue to monitor weekly weights. A 11/14/23 Nutrition Dietary Note contained no information related to Resident 52's weight loss. There was no documentation in Resident 52's electronic record that discussed the resident's weight loss. On 11/27/23 at 9:36 AM Resident 52 stated she/he lost weight since admission because the food was bad. Resident 52 stated the meat was tough, and vegetables were either half raw or cooked too much with no flavor. Resident 52 stated her/his spouse came to the facility for lunch and dinner and ate her/his meal. Resident 52 stated she/he was aware the facility offered alternative meals and accepted at times. Resident 52 stated she/he asked for ice cream around 10:00 PM so she/he did not wake up hungry. On 11/27/23 at 12:40 PM Resident 52 was observed with a lunch tray in her/his room, the chicken was eaten and half of the mashed potatoes. Resident 52 was asked about the flavor of the meal and stated she/he did not try the food but would when her/his spouse was finished. On 11/27/23 at 12:43 PM Resident 52's spouse was observed eating the resident's meal. On 11/28/23 at 12:29 PM Resident 52's spouse was observed eating the resident's meal. On 11/28/23 at 1:05 PM Staff 22 (CNA) stated staff were aware Resident 52's spouse ate the resident's meals at lunch and dinner. On 11/29/23 at 10:33 AM Staff 33 (Dietary Manager) stated she was aware Resident 52's spouse ate the resident's meals and staff should have intervened. On 11/29/23 at 10:35 AM Staff 36 (RD) stated she was alerted by the nurses if a resident had significant weight loss. Staff 36 stated once she was alerted, she would follow-up with the resident and reassess. Staff 36 stated nursing staff should have notified her sooner of the weight loss so interventions were put in place. On 11/29/23 at 11:04 AM Staff 40 (LPN Unit Manager) acknowledged staff were aware Resident 52's spouse ate some of the resident's meals and she was aware of the weight loss. 26991 3. Resident 375 was admitted to the facility in 2023 with a diagnosis of protein malnutrition. A 9/18/23 hospital Orders at Discharge form revealed Resident 375 was to be administered a nutritional supplement with meals at least twice daily. Progress Notes by Staff 36 (RD) revealed on 9/20/23 she assessed the resident and recommended a protein drink and Resident 375 was agreeable. On 9/25/23 she followed-up with Resident 375 and the resident stated she/he received the protein drink once or twice a day and preferred to get the drink two times a day. A 9/2023 MAR revealed Resident 375 did not receive a protein drink as ordered, at least twice a day on 9/18/23, 9/20/23, 9/21/23, and 9/25/23. On 11/30/23 at 10:35 AM Staff 36 stated she assessed Resident 375 on 9/20/23 and at the time of the assessment the resident was not provided a protein drink with meals or between meals. The hospital may have ordered a specific brand of protein drink, but she ordered what the facility had available on hand with the equivalent nutrients. On 11/30/23 at 10:53 AM Staff 2 (Regional Director of Clinical) acknowledged Resident 375 had orders upon admission for a protein drink to be provided at least twice a day and it was not given as ordered.

Based on observation, interview, and record review it was determined the facility failed to accurately assess, care plan, and provide pressure ulcer treatments for 2 of 3 sampled residents (#s 17 and 66) reviewed for pressure ulcers. Resident 17 experienced multiple worsening pressure ulcers. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses including a Stage 2 (partial thickness loss of skin with shallow open area) pressure ulcer to the sacrum (bone at the base of the spine) and malnutrition. An 10/12/23 Skin and Wound Evaluation Report indicated Resident 17 had a Stage 3 (full thickness tissue loss) to her/his left buttocks and three open areas to the right buttocks. An 10/12/23 Nutritional Evaluation indicated Resident 17 had an open wound on the left buttocks but later indicated Resident 17's skin was free and clear of open wounds. An 10/17/23 Admission MDS indicated Resident 17 had a Stage 3 pressure ulcer to her/his left buttocks and continue with monitoring of nutrition and skin weekly in NAR (Nutrition At Risk) meetings. An 10/11/23 care plan was not revised after the assessment to include the resident's pressure ulcer. The Skin and Wound Evaluation Reports, including photos, indicated the following: -10/18/23 Resident 17 had one Stage 3 pressure ulcer to the left buttocks with 80 percent slough (yellow/white material in the wound bed). The photos revealed one Stage 3 wound on the left buttocks and one Stage 3 wound on the right buttocks. -10/25/23 Resident 17 had a Stage 3 pressure ulcer to her/his coccyx (tail bone). The photos revealed one Stage 3 wound on the left buttocks and one Stage 3 wound on the right buttocks. -10/31/23, 11/15/23 and 11/20/23 Resident 17 had a Stage 3 to her/his coccyx. The photos revealed one Stage 3 wound on the left buttocks and one Stage 3 wound on the right buttocks. -11/20/23 United Wound Clinic (Wound Consultant) indicated Resident 17 had a Stage 3 pressure ulcer to the left buttocks and a Stage 2 pressure ulcer to the right buttocks. The photos revealed one Stage 3 wound on the left buttocks and one Stage 3 wound on the right buttocks. Based on reviewed photos, the assessments inaccurately described the wound locations. On 11/29/23 at 10:10 AM Staff 43 (LPN Wound Nurse) was observed to perform a dressing change for Resident 17. Upon observation the resident had three wounds to bilateral buttocks and one to the gluteal cleft (the crease between the buttocks). The pressure ulcer to the left buttocks was approximately 4.37 centimeters with slough and bleeding. The pressure ulcer to the right buttocks was approximately the size of a 50 cent piece with slough, and the pressure ulcer to the gluteal cleft was approximately the size of a dime with slough. Staff 43 accknowledged the wounds contained slough. On 11/29/23 at 2:26 PM Staff 36 (RD) acknowledged she performed a nutritional evaluation for Resident 17 for diabetic control and not for the wounds. Staff 36 acknowledged Resident 17 was not reviewed by the NAR committee for her/his wounds. On 11/30/23 at 1:04 PM Staff 2 (Regional Director of Clinical) acknowledged Resident 17 had multiple Stage 3 pressure ulcers to the right and left buttocks and the assessments for the wounds were not accurate. On 11/30/23 at 2:27 PM Staff 40 (LPN Unit Manager) acknowledged Resident 17's Stage 3 pressure ulcer was not on the comprehensive care plan. 35855 2. Resident 66 was admitted to the facility in 2023 with diagnosis of sepsis (infection in the blood). A 11/14/23 Admission MDS and Pressure Ulcer Injury CAA indicated Resident 66 was at risk for pressure ulcers and did not have any unhealed pressure ulcers. Resident 66 was at risk for skin integrity compromise because of her/his limited ability to respond to pressure discomfort and had very limited physical activity and limited ability to change and control body position. A 11/14/23 care plan indicated Resident 66 had a potential for skin impairment with interventions which included heel elevation with pillows, floatation device or heel boots as indicated. A 11/2023 Documentation Survey Report revealed staff were to complete skin observation every shift. Out of 68 opportunities Resident 66's skin was not monitored 10 times. A 11/23/23 Nursing Note revealed Resident 66 was identified to have a DTI (deep tissue injury which presents as a blood filled blister) to her/his left heel and left lateral calf. No investigation was found in Resident 66's clinical records for the onset of the calf or heel DTIs. A 11/23/23 Wound Evaluation revealed Resident 66 had a DTI on the left heel which was facility acquired. The area of the wound was 7.56 cm, length of 3.38 cm and width of 2.73 cm. The DTI was noted with a purple fluid filled blister. The note indicated the side of the calf also presented with a soft purple non-blanching (skin that remains white when pressed) area with the surrounding skin intact and edema (swelling due to excessive fluid accumulation) noted. A request was made to the physician for orders. A 11/2023 TAR instructed staff to provide wound care for Resident 66 as follows: -DTI to the left side of the calf, clean and apply pad for protection every day for wound care with a start date of 11/24/23. Out of five opportunities wound care was not provided two times. -DTI to the left heel, keep clean, dry, and covered with a non-adhesive foam until physician orders came in with a start date of 11/24/23 and end date of 11/28/23. Out of five opportunities care was not provided two times. -Make sure Resident 66 wore heel boots while in bed for protection and prevent further skin breakdown with a start date of 11/23/23. Out of 15 opportunities the boots were not checked three times. A 11/28/23 Administration Note revealed treatment to the left side of calf DTI, keep clean, dry and covered with pad for protection every day shift for protection. It was documented the dressing was changed on 11/27/23. There was no documentation treatment was completed as physician ordered for 11/28/23. On 11/30/23 at 1:23 PM and 12/1/23 at 10:48 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) confirmed the investigation for Resident 66's DTIs wounds were late. Staff 2 confirmed treatments were missed.

Based on interview and record review it was determined the facility failed to follow physician orders for 4 of 10 sampled residents (#s 20, 23, 63, and 66) reviewed for medications, hospitalization , and pressure ulcers. Resident 63 required acute care intervention for fluid overload. Findings include: 1. Resident 63 was admitted to the facility in 2023 with a diagnosis of congestive heart failure. A 11/7/23 hospital Orders at Discharge revealed Resident 63 was to be administered torsemide (diuretic/removes excess fluid from the body) daily as needed for swelling, and for weight gain greater than five pounds in three days. On 11/7/23, upon admission, Resident 63 weighed 263 pounds. Resident 63's record did not have another weight until 11/9/23, two days after admission, which was 273, a ten pound weight gain. A 11/9/23 Progress Note by Staff 40 (LPN Unit Manager) revealed the resident had a three percent weight gain (ten pounds) and obtaining a reweigh. Resident 63's clinical record revealed no reweigh. A 11/10/23 physician admission note revealed the resident was assessed to have edema, clear lungs and was not in distress. The resident had a three percent weight gain. Staff were to continue torsemide PRN. Resident 63's record revealed the only weight check after 11/9/23 was on 11/25/23 and the resident's weight was 273 pounds, a ten pound weight gain. Resident 63's Progress Notes revealed the resident was assessed to have two plus pitting edema (mild edema) on the following dates: -11/7/23 -11/8/23 -11/9/23 -11/13/23 -11/14/23 -11/15/23 A 11/2023 MAR revealed Resident 63 was not administered torsemide on the dates she/he was assessed to have edema. A 11/25/23 Progress Note revealed Resident 63 had a ten pound weight gain in the morning and was administered torsemide. The resident later developed shortness of breath and her/his oxygen saturation levels on room air decreased to 90 percent. The resident's heart rate was 102 at rest and the resident reported new onset of chest pain radiating from the abdomen to her/his jaw. Emergency services were called and the resident was verified to have an abnormal heart rhythm and was sent to the hospital. The resident was admitted to the hospital, assessed to have infiltration to the lungs (abnormal substance in the lung associated with conditions including fluid accumulation) and was administered intravenous (through the veins) diuretics and the physician reported Resident 63 would be stable after the fluid was removed. On 11/29/23 at 9:20 AM Staff 40 (LPN Unit Manager) stated when an order was written for PRN diuretic based on weight gain, staff were to obtain weights daily. Staff generally documented the weights on the MAR/TAR in order to easily track the weights associated with the medications. Staff 40 indicated a reweigh was not obtained on 11/9/23 and Resident 63 did not refuse to be re-weighed. Staff 40 acknowledged Resident 63 did not receive a PRN diuretic until the day she/he was discharged to the hospital. 35855 2. Resident 20 was admitted to the facility in 2022 with diagnosis of Parkinson's disease (A progressive disorder which affects the nervous system). A 11/2023 MAR instructed staff to administer carbidopa-levodopa (used to treat symptoms of Parkinson's disease) one tablet at bedtime for Parkinson's disease. From 11/5/23 through 11/7/23 the MAR instructed the reader to review Administration notes. On 11/5/23, 11/6/23, and 11/7/23 Administration Notes revealed to administer one tablet at bedtime of carbidopa-Levodopa for Parkinson's disease. The note indicated the medication was not available. On 12/1/23 at 10:41 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) stated the medication was ordered on 10/29/23 and the facility had issues obtaining medication. The expectation was for staff to contact the pharmacy again if the medication was not received. 3. Resident 23 was admitted to the facility in 2023 with diagnosis of bacteremia (live bacteria in the bloodstream). a. An 10/2023 TAR instructed staff to complete the following treatments: -Turbo flush Resident 23's PICC line (peripherally inserted central catheter, a long thin tube that was inserted through a vein in the arm and passed through to the larger veins near the heart). For the month of 10/2023 there were four times the PICC line was not flushed. - Cefazolin sodium dextrose intravenous solution (an antibiotic to treat bacterial infections) use two grams intravenously every eight hours with a start date of 10/2/23 and end on 10/30/23. Resident 23's cefazolin treatment was missed six instances. On 12/1/23 at 10:54 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) confirmed Resident 23 missed multiple treatments. b. A 11/2023 TAR instructed staff to treat Resident 23's wounds as follows: -Left medial ankle wound, cleanse with wound cleanser, and apply a dressing on day shift on Mondays, Wednesdays, and Fridays with a start date of 10/20/23. Out of 12 opportunities Resident 23's wound care was not completed two times. -Left lateral ankle abscess, flush the wound, and apply a dressing every day with a start date of 11/16/23. Out of 15 opportunities Resident 23's wound care did not occur three times. On 12/1/23 at 10:54 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) confirmed Resident 23 missed multiple treatments. 4. Resident 66 was admitted to the facility in 2023 with diagnosis of sepsis (infection in the blood). A 11/2023 TAR instructed staff to provide the treatment and care for Resident 66 as follows: -Right forearm and hand, cleanse the wounds, pat dry and apply a dressing every day shift starting 11/10/23. Out of 21 opportunities wound care was not provided six times. -Geri sleeves (protect the upper extremities from abrasions, bruises, snags, and tears) to both upper arms for protection of fragile skin with a start date of 11/15/23. Out of 29 opportunities there were seven times care was not provided. -Daily weights one time a day for monitoring of congestive heart failure and edema (excess fluid accumulation) with a start date of 11/15/23. Out of 16 opportunities Resident 66 was not weighed seven times. -Obtain baseline weight one time a day with a start date of 11/9/23 and discontinued on 11/14/23. Out of the six opportunities Resident 66 refused one time and two times her/his weight was not completed. On 12/1/23 at 10:54 AM Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) confirmed Resident 23 missed multiple treatments.

Based on Based on interview and record review it was determined the facility failed to ensure narcotic pain medication was administered as ordered for 1 of 2 sampled residents (#1) reviewed for medication errors. This failure was determined to be an immediate jeopardy situation because Resident 1 received 100 mg of oxycodone (narcotic pain medication) rather than 5 mg as ordered twice within a four-hour period. Findings include: Resident 1 admitted to the facility on [DATE] on hospice services with diagnoses including stomach cancer, dysphagia (difficulty swallowing) and left hip fracture. Resident 1 died on [DATE]. The [DATE] Physician Order instructed to administer oxycodone 5 mg per 5 ml, administer 2.5 to 5 ml every four hours as needed for pain. On [DATE] a revised oxycodone concentration level was ordered which instructed the pharmacy to dispense 100 mg liquid oxycodone in a 20 mg per 1 ml concentration. Resident 1 was to receive 5 mg (0.25 ml) every four hours as needed for pain. The ,d+[DATE] MARs revealed oxycodone 5 mg was administered on [DATE] at 10:00 PM [by Staff 4, Agency RN] and [DATE] at 2:00 AM [by Staff 5, LPN]. The [DATE] Progress Note revealed Resident 1 passed away at 7:45 AM. The [DATE] Facility Investigation revealed Resident 1's last bottle of 5 mg per 5 ml was administered on [DATE] at 6:00 PM. A new bottle of oxycodone was opened at the next scheduled administration time ([DATE] at 10:00 PM). Resident 1 was administered 100 mg of oxycodone instead of the ordered 5 mg on [DATE] at 10:00 PM and [DATE] at 2:00 AM. Both Staff 4 and Staff 5 failed to verify the medication dosage by using the six medication rights prior to the oxycodone administration. A written statement by Staff 5 indicated she opened the new bottle of oxycodone for the 10:00 PM dose and did not visualize the bottle to to ensure the medication concentration on the bottle matched Resident 1's MAR. Staff 5 verified she administered 5 ml (100 mg) of oxycodone. The investigation indicated the facility was not able to rule out that the medication error did not contribute to Resident 1's death. On [DATE] at 1:49 PM Staff 5 stated Staff 4 opened the new bottle of oxycodone and administered the incorrect dose at 10:00 PM. Staff 5 stated she did not visualize the bottle of oxycodone and also administered the incorrect dose of oxycodone to Resident 1. Staff 5 stated she was unable to recall how Resident 1 was breathing prior to the oxycodone administration. On [DATE] at 11:45 AM Staff 3 (RNCM) stated she discovered the medication error when she was given the oxycodone 20 mg per 5 ml bottle to destroy after the resident's death. On [DATE] at 9:55 AM Staff 1 (Administrator) and Staff 2 (Regional RN/Interim DNS) confirmed oxycodone 100 mg was administered to Resident 1 instead of oxycodone 5 mg on [DATE] at 10:00 PM and [DATE] at 2:00 AM. Staff 1 and Staff 2 stated both nurses were immediately suspended and had not returned to the facility. Staff 2 stated the facility recognized both medication errors and a plan of correction was put into place. The facility identified all residents who received medications were at risk, completed a baseline audit for medication errors from [DATE] through [DATE] and initiated training and education with all the nurses and medication technicians related to the six rights of medication administration. Staff 2 stated the facility initiated the observation of every nurse and medication technician for medication administration prior to the start of their next shift. Audits were initiated which included medication pass observation on ten percent of the nurses and medication technicians who pass mediation weekly for four weeks, then monthly for two months. The DON or designee would complete the audits on new hires to validate the education on the six rights of medication administration and a medication observation would be completed prior to working independently. The findings would be reported to QAPI (Quality Assurance Performance Improvement committee) monthly for three months for review and further recommendations. Immediacy for this concern was removed on [DATE] at 4:00 PM. On [DATE] at 2:05 PM Staff 1 and Staff 2 were notified the incident on [DATE] through [DATE] was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance. Survey determined the Past Non-compliance was corrected on [DATE] when the facility identified deficient practice, initiated corrections and completed staff education and training. The Plan of Action included: Systemic Changes: 1. The DON/designee re-educated all nursing staff on [DATE] through [DATE] related to steps to complete a medication pass including the six rights of medication administration. This would be ongoing prior to the start of their shift and with new hires. 2. The DON/designee would conduct a medication observation with each licensed nurse and CMA. 3. All newly hired licensed nurses and CMAs would complete education on the six rights of medication administration and complete a medication observation prior to being on their own on the floor. Monitoring: 1. The DON/designee would perform medication pass observations on 10% of licensed nurses and CMAs who pass medications weekly for 4 weeks and then monthly for two months. 2. The DON/designee would complete audits on newly hired staff to validate their education on the six rights of medication administration and complete a medication observation prior to the newly hired staff working independently. Audits would be completed weekly for four weeks then monthly for two months. The findings would be reported to QAPI monthly for three months for review and further recommendations. Additionally, the facility identified all residents who received medications were at risk and a baseline audit was completed for medication errors in the last 30 days [DATE] through [DATE].

Based on interview and record review it was determined the facility failed to provide care and services in compliance with professional standards for 2 of 2 staff (#s 4 and 5) reviewed for medication errors. This failure was determined to be an immediate jeopardy situation because Staff 4 (Agency RN) and Staff 5 (LPN) both administered 100 mg of oxycodone (narcotic pain medication) rather than the prescribed 5 mg within a four-hour period. Findings include: Resident 1 admitted to the facility on [DATE] on hospice services with diagnoses including stomach cancer, dysphagia (difficulty swallowing) and left hip fracture. Resident 1 died on [DATE]. The [DATE] Physician Order instructed to administer oxycodone 5 mg per 5 ml, administer 2.5 to 5 ml every four hours as needed for pain. On [DATE] a revised oxycodone concentration level was ordered which instructed the pharmacy to dispense 100 mg liquid oxycodone in a 20 mg per 1 ml concentration. Resident 1 was to receive 5 mg (0.25 ml) every four hours as needed for pain. The ,d+[DATE] MARs revealed oxycodone 5 mg was administered on [DATE] at 10:00 PM [by Staff 4] and [DATE] at 2:00 AM [by Staff 5]. The [DATE] Progress Note revealed Resident 1 passed away at 7:45 AM. The [DATE] Facility Investigation revealed Resident 1's last bottle of 5 mg per 5 ml was administered on [DATE] at 6:00 PM. A new bottle of oxycodone was opened at the next scheduled administration time ([DATE] at 10:00 PM). Resident 1 was administered 100 mg of oxycodone instead of the ordered 5 mg on [DATE] at 10:00 PM and [DATE] at 2:00 AM. Both Staff 4 and Staff 5 failed to verify the medication dosage by using the six medication rights prior to the oxycodone administration. A written statement by Staff 5 indicated she opened the new bottle of oxycodone for the 10:00 PM dose and did not visualize the bottle to to ensure the medication concentration on the bottle matched Resident 1's MAR. Staff 5 verified she administered 5 ml (100 mg) of oxycodone. The investigation indicated the facility was not able to rule out that the medication error did not contribute to Resident 1's death. On [DATE] at 1:49 PM Staff 5 stated Staff 4 opened the new bottle of oxycodone and administered the incorrect dose at 10:00 PM. Staff 4 stated she did not visualize the bottle of oxycodone and also administered the incorrect dose of oxycodone to Resident 1. Staff 5 stated she was unable to recall how Resident 1 was breathing prior to the oxycodone administration. On [DATE] at 11:45 AM Staff 3 (RNCM) stated she discovered the medication error when she was given the oxycodone 20 mg per 5 ml bottle to destroy after the resident's death. On [DATE] at 9:55 AM Staff 1 (Administrator) and Staff 2 (Regional RN/Interim DNS) confirmed oxycodone 100 mg was administered to Resident 1 instead of oxycodone 5 mg on [DATE] at 10:00 PM and [DATE] at 2:00 AM. Staff 1 and Staff 2 stated both nurses were immediately suspended and had not returned to the facility. Staff 2 stated the facility recognized both medication errors and a plan of correction was put into place. The facility identified all residents who received medications were at risk, completed a baseline audit for medication errors from [DATE] through [DATE] and initiated training and education with all the nurses and medication technicians related to the six rights of medication administration. Staff 2 stated the facility initiated the observation of every nurse and medication technician for medication administration prior to the start of their next shift. Audits were initiated which included medication pass observation on ten percent of the nurses and medication technicians who pass mediation weekly for four weeks, then monthly for two months. The DON or designee would complete the audits on new hires to validate the education on the six rights of medication administration and a medication observation would be completed prior to working independently. The findings would be reported to QAPI (Quality Assurance Performance Improvement committee) monthly for three months for review and further recommendations. The immediacy was determined to be removed on [DATE] at 4:00 PM. On [DATE] at 2:05 PM Staff 1 and Staff 2 were notified the incident on [DATE] through [DATE] was an Immediate Jeopardy situation. As the facility identified the deficient practice and instituted corrections, this was determined to qualify for the designation as past non-compliance. Survey determined the Past Non-compliance was corrected on [DATE] when the facility identified deficient practice, initiated corrections and completed staff education and training. The Plan of Action included: Systemic Changes: 1. The DON/designee re-educated all nursing staff on [DATE] through [DATE] related to steps to complete a medication pass including the six rights of medication administration. This would be ongoing prior to the start of their shift and with new hires. 2. The DON/designee would conduct a medication observation with each licensed nurse and CMA. 3. All newly hired licensed nurses and CMAs would complete education on the six rights of medication administration and complete a medication observation prior to being on their own on the floor. Monitoring: 1. The DON/designee would perform medication pass observations on 10% of licensed nurses and CMAs who pass medications weekly for 4 weeks and then monthly for two months. 2. The DON/designee would complete audits on newly hired staff to validate their education on the six rights of medication administration and complete a medication observation prior to the newly hired staff working independently. Audits would be completed weekly for four weeks then monthly for two months. The findings would be reported to QAPI monthly for three months for review and further recommendations. Additionally, the facility identified all residents who received medications were at risk and a baseline audit was completed for medication errors in the last 30 days [DATE] through [DATE]. Refer to F760

46841 Based on interview and record review it was determined the facility failed to recognize and respond to Resident 2's respiratory status change of condition for 1 of 3 sampled residents (#2) reviewed for change in condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize, treat, and notify the provider of Resident 2's respiratory decline which resulted in hospitalization for pneumonia and death. Findings include: Resident 2 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure and COPD (Chronic Obstructive Respiratory Disease). The 8/22/23 Physician Order revealed an order for oxygen 0-4 LPM (liters per minute) to maintain oxygen saturations between 88-92% via nasal cannula. The 8/16/23 Cardiovascular Status Care Plan included interventions to assess for SOB (shortness and breath) and cyanosis (lack of oxygen), monitor vital signs and to notify the provider of any significant abnormalities. Further instructed to monitor, document, and report PRN any changes in lung sounds on auscultation (listening with a stethoscope, i.e. crackles), edema and weight changes. The 8/28/23 Nurse Practitioner Progress Note revealed Resident 2's respirations were unlabored with no SOB, the resident denied a cough or SOB, and the resident did not have edema in her/his extremities. Nursing would continue to monitor and report status changes as needed. The 8/29/23 at 11:16 PM Progress Note revealed Resident 2's oxygen saturation on four liters of oxygen was 84%. The resident reported SOB with any movement and a continuous productive cough. Lung sounds were noted to be diminished in all lobes. The 8/30/23 at 10:20 PM Progress Note revealed Resident 2's oxygen saturation on four liters of oxygen was 87%. The resident's lung sounds had crackles in all lobes, the resident had SOB when lying flat and was breathless during conversation. The 8/31/23 at 12:10 PM Progress Note revealed Resident 2 had a decrease in cognition, oxygen saturation levels decreased, and the resident was notably weaker. The resident had a productive cough with copious amounts of thick, dark yellow phlegm, an audible wheeze and 2+ pitting edema (pressure would leave a skin indentation) in both lower extremities. The 9/2/23 at 11:30 AM Progress Note clarified 911 was called on 8/31/23 and the resident was transported to the ER (emergency room ) for significant respiratory distress and decreased cognition. The 9/2/23 at 10:54 AM Progress Note indicated Resident 2 was admitted to ICU (Intensive Care Unit) and had passed away on 9/2/23. Resident 2's meal intake revealed the following: 8/28/23 meal intake varied; first full meal refusal was at lunch. 8/29/23 all meals refused. 8/30/23 intake for all meals documented at 0-25%. 8/31/23 no documented breakfast and refused lunch. Resident 2's weight record revealed a weight of 130.2 pounds on 8/16/23 and 106.9 pounds on 8/18/23. The August 2023 TAR revealed the following: 8/28/23 night shift - 92% on oxygen at three LPM. 8/29/23 day shift - 88% on oxygen at four LPM. 8/29/23 night shift - 84% on oxygen at four LPM. 8/30/23 day shift - not documented. 8/30/23 night shift - 87% on oxygen at four LPM. 8/31/23 day shift - not documented. The Oxygen Saturation Summary from 8/25/23 - 8/31/23 indicated Resident 2's oxygen levels were: 8/28/23 88-92% 8/29/23 83-88% 8/30/23 84% 8/31/23 77-87% Resident's August 2023 MAR revealed the following prn: Lorazepam (medication used for anxiety) was administered prn for anxiety on 8/29/23 at 10:22 PM and on 8/30/23 at 4:39 PM. Albuterol inhaler (breathing treatment) was administered prn on 8/28/23 at 9:51 AM and 3:26 PM. On 8/31/23 all 8:00 AM scheduled oral medications were refused by the resident. Review of Resident 2's electronic health record revealed no evidence the resident's medical provider was notified of any change of condition including respiratory status, oxygen saturations, meal intake and weight changes on 8/29/23, 8/30/23 or 8/31/23. On 9/20/23 at 12:33 PM Staff 5 (Agency LPN) stated she did not contact the provider on 8/30/23 with Resident 2's change in respiratory status (crackles in lungs all lobes bilaterally, SOB while lying flat, breathlessness during conversation, O2 saturation 87% on oxygen at four LPM) as she thought the resident was at baseline. On 9/20/23 at 1:31 PM Staff 3 (Unit Manager) verified Resident 2 experienced a change of condition on 8/29/23 through 8/31/23, the facility did not follow physician orders related to oxygen, did not follow care plan interventions, and did not respond to the resident's change of condition in a timely manner which resulted in a delay of treatment, hospitalization , and death. On 9/21/23 at 12:14 PM Staff 6 (Nurse Practitioner) stated the facility did not notify her of Resident 2's change of condition or hospitalization . Staff 6 stated the normal procedure was for staff to report a resident's change of condition or need for hospitalization to the provider. On 9/20/23 at 2:42 PM the facility was notified of Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 9/20/23 at 4:52 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Education of all nurses to begin on 9/20/23 and would be completed by 9/22/23 at 6:00 PM or prior to the start of shift for agency staff. *All nurses would be provided education on following the resident care plans, doctor's orders, and responding to/documenting/and notifying the resident provider and Director of Nursing of a resident change in condition. *Ensure all residents with acute or chronic respiratory failure have care plans and orders to ensure safety and were at their baseline. *All residents had a potential for a change in condition and delay in care if timely communication with the provider and interventions were not initiated. *The facility would complete respiratory assessments on residents with acute or chronic respiratory failure to ensure they are at baseline. *DNS would audit care plans and orders on residents with acute or chronic respiratory failure to ensure accuracy and completeness and they were being followed. *DNS would audit resident progress notes and vitals to identify residents at risk for a change in condition. *Audits would be completed weekly for four weeks and then monthly for two weeks. Results of audits would be reviewed weekly at Quality Assurance Performance Improvement for four weeks and then monthly for two months to determine if further auditing was appropriate. On 9/25/23 at 12:09 PM staff interviews verified re-education per the immediacy removal plan was completed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented.

Based on interview and record review it was determined the facility failed to administer medication as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#4) reviewed for medications. Resident 4 experienced adverse side effects of the medications and was hospitalized for [REDACTED]. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 8/22/19 Investigation for Medication Error report revealed Staff 7 (LPN) administered the morning medications to Resident 4 which were intended for Resident 4's roommate. The medications included the following: Dafrafenib 100 mg (A drug for treatment of [REDACTED]. Side effects include a skin rash, [MEDICAL CONDITION] and trouble breathing. Mekinist 2 mg: (A drug for the treatment of [REDACTED]. Side effects include cardiac heart failure, skin rash, bleeding and decreased urine output. [MEDICATION NAME] release 60 mg (narcotic). Side effects include respiratory distress. [MEDICATION NAME] 20 mg (heartburn). Side effects include diarrhea and stomach pain. Resident 4's (MONTH) MAR indicated [REDACTED]. Staff 7 immediately notified the charge nurse and Resident 4 was monitored. The resident was unable to work with therapy at 7:30 am due to drowsiness. The physician was called and the resident was placed on one on one supervision. The resident's oxygen levels decreased and at 10:20 am the physician gave orders to send Resident 4 to the hospital. The 8/22/19 Hospital Report revealed Resident 4 was evaluated for a drug overdose and somnolence following an unintentional ingestion of extended use [MEDICATION NAME], Dafrafenib and Mekinist. The resident responded to [MEDICATION NAME] (overdose of opioids) but had no sustained response and had apnea (cessation of breathing) and episodes of [MEDICAL CONDITION] (abnormal heart action). The resident was monitored closely due to acute [MEDICAL CONDITION]ly related to the [MEDICAL CONDITION] drugs which had an 80% association with abnormal liver functions. The resident also had [DIAGNOSES REDACTED] which was mainly present on her/his back (inflammation of skin disease with redness and scaling that affects nearly the entire cutaneous surface 90% or more of skin affected). The resident was admitted to the hospital due to the [MEDICATION NAME] extended release sedation which lasted over nine hours. On 8/25/19 the resident's systems were reviewed and were all negative and the resident's liver functions improved. The resident was expected to discharge from the hospital on [DATE]. Resident 4's (MONTH) MAR indicated [REDACTED]. Staff 7 did not practice the five rights of medication administration to reduce significant medication errors including administering the drugs to the right patient. By not implementing the five rights Resident 4 was sent to the hospital for four days for an overdose of opioids, acute [MEDICAL CONDITION] a large rash on the resident's back caused by ingesting another resident's narcotic and [MEDICAL CONDITION] medications. On 11/18/19 at 10:29 AM Staff 7 indicated she was new and overwhelmed and did not know how to tell people to back off of her medication cart when they gathered around the cart. She popped Resident 4's roommate's medications and gave them to Resident 4 without confirming the name of the resident to whom she was administering medications. She indicated the resident was sent to the hospital and she received retraining on passing medications. On 11/18/19 at 11:50 Am Staff 2 (DNS) acknowledged the medication error and provided the retraining documents for Staff 7. Survey determined the facility instituted the following medication corrections for the 8/22/19 significant medication error for Resident 4: -On 8/22/19 the facility completed a thorough investigation of the error and ruled out abuse and neglect. The error was made due to Staff 7 not [MEDICATION NAME] the 5 rights of medication administration by not ensuring the correct resident recevied the correct medications. -On 8/22/19 Staff 7 completed a Competency Check on oral medication administration. On 8/22/19 Staff 7 recevied a Performance Review which indicated she gave the wrong medications to Resident 4 which resulted in a significant medication error. Medication competency was completed, verbal education on the 5 rights of medication administration was reviewed and Staff 7 recevied training on medication safety. -On 8/22/19 Staff 7 completed a course in Avoiding Medication Related Problems. -On 8/27/19 the nurses and CMAs completed a medication administration training and Staff 2 (DNS) completed a Performance Improvement Action Plan for Medication Pass for staff who passed medications.

Based on interviews and record reviews it was determined the facility failed to assess and treat a change of condition in a timely manner for 1 of 3 sampled residents (# 9). Resident 9 did not receive treatment for [REDACTED]. Resident 9 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 8/28/19 admission MDS revealed the resident did not have issues with eating, required a two person extensive assistance with bed mobility, transfers, locomotion and hygiene. The 9/4/19 care plan revealed the resident required a one person extensive assist for showers, toilet use and limited assistance for turning and repositioning, dressing, personal hygiene and oral care and transferring. The resident was able to self propel in her/his wheelchair to go to the smoking area and ate independently in the dining room. On 10/9/19 the facility faxed the physician of noted changes including confusion, calling out for family, refusal of care, more incontinent episodes, increased sleepiness and required oxygen more frequently related to low oxygen saturation levels. The resident denied signs and symptoms of a UTI and the physician ordered a UA on 10/9/19. The progress notes on 10/12/19, 10/13/19 and 10/20/19 revealed the resident was unable to safely swallow and unable to safely swallow medications. The progress notes indicated the charge nurse was aware. There was no assessment of the resident's inability to safely swallow. The resident's Nutrition Monitoring sheet from 10/1/19 to 10/23/19 revealed the resident refused to eat 15 times and ate 0-25% of meals 13 times. There was no assessment from the dietician. The progress notes from 10/13/19 through 10/22/19 revealed the resident's insulin was held due to the resident not eating on four occasions, and the resident's blood sugars measured lower than usual and at times did not require insulin due to the resident's diminished appetite. On 10/17/19 the facility collected the urine sample which was eight days after the UA was ordered. On 10/21/19 the facility faxed the physician the results of the UA which was positive for bacteria and on 10/21/19 the physician ordered an antibiotic for five days. The 10/23/19 progress note revealed the resident was not at her/his baseline and the clinician completed a full body assessment and the resident would not open her/his eyes. The resident was on oxygen and heart sounds were diminished and was unable to hear lung sounds over her/his moaning. There were bowel tones in the upper quadrant and there was a lump on the lower quadrant, the stomach was round and soft, the pedal pulse was light and the upper extremities were extremely flaccid. The physician was notified and the resident was sent to the hospital. The 10/23/19 hospital admit notes revealed the resident was admitted for [MEDICAL CONDITION] with acute organ dysfunction, UTI (with white blood cells too numerous to count and bacteria at Many), bibasilar [MEDICAL CONDITION] infiltrate and pleural effusions (substance such as pus, blood or protein lingering in the lungs and a build up of fluid), electrolyte abnormalities and altered mental status. The resident was administered intravenous antibiotics, three liters of fluid and was sent to a different hospital to the intensive care unit for further critical care. The facility failed to obtain the UA in a timely manner (eight days after the 10/9/19 order). The facility also failed to obtain a swallow assessment after there were three entries of the resident's inability to safely swallow, and an assessment of the resident's decline with eating and inability to feed her/himself at times. On 11/5/19 at 1:19 AM Staff 14 (RD) indicated she performed a nutritional assessment on the resident when she/he was first admitted but did not get a referral to see the resident again to assess the resident's nutritional needs. On 11/6/19 at 9:30 AM Witness 1 (Complainant) indicated she believed during early to mid (MONTH) the resident had a change of condition that was not assessed. She indicated the resident layed in bed and was not able to do much for her/himself and required help with eating and did not get the assistance she/he required. The resident was not talking and was not up in her/his chair to go to the smoking area like she/he did in the past. The resident was only able to stay up in her/his chair for 20 minutes at a time and cried to go back to bed. On 11/18/19 at 11:12 AM Staff 8 (CNA) indicated the resident was not eating on her/his own and she had to sit to help the resident eat because the resident was unable to get the food in her/his mouth. The resident ate when she/he was fed and was always in bed and did not ask to smoke. On 11/18/19 at 11:37 AM Staff 13 (Speech Language Pathologist) indicated he did not get a referral from the nursing department to conduct a screen on the resident for unsafe swallowing. On 11/18/19 at 1:29 PM Staff 3 (RN Unit Manager) indicated she was unaware of the resident's inability to swallow or eat, Staff 3 indicated they were considering doing a change of condition on the resident but the resident's condition fluctuated so the resident was in the monitoring period. On 11/18/19 at 2:02 PM Staff 2 (DNS) acknowledged waiting eight days to obtain a UA was too long and if the progress notes indicated the resident was unable to safely swallow an assessment should have been completed and a referral made to the speech therapist and dietician.

Based on interview and record review it was determined the facility failed to ensure Staff 7 (LPN) adhered to professional standards related to medication administration for Resident 4 reviewed for a medication error. Resident 4 experienced a decline in condition which required an admission to the hospital for four days for medical treatment. Findings include: Per Division 45 Standards and Scope of Practice for the LPN and RN: [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency (c) Accepting an assignment when individual competency necessary to safely perform the assignment have not been established or maintained. (8) Conduct related to other federal or state statute or rule violations (q) Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 8/22/19 Investigation for Medication Error report revealed Staff 7 (LPN) administered medications to Resident 4 which were intended for her/his roommate. The medications included the following: Dafrafenib 100 mg (A drug for treatment of [REDACTED]. Side effects include a skin rash, [MEDICAL CONDITION] and trouble breathing. Mekinist 2 mg: (A drug for the treatment of [REDACTED]. Side effects include cardiac heart failure, skin rash, bleeding and decreased urine output. Extended Release [MEDICATION NAME] 60 mg (narcotic). Side effects include respiratory distress. [MEDICATION NAME] 20 mg (heartburn). Side effects include diarrhea and stomach pain. Staff 7 immediately notified the charge nurse about the error which occurred at the 7:30 AM medication pass. Resident 4 was monitored and was unable to work with therapy at 7:30 am due to drowsiness. The physician was called and the resident was placed on one on one supervision. The resident's oxygen levels decreased (did not note the percentage) and at 10:20 am the physician gave orders to send Resident 4 to the hospital. Resident 4's (MONTH) MAR indicated [REDACTED]. The 8/22/19 Hospital Report revealed Resident 4 was evaluated for a drug overdose and somnolence following an unintentional extended use [MEDICATION NAME], Dafrafenib and Mekinist ingested at the facility. The resident responded to [MEDICATION NAME] (overdose of narcotics) but had no sustained response. The resident also experienced apnea (cessation of breathing) and episodes of [MEDICAL CONDITION] (abnormal heart action). The resident was monitored closely due to acute [MEDICAL CONDITION]ly related to the [MEDICAL CONDITION] drugs which had an 80% association with abnormal liver functions. The resident also had [DIAGNOSES REDACTED] which was mainly present on her/his back (inflammation of skin disease with redness and scaling that affects nearly the entire cutaneous surface 90% or more of skin affected). The resident was admitted to the hospital due to the [MEDICATION NAME] extended release sedation which lasted over nine hours. On 8/25/19 the resident's systems were reviewed and were all negative and the resident's liver functions returned to normal functions. The resident was expected to discharge from the hospital on [DATE]. Staff 7 did not practice the five rights of medication administration including the right patient. By not implementing the five rights Resident 4 was sent to the hospital for four days for an overdose of narcotics, acute [MEDICAL CONDITION] a large rash on the resident's back caused by ingesting the wrong medications. On 11/18/19 at 10:29 AM Staff 7 indicated she was new and overwhelmed and did not know how to tell people to let her work without interruptions. She indicated staff brought residents to her cart for medication administration and was confused with the extra people around. She prepared Resident 4's roommate's medications and wrote the room number on the cup but did not label which bed, and gave the medications to Resident 4 without confirming the name of the resident to whom she administered the medications. She indicated the resident was sent to the hospital and she received retraining on passing medications. On 11/18/19 at 11:50 Am Staff 2 (DNS) acknowledged the medication errors and provided the retraining documents for Staff 7. Survey determined the facility instituted the following medication corrections for the 8/22/19 significant error for Resident 4: -On 8/22/19 the facility completed a thorough investigation of the error and ruled out abuse and neglect. The error was made due to Staff 7 not [MEDICATION NAME] the 5 rights of medication administration by not ensuring the correct resident received the correct medications. -On 8/22/19 Staff 7 completed a Competency Check on oral medication administration. On 8/22/19 Staff 7 received a Performance Review which indicated she gave the wrong medications to Resident 4 which resulted in a significant medication error. Medication competency was completed, verbal education on the 5 rights of medication administration was reviewed and Staff 7 recevied training on medication safety. -On 8/22/19 Staff 7 completed a course in Avoiding Medication Related Problems. -On 8/27/19 the nurses and CMAs completed a medication administration training and Staff 2 (DNS) completed a Performance Improvement Action Plan for Medication Pass for staff who passed medications. Refer to F 760

Based on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were appropriately assessed, monitored and treated for [REDACTED].#27) reviewed for pressure ulcers. This resulted in an avoidable scrotum pressure ulcer consistent with the definition of a Stage 3 Pressure Ulcer and the development of a secondary ulcer on the scrotum. This placed residents at risk for complications related to pressure ulcers. Findings include: 1a. Resident 27 was admitted to the facility in 4/2013 with [DIAGNOSES REDACTED]. Resident 27's 5/12/18 Quarterly MDS revealed the following: -Cognition was severely impaired, never/rarely made decisions; -Extensive assistance with two person physical assist for bed mobility and toileting; -Extensive assistance with one person physical assist for locomotion on and off the unit, dressing, personal hygiene; -Total dependence with one person physical assist for toileting; -Total dependence with two person physical assist for transfers; -One Stage 2 pressure ulcer (partial loss of skin with red or pink wound bed, without slough) date of oldest Stage 2 of 5/5/18. A 5/21/18 Nurse Practitioner Note revealed the resident was seen for a swollen scrotum with an open area. Staff 16 (ANP, Advanced Nurse Practitioner) was notified the resident had a large firm area and more open areas to the scrotum. The scrotal [MEDICAL CONDITION] and bruising/abrasion appears the scrotum may have gotten pinched using the commode or shower chair. The firm area does not appear to be a mass or growth although this will require ongoing monitoring. Cleanse area and apply zinc oxide three times a day. The care plan indicated specific instructions on which shower chair to use, and placement on the commode and shower chair to prevent pinching of the tissue. The care plan with a revision date of 6/7/18 revealed a 5/21/18 hematoma to the scrotum, no instructions were listed on what shower chair to use or placement on the commode and shower chair to prevent pinching of the tissue. No investigation was completed until 7/8/18 to determine the original wound type, why the wound developed, any external and or internal contributing factors of the wound and anyone who might have additional information about the wound. The 11/2017 CMS State Operations Manual, Appendix PP, defines a Stage 3 Pressure Ulcer as a Full-thickness (extend past the two layers of skin into the subcutaneous tissue like fat and muscle) skin loss in which subcutaneous fat (fat underneath the skin) may be visible in the ulcer and granulation tissue (new growth of connective tissue)and epibole (rolled wound edges) are often present. Slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and or eschar (dead skin tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity (fatty areas) can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable pressure ulcer or pressure injury. A 5/23/18 Nurse's Note revealed the resident continued with open areas to the scrotum, the area had scant bloody drainage. The area was firm and appeared tender to the touch or movement. The area was cleansed and covered with barrier cream per physician order. CNAs were advised to lay the resident down between meals to rest the area. A 5/25/18 Nurse Practitioner Note revealed the resident was seen for the scrotal wound and swelling. The scrotal wound was swollen, firm and very tender when touched as the resident cried out, but unable to verbally communicate anything. The area that was open on the underside of the scrotum appeared to have necrotic (dead) tissue, some slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and some very dark coloration, foul odor, bleeding but no other exudate (fluid leaking from a wound). The order was to cleanse very gently with wound cleanser, apply oil [MEDICATION NAME] or xeroform dressing with a long non-adherent dressing and to try to raise the scrotum off the legs. The resident needed to be seen by urology to further assess the wound and recommend an appropriate treatment. The wound was suspicious of something malignant rather than an area that got pinched, the firm area was larger than it was the previous Monday. A 6/1/18 Nurse's Notes revealed a message was left with the urologist office to schedule an appointment seven days after the recommendation from the ANP. The appointment was set for 7/5/18, the soonest date the urologist could see the resident. No comprehensive wound assessment was completed between 5/25/18 through 6/2/18 (eight days). A 6/2/18 physician's orders [REDACTED]. On 6/2/18 the Wound Assessment Details Report completed by Staff 16 (LPN) revealed the following: Wound: scrotum; Type: trauma; Classification: Hematoma (bruise or blood/bleeding under the skin); Source: facility acquired; Clinical stage: full thickness (extend past the two layers of skin into the subcutaneous tissue like fat and muscle); Tissue Type: bright pink/red 25%, slough loosely adherent 10%, Necrotic 65%; Exudate: moderate amount, bloody; Size in CM: 5.0 x 2.0 x unknown. A 6/2/18 Nurses's Note revealed an open area to the scrotum with bloody drainage, black slough on the wound bed, striations of open areas noted throughout the scrotum. Treatment orders completed, wound rounds initiated. The family was notified. The resident appeared uncomfortable when providing care. A 6/5/18 Nurse Practitioner (NP) Note revealed the resident was seen for scrotal wound and pain. The NP was uncertain of the etiology (cause of the wound) and indicated the wound may be from getting pinched, may be bruising or pressure or may be from an internal condition that was coming to the surface. The NP recommended to continue wound care, and position on her/his side every two hours to prevent pressure on the scrotum and buttocks. The NP would contact the family and explain why the resident needed sent out to the emergency department (ED) for an evaluation because urology was unable to see the resident until 7/2018. A 6/7/18 Emergency Department Report revealed the resident presented to the emergency department for an evaluation of the scrotal lesion with an onset of one month ago. The physical exam revealed a pressure sore on the scrotum. The scrotum had a mildly bloody, yellow drainage. The clinical [DIAGNOSES REDACTED]. The wound care clinic (experts in wounds and the treatment of [REDACTED]. The wound care clinic suggested a foam dressing on the sore and wanted to follow up with the resident outpatient. No comprehensive wound assessment was completed between 6/2/18 through 6/9/18 (eight days). On 6/10/18 the Wound Assessment Details Report completed by Staff 16 (LPN) revealed the following: Wound: scrotum; Type: trauma; Classification: hematoma; Source: facility acquired; Clinical stage: full thickness; Tissue Type: Bright pink/red 25%, slough loosely adherent 10%, Necrotic 65%; Exudate: moderate amount, bloody; Size in CM: 5.0 x 2.0 x unknown; No updated reclassification or staging occurred. A 6/14/18 Treatment Plan Recommendation by Staff 8 (RNCM) revealed the wound documentation was reviewed and agreed with the data collected from the 6/10/18 Wound Assessment Details Report. The resident was seen in the emergency room . The nurse practitioner addressed wound care treatment at that time. On 6/17/18 the Wound Assessment Details Report completed by Staff 16 (LPN) revealed the following: Wound: Scrotum; Type: Trauma; Classification: Hematoma; Source: facility acquired; Clinical stage: full thickness; Tissue Type:Bright pink/red 25%, bright beefy red 45%, slough loosely adherent 10%, Necrotic 20%; Exudate: moderate amount, bloody; Size in CM: 5.0 x 2.0 x unknown. A 6/22/18 Weekly Skin Assessment did not address the scrotum wounds. A 6/28/18 Treatment Plan Recommendation by Staff 8 (RNCM) revealed the wound documentation for the scrotum was reviewed and agreed with the data 6/17/18 Wound Assessment Details Report. The resident continued to slide into a position of comfort causing friction and possible shearing to the area adding pressure to the area. Interventions remained appropriate, and the recommendation indicated to continue treatment and monitor. A 6/29/18 Weekly Skin Assessment revealed scrotum wounds with treatment in place. Wound Assessment Details Reports on 6/23/18 by Staff 16 (LPN), 6/30/18 by Staff 26 (RN) and 7/7/18 by Staff 26 revealed the the following: Wound: scrotum; Type: trauma; Classification: Hematoma; Source: facility acquired; Clinical stage: full thickness; Tissue Type: bright pink/red 25%, bright beefy red 45%, slough loosely adherent 10%, Necrotic 20%; Exudate: moderate amount, bloody; Size in CM: 5.0 x 2.0 x unknown. A 7/2/18 Nurse's Note revealed the resident's family canceled the urology appointment because the family was going to be out of town and felt the area was improving. On 7/6/18 a Weekly Skin Assessment revealed scrotum wounds, one on the posterior and one on the anterior area of the scrotum. Treatment was in place. Review of the resident's records from 6/7/18 through 7/11/18 revealed no documented attempts to send the resident to outpatient wound care the ED recommended on 6/7/18. On 7/8/18 a Nurse's Note revealed the resident had two open areas to the scrotum, one anterior that was clean, superficial and healing, and another posterior that had slough present. Further review of the resident's medical records on 7/11/18 revealed no additional information such as measurements or classification of the secondary scrotum wound. In an interview on 7/9/18 at 3:45 PM Staff 14 (CNA) stated she was aware of the wound. She could not state why the resident developed wounds. The resident was in pain when she worked with her/him, she/he cried out. In an interview on 7/10/18 at 8:35 AM Staff 15 (CNA) stated she was aware of the scrotal wound. The resident often refused bowel care on the toilet because of pain. The scrotum wound had gotten much worse from when it was first discovered. In an interview on 7/10/18 at 12:31 PM Staff 2 (DNS), in the presence of Staff 3 (Regional Nurse Consultant), stated she could not say why the documentation was inconsistent with staging and identification of the wound. She expected weekly wound assessments to be completed. She expected the RN's to ensure accuracy of wound classification and wound documentation. Staff 2 felt the staff were not sure what classification to assign the scrotum wound. When they received additional information from the ED, the wound should have been re-evaluated and re-classified and reflected on the 6/10/18 Wound Assessment Details Report. In an interview on 7/9/18 at 5:18 PM, 7/10/18 at 11:36 AM and 7/11/18 at 4:11 PM Staff 8 (RNCM) stated she completed the investigation of the wound on 7/8/18 and it was late. She did expect investigations to be completed when the wound first appeared. When the scrotum wound started the nurse practitioner thought it was an abrasion/bruise from the way the resident sits. In her professional opinion the wound did not look like a hematoma as the wound rounds stated which she had reviewed and signed off on. The last time Staff 8 saw the wound was during a dressing change approximately one week ago and only saw one healing area on the posterior side of the scrotum. She tried to see the wounds approximately every week but it could be longer. Staff 8 tried to check in with the LPNs as they did the wound rounds if it matched up with her schedule. If she was unable to witness the wound round she would review the data from the LPN assessment and then try to put eyes on the wound as soon as she could. She was unaware of a secondary wound to the scrotum until 7/11/18 and had not reviewed or been told about the 6/29/18 and 7/6/18 Weekly Skin Sheet that identified more than one scrotum wound. There was no follow up to the outpatient wound clinic because the family did not want the resident to go out due to being combative and anxious so Staff 8 continued to treat the resident to minimize her/his discomfort. In an interview on 7/10/18 at 12:52 PM Staff 16 (ANP) in the presence of Staff 2 and 3. Staff 16 stated she was uncertain of what the scrotum wound was when it was first brought to her attention. In the past the resident had a pressure ulcer there but she was not convinced it was pressure related. When the resident was seen at the ED they diagnosed the wound as a pressure ulcer and had been treated at the facility as a pressure ulcer. In an interview on 7/10/18 at 1:07 PM Staff 17 (LPN) stated she did not feel, as an LPN she should be staging wounds because she was not comfortable staging wounds although she did. The wound software required staging when doing rounds, so she put in her best opinion, then relied on the floor nurse and management to ensure the accuracy. She was perplexed about the scrotum wound, but the ED classified it as a pressure ulcer. In an interview on 7/11/18 at 3:08 PM Staff 24 (LPN) stated she started working with the resident approximately one month ago and the scrotum wounds were there. Staff 24 went on to say the second wound was new to her, the one toward the anus. When there is a new wound the LPNs check with the RNCM and get help as well as ask the ANP to obtain a treatment recommendation. Staff 24 always asked someone more educated about what to do with a wound. The responsibility of the LPNs was to collect the data and input the wound information in the Wound Round Assessment Detail Report. Staff 24 indicated she entered unknown as the stage because she was not comfortable staging the pressure ulcers. In an interview on 7/11/19 at 3:30 PM Staff 27 (RNCM) stated she was alerted of the second scrotum wound on 7/7/19 or 7/8/18 from Staff 17. Staff 27 thought it was the same kind of wound the resident already had and kept the same treatment. Staff 27 only went by what was explained to her and did not look at the wound to determine the type of wound it was. Staff 27 stated she only went off the report from the LPN. b. On 5/5/18 at 5:03 PM a Nursing Note revealed Staff 17 (LPN) was alerted by a CNA when trying to transfer the resident. The dressing fell off the resident's coccyx area and the wound was bleeding. Staff 17 noted an open area to the left buttock near the gluteal fold with moderate bloody drainage which stopped with cleansing. The MD was notified and treatment orders and wound documentation were initiated. Resident 27's clinical records revealed no information related to a wound or treatment prior to the 5/5/18 at 5:03 PM Nurse Note. A 5/5/18 incident report, revised 5/15/18 revealed Staff 17 was alerted the resident had a skin breakdown area with red bloody appearing drainage. The resident was unable to describe the event. The injury was located on the left buttock. The injury type was blank. A 5/5/18 physician's orders [REDACTED]. Change every three days and as needed. The 5/5/18 Wound Assessment Details Report completed by Staff 17 (LPN) revealed the following: -Wound: left buttock; -Type: pressure -Classification: Ulceration -Source: facility-acquired -Clinical stage: Stage 2 -Tissue types: [MEDICATION NAME] (skin tissue) 80% pink or red, 20% deep maroon; -Exudate (fluids leaking from a wound): moderate, bloody; -Size in CM: 3.0 x 3.0 x unknown The 5/6/18 Wound Assessment Details Report completed by Staff 26 (RN) was the same as the 5/5/18 report. A 5/7/18 physician's orders [REDACTED]. No comprehensive wound assessment was completed between 5/7/18 through 5/18/18 (12 days). The 5/17/18 Treatment Plan Recommendation by Staff 8 (RNCM) revealed wound documents were reviewed the area was not pressure, but was due to shearing. The 5/19/18, 5/24/18, 5/28/18, 6/10/18 and 6/17/18 Wound Assessment Details Report revealed the following: -Wound: left buttock; -Type: trauma; -Classification: abrasion; -Source: facility-acquired; -Clinical stage: superficial; -Tissue types: [MEDICATION NAME] (top layer of skin) 80% pink or red, 20% deep maroon; -Exudate (fluids leaking from a wound): scant, serosanguineous; -Size in CM: 2.5 x 1.0 x unknown. No weekly wound report was completed between 5/29/18 through 6/9/18 (12 days later). The 6/18/18 Nurse Practitioner Note revealed the resident had a Stage 2 coccyx wound, possible pressure. The wound was difficult to discern because of the dark pigment of Resident 27's skin. The Nurse Practitioner directed the staff to monitor the integrity of the skin daily when performing wound care and ensure a pressure relief cushion in the resident's chair. The 6/23/18 and 6/30/18 Wound Assessment Details Report revealed the following: -Wound: left buttock; -Type: trauma; -Classification: abrasion; -Source: facility-acquired; -Clinical stage: superficial; -Tissue types: [MEDICATION NAME] (top layer of skin) 80% pink or red, 20% deep maroon; -Exudate (fluids leaking from a wound): scant, serosanguineous; -Size in CM: 2.5 x 1.0 x unknown. The 7/7/18 Wound Assessment Details Report revealed the following: -Wound: left buttock; -Type: trauma; -Classification: abrasion; -Source: facility-acquired; -Clinical stage: partial thickness; -Tissue types: [MEDICATION NAME] (top layer of skin) 80% pink or red, 20% deep maroon; -Exudate (fluids leaking from a wound): scant, serosanguineous; -Size in CM: 3.5 x 1.25 x 0.25. The 7/10/18 Nurse Practitioner Note revealed an ongoing wound to the left buttocks and coccyx wound. The left buttocks and coccyx wound was a pressure sore likely caused by shearing. The Nurse Practitioner directed staff to cleanse the wound with wound cleanser, dry, apply foam dressing and change every two days and as needed for soiling and to continue to keep the resident off the area as much as possible. During an observation by RN Surveyor on 7/11/18 at 1:40 PM Staff 24 (LPN), with Staff 2 (DNS) present, performed a dressing change on the resident. The wound between the buttocks had purple outer edges. The left inner cheek had a large open area that was bleeding and worsened when touched. The wound bed appeared beefy red was bleeding with a slight bit of pink. No additional information was provided by the facility as of 7/11/18 related to a treatment already in place prior to 5/5/18. In an interview on 7/9/18 at 5:18 PM and 7/10/18 at 11:36 AM Staff 8 (RNCM) stated she felt a lot of the coccyx wound appeared to be moisture and shearing related. Staff 8 indicated she could make changes to the clinical record regarding the assessment of the Stage 2 wound (made by a LPN) in the progress notes and would hope it would be documented why it was changed in the progress notes. Staff 8 tried to check in with the LPNs as they do the wound rounds if it matched up with her schedule. If she was unable to witness the wound round she would review the data from the LPN assessment and then try to put eyes on the wound as soon as she could. In an interview on 7/10/18 at 12:31 PM Staff 2 (DNS), with Staff 3 (Regional Nurse Consultant) present, stated she could not say why the documentation was inconsistent with staging and identification of the coccyx and buttocks wound. Staff 2 indicated staff should not downstage a wound. She expected weekly wound assessments to be completed and was uncertain of prior treatment to the coccyx before 5/5/18. In an interview on 7/10/18 at 1:07 PM Staff 17 (LPN) verified when she was alerted about the wound on 5/5/18 there was a dressing in place but it was the first time she had witnessed the wound on the buttocks. Staff 17 stated she did not feel, as an LPN, she should be staging wounds because she was not comfortable staging wounds. The wound software in the clinical record required wounds to be staged during wound rounds, so she put in her best opinion, then relied on the RNs and RNCMs to ensure the accuracy. In an interview 7/10/18 at 1:43 PM Staff 2 stated she was unaware the LPNs were not comfortable with wounds. The last wound training was in the Summer of (YEAR). Staff 2 further stated the RNs should put eyes on wounds and not rely on gathered documentation from the LPN to assess wounds.

Based on interview and record review it was determined the facility failed to transfer information of a resident's medication allergy to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received [MEDICATION NAME] after the resident had a previous allergic reaction to the medication which resulted in the resident being sent to the hospital for evaluation and treatment. This placed residents at risk for adverse medication reactions. Findings include: Resident 175 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of a nursing note dated 10/7/13 written at 11:42 am revealed the facility received a fax from the resident's physician indicating the resident was to receive [MEDICATION NAME] for a UTI. Review of a doctor's note dated 10/18/13 revealed the resident developed a new allergic reaction to [MEDICATION NAME]. Review of a pharmacy review note dated 10/25/13 revealed the resident had an allergy to [MEDICATION NAME]. Review of a nursing note dated 11/4/13 written at 4:25 pm revealed the facility received an order for [REDACTED]. Review of a November 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an interview on 11/20/13 at 10:50 am Staff 1 (DNS) acknowledged the resident's allergy to [MEDICATION NAME] documentation was not transferred to the resident's MAR. Refer to F333.

Based on interview and record review it was determined the facility failed to document a resident's medication allergy to [MEDICATION NAME] (antibiotic) for 1 of 6 sampled residents (#175) reviewed for medications. The resident received [MEDICATION NAME] after the resident had a previous allergic reaction to the medication which resulted in the resident being sent to the hospital for evaluation. This placed residents at risk for adverse medication reactions. Findings include: Resident 175 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Review of a nursing note dated 10/7/13 written at 11:42 am revealed the facility received a fax from the resident's physician indicating the resident was to receive [MEDICATION NAME] for a UTI. Review of a October 2013 MAR revealed the resident received [MEDICATION NAME] on 10/7/13 at 5:00 pm. Review of a nursing note dated 10/8/13 at 12:47 pm revealed the resident complained of nausea and was short of breath. The note indicated the resident's oxygen saturation was 88% on 3 liters per minute of oxygen and had a red rash on the arms, chest and trunk. The note indicated the resident's physician was notified and the [MEDICATION NAME] was discontinued. Review of a nursing note dated 10/9/13 written at 11:31 pm revealed the resident continued on a different antibiotic after a negative response to a previous antibiotic ([MEDICATION NAME]). The note indicated the resident breathing was normal and the resident's rash was diminished. Review of a doctor's note dated 10/18/13 revealed the resident had developed a new allergic reaction to [MEDICATION NAME]. Review of a pharmacy review note dated 10/25/13 revealed the resident had an allergy to [MEDICATION NAME]. Review of a nursing note dated 11/4/13 written at 4:25 pm revealed the facility received an order for [REDACTED]. Review of a November 2013 MAR revealed the resident received [MEDICATION NAME] on 11/4/13 at 5:00 pm. The MAR did not have documentation of the resident's allergy to [MEDICATION NAME]. Review of a nursing note dated 11/4/13 written at 7:45 pm revealed the resident had received [MEDICATION NAME] as ordered by the resident's physician and at 6:00 pm the resident complained of shortness of breath. The note indicated the resident's oxygen saturation was in the "60's" and the resident was "working hard to breathe." The resident's physician was notified and the resident was sent to a local hospital for evaluation and treatment. Review of an incident investigation dated 11/5/13 revealed on 10/7/13 the resident was treated for [REDACTED]. The note indicated the resident had a reaction to the medication and a new antibiotic was ordered and the resident's symptoms resolved. On 11/4/13 the resident was diagnosed with [REDACTED]. The investigation indicated the MAR did not list [MEDICATION NAME] as an allergy and the resident was given one dose of [MEDICATION NAME]. The investigation also indicated the resident's chart listed the resident's allergy to [MEDICATION NAME] and staff immediately notified the resident's physician. The resident developed shortness of breath and was sent to a local hospital for evaluation. In an interview on 11/18/13 at 8:55 am Witness 2 (Complainant) indicated on 10/7/13 the resident was diagnosed with [REDACTED]. Witness 2 said the resident had an allergic reaction to the medication, the medication was stopped and the resident was started on another antibiotic. Witness 2 said the resident was diagnosed on [DATE] with another UTI, the resident received [MEDICATION NAME], had an allergic reaction and was sent to the hospital for evaluation. In an interview on 11/20/13 at 10:20 am Staff 11 (LPN) said on 10/7/13 the resident had an allergic reaction to [MEDICATION NAME]. Staff 11 said the resident developed a rash on the face and trunk and had no history of an allergy to [MEDICATION NAME]. The resident's physician was notified the resident's antibiotic was changed and the resident's allergy was documented on the front cover of the resident's chart to indicate an allergy to [MEDICATION NAME]. Staff 11 said she had not updated the resident's MAR to indicate an allergy to [MEDICATION NAME]. In an interview on 11/20/13 at 10:50 am Staff 1 (DNS) acknowledged the resident's allergy to [MEDICATION NAME] documentation was not transferred to the resident's MAR and the resident had received [MEDICATION NAME] which resulted in the transfer to a local hospital for evaluation and treatment.

Based on interview and record review it was determined the facility failed to promptly notify physicians of critically high blood tests for 2 of 6 residents with critical potassium levels (#s 1 and 2). Resident 1 required hospitalization to correct the abnormal potassium and phosphorus levels. Findings include: According to facility policy dated April 2006, "when test results are provided to the facility, the attending physician shall be promptly notified of the results." 1. Resident 1 was admitted to the facility in March 2011 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident received total [MEDICATION NAME] nutrition (TPN, nutritional support delivered through a central venous line). On 4/1/11 at 12:55 pm, blood tests faxed to the facility from the laboratory included a critical high potassium level of 7.10 (normal ranges 3.5-5.5) and a critical high phosphorus level of 7.8 (normal ranges 2.5-4.5). On 4/1/11 about 1 pm, the laboratory blood tests results were faxed to the doctor and the pharmacy, according to Staff 3 (RN, charge nurse). On 4/1/11 at 5:30 pm, Witness 1 (Physician) became aware of critical high blood tests and Resident 1 was immediately sent to an emergency room (ER) for treatment of [REDACTED]. On 4/26/11 at 11:30 am, Staff 3 (RN, Charge Nurse) stated he faxed blood test results for Resident 1 to the pharmacy and the physician about 1 pm on 4/1/11. He stated he normally reviewed laboratory reports prior to faxing them for any critical blood test values that might need prompt attention. Staff 3 noted Resident 1's laboratory report dated 4/1/11 did not have a circle and initial next to the critical high results indicating he had overlooked them. Staff 3 did not call the physician office. Staff 3 stated he did not involve the DNS in the changing orders and status for Resident 1. On 4/27/11 at 10:00 am, Staff 2 (DNS) stated prompt treatment and monitoring of the critical high potassium and phosphorus in the hospital would likely have mitigated any serous effects and resulted in less trauma to Resident 1. The ER report dated 4/1/11 indicated Resident 1 was admitted with a critical high potassium level of 7.0, according to the hospital laboratory. Resident 1 experienced a decrease in consciousness, had a [MEDICAL CONDITION], and [DIAGNOSES REDACTED] while in the emergency room . Resident 1 was treated and admitted to the hospital that evening. On 4/28/11 at 12:15 Witness 1 (Physician) reported her office was not notified promptly by phone regarding critical high blood test results for Resident 1. Witness 1 stated laboratory results had been faxed to the office at 1:00 pm, from the facility. These results were not noted and reviewed until about 5:30 pm. She immediately contacted the facility to transport Resident 1 to the emergency room for required monitoring and treatment of [REDACTED]. Refer to F309 example 1. 2. Resident 2 was admitted to the facility in February 2011 with [DIAGNOSES REDACTED]. On 2/17/11 Laboratory results were faxed to the facility at 2:15 pm, indicating a critical high potassium level of 6.30 (normal range 3.5-5.5) NN dated 2/17/11 at 6:00 pm, indicated laboratory results were faxed to the M.D. A fax dated 2/22/11 at 5:00 pm, indicated the physician follow up regarding critical lab values for Resident 2. The physician ordered medication changes and new blood work to be completed in relation to the critical high lab values of 2/17/11. No phone call or fax follow up to critical laboratory results were located in NN for the 5 day period from Thursday 2/17/11 until Tuesday evening 2/22/11. On 4/27/11 at 3:30 pm, Staff 2 (DNS) stated the facility had no procedure to monitor physician response to critical high laboratory reports the facility sent to them. Staff 2 stated the nurses would report any ongoing resident issues at change of shift for the following shift to follow up with. On 4/29/11 at 2:45 pm, Staff 4 (LN) stated she faxed critical blood test results for Resident 2 to her physician on 2/17/11. Staff 4 stated staff would not call a physician office after hours with a lab report, just fax it. Staff 4 reported she was unaware of any way to monitor physician response after a fax with critical lab values was sent to the physician. Refer to F309 example 2.

Based on interview and record review it was determined the facility failed to provide care and services in coordination with the resident's physician for 2 of 6 sampled residents (#s 1 and 2). Resident 1 required hospitalization to monitor and treat critical high potassium and phosphorus levels. Findings include: According to facility policy dated April 2006, "when test results are provided to the facility, the attending physician shall be promptly notified of the results" 1. Resident 1 was admitted to the facility in March 2011 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident received total [MEDICATION NAME] nutrition (TPN, nutritional support delivered through a central venous line). admission orders [REDACTED]. The Care Plan dated 3/24/11 indicated the resident needed limited assistance for ADL's, the assistance of 2 staff for transfers and tolerated sitting up for 15 minutes at a time. The resident received occupational and physical therapy for strengthening and mobility. On 4/1/11 according to NN and Fax reports care proceeded as follows for Resident 1: At 12:55 pm, blood tests faxed to the facility included a critical high potassium level of 7.10 (normal ranges 3.5-5.5) and a critical high phosphorus level of 7.8 (normal range 2.5-4.5). These blood tests were faxed to the doctor and the pharmacy about 1 pm according to Staff 3 (RN, charge nurse). At about 2:00 pm, critical high blood tests were communicated to the facility from the laboratory and pharmacy by telephone according to Staff 3 (RN, charge nurse) According to a telephone order form, at 2:20 pm, the pharmacy directed nursing to "discontinue TPN immediately, and begin an Intravenous Line (IV) of [MEDICATION NAME] 5% in water (D5W) @ 40 ml/hour until reformulated TPN delivered tonight." The April 2011 MAR indicated [REDACTED] At 3:20 pm, according to a telephone order form, the pharmacy directed the facility to increase the IV D5W to 125 ml/hr until arrival of the reformulated TPN. The April 2011 MAR indicated [REDACTED]. At 4:00 pm, a CBG revealed a blood sugar of 203. According to the April 2011 MAR, 8 units of [MEDICATION NAME] Insulin were given, following the prescribed sliding scale for Resident 1. At 5:30 pm, Witness 1 (Physician) became aware of a fax indicating critical high blood test results for Resident 1. Resident 1 was immediately sent to an emergency room (ER) for treatment of [REDACTED]. On 4/26/11 at 11:30 am, Staff 3 (RN, Charge Nurse) stated he faxed blood test results for Resident 1 to the pharmacy and the physician about 1 pm on 4/1/11. He stated he normally reviewed laboratory reports prior to faxing them for any critical blood test values that might need prompt attention. Staff 3 noted Resident 1's laboratory report dated 4/1/11 did not have a circle and initial next to the critical high results indicating he had overlooked them. Staff 3 stated he did not call the physician office, or notify the DNS of critical high blood tests and the change in treatment ordered for Resident 1. On 4/27/11 at 10:00 am, Staff 2 (DNS) stated it was a nursing standard of care to call and report all critical high blood test results as soon as possible to the resident's attending physician. Staff 2 stated staff could not rely on a fax notification at a busy physician office. Staff 2 stated she was not aware of the changing orders or critical high laboratory reports for Resident 1 prior to the resident being sent to the ER. Staff 2 agreed that prompt treatment and monitoring of the critical high potassium and phosphorus in the hospital would likely have mitigated any serious effects and resulted in less trauma to Resident 1. The ER report dated 4/1/11 indicated Resident 1 was admitted with a critical high potassium level of 7.0 according to the hospital laboratory. Resident 1 experienced a decrease in consciousness, had a [MEDICAL CONDITION], and [DIAGNOSES REDACTED] while in the emergency room . Resident 1 was treated and admitted to the hospital that evening. On 4/28/11 at 12:15 Witness 1 (Physician) reported her office was not notified promptly by phone regarding critical high laboratory values for Resident 1. Witness 1 stated a fax had been sent earlier in the day from the facility, but was not reviewed until about 5:30 pm. The physician immediately contacted the facility to transport Resident 1 to the emergency room for required monitoring and treatment of [REDACTED]. 2. Resident 2 was admitted to the facility in February 2011 with [DIAGNOSES REDACTED]. On 2/17/11 Laboratory results were faxed to the facility at 2:15 pm, indicating a critical high potassium level of 6.30 (normal range 3.5-5.5) NN dated 2/17/11 at 6:00 pm, indicated laboratory results were faxed to the M.D. A fax dated 2/22/11 at 5:00 pm, indicated the physician followed up regarding critical lab values for Resident 2. The physician ordered medication changes and new blood work to be completed in relation to the critical high lab values of 2/17/11. No phone call or fax regarding critical laboratory results were located in NN for the 5 day period from Thursday 2/17/11 until Tuesday evening 2/22/11. On 4/27/11 at 3:30 pm, Staff 2 (DNS) stated the facility had no procedure to track physician response to critical labs the facility reported to them. Staff 2 stated the nurses would report any ongoing resident issues at change of shift. On 4/29/11 at 2:45 pm, Staff 4 (LN) stated she faxed critical lab values for Resident 2 to her physician on 2/17/11. Staff 4 stated staff would not call a physician office after hours with a lab report, just fax it.

Based on interview and record review it was determined the facility failed to follow nursing standards of practice for 2 of 6 sampled residents with critical high blood tests (#s 1 and 2). Resident 1 required hospitalization to correct the high potassium and phosphorus levels. Findings include: The Oregon State Board of Nursing Nurse Practice Act, Conduct Derogatory: Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, (3) Conduct related to communication, (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner. 1. Resident 1 was admitted to the facility in March 2011 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident received total [MEDICATION NAME] nutrition (TPN, nutritional support delivered through a central venous line). admission orders [REDACTED]. On 4/1/11 at 12:55 pm, blood tests faxed to the facility from the laboratory, included a critical high potassium level of 7.10 (normal ranges 3.5-5.5) and a critical high phosphorus level of 7.8 (normal range 2.5-4.5). On 4/1/11 about 1:00 pm, the blood tests were faxed to the doctor and the pharmacy by Staff 3 (RN, Charge Nurse). On 4/1/11 at approximately 2:00 pm, critical high blood tests were communicated to the facility from the laboratory and pharmacy by telephone. Staff 3 ended his shift without contacting the resident's physician regarding critical high blood tests, and did not make arrangements for other staff to follow up with the physician. On 4/1/11 at 5:30 pm, Witness 1 (Physician) became aware of the fax with critical high blood test results for Resident 1. Resident 1 was immediately sent to an emergency room (ER) for treatment of [REDACTED]. On 4/26/11 at 11:30 am, Staff 3 (RN, Charge Nurse) stated he faxed blood test results for Resident 1 to the pharmacy and the physician about 1 pm on 4/1/11. He stated he normally reviewed laboratory reports prior to faxing them for any critical blood test values that might need prompt attention. Staff 3 noted Resident 1's laboratory report dated 4/1/11 did not have a circle and initial next to the critical high results indicating he had overlooked them. Staff 3 stated he did not call the physician office, or notify the DNS of critical high blood tests and the changing treatments for Resident 1. The ER report dated 4/1/11 indicated Resident 1 was admitted with a critical high potassium level of 7.0, according to the hospital laboratory. Resident 1 experienced a decrease in consciousness, had a [MEDICAL CONDITION], and [DIAGNOSES REDACTED] while in the emergency room . Resident 1 was treated and admitted to the hospital that evening. On 4/28/11 at 12:15 Witness 1 (Physician) reported her office was not notified promptly by phone regarding critical high laboratory values for Resident 1. Refer to F309 example 1. 2. Resident 2 was admitted to the facility in February 2011 with [DIAGNOSES REDACTED]. On 2/17/11 Laboratory results were faxed to the facility at 2:15 pm, indicating a critical high potassium level of 6.30 (normal range 3.5-5.5) NN dated 2/17/11 at 6:00 pm, indicated laboratory results were faxed to the M.D. A fax dated 2/22/11 at 5:00 pm, indicated the physician directives regarding critical high blood test results for Resident 2. The physician ordered medication changes and new blood work to be completed in relation to the critical high blood tests of 2/17/11. No phone call or fax regarding the critical high laboratory results were located in NN for the period from Thursday 2/18/11 until Tuesday evening 2/22/11. On 4/29/11 at 2:45 pm, Staff 4 (LN) stated she faxed critical lab values for Resident 2 to the physician on 2/17/11. Staff 4 stated staff would not call a physician office after hours with a lab report, just fax it. Refer to F309 example 2.

Based on interviews and record review it was determined the facility failed to provide a safe medication system and administered an antibiotic to a resident with a known allergy to that antibiotic for 1 of 3 sampled residents (#1). Resident 1 developed a significant adverse drug reaction in a form of a rash and the resident's scheduled surgery was delayed. Findings include: Resident 1 was readmitted to the facility in September 2010 with [DIAGNOSES REDACTED]. Review of the resident's September 2010 hospital "Medication Reorder and/or Discharge List", the facility 9/21/10 Initial Data Collection Form, the September 2010 MAR and the Allergic sticker (found on the front of the chart) revealed the resident was allergic to medications including [MEDICATION NAME] (a [MEDICATION NAME]) and [MEDICATION NAME]. Review of the 9/27/10 Physician's Telephone order revealed the resident was to be administered [MEDICATION NAME] (a [MEDICATION NAME]) BID for 10 days. Review of the resident's 9/27/10 Physician Fax revealed "Pt has listed pcn ([MEDICATION NAME]) allergy, should we still use?" The Fax was noted on 9/30/10 with the response "no." The fax also revealed the physician ordered Keflex (antibiotic) to be given instead of the [MEDICATION NAME]. Review of the Resident's September 2010 MAR revealed the resident was administered six doses of [MEDICATION NAME] between 9/27/10 and 9/30/10. Review of the 10/1/10 through 10/4/10 Nurses Progress Notes revealed the resident had a raised rash on the trunk and upper thighs and required medication for the rash and the resident's complaint of itch. Review of the 10/4/10 hospital Consultation Report revealed the resident was admitted to the hospital on [DATE] with anticipation of surgery for [REDACTED]. The resident's [DIAGNOSES REDACTED]." Review of the hospital Discharge Summary revealed the resident's discharge [DIAGNOSES REDACTED]. Review of the resident's 10/5/10 MDS revealed the resident did not have a memory problem and the resident understood others and others understood the resident. Review of the 12/13/10 Board of Pharmacy inquiry response revealed Resident 1 had an allergic reaction to a medication that was pulled from the facility e-kit by the facility staff. The resident's allergies [REDACTED]. Witness 2 (Consulting Pharmacist) called the facility to inform the facility about the medication allergy on 9/27/10 and Staff 6 (RN) stated the order for [MEDICATION NAME] would be clarified with the physician. The facility requested a clarification via fax, but the facility administered six doses of [MEDICATION NAME] between 9/27/10 and 9/30/10. The physician discontinued the [MEDICATION NAME] due to the allergy concern on 9/30/10. Review of the 12/15/10 facility Medication Error Report revealed the resident was given six doses of [MEDICATION NAME] despite the resident having [MEDICATION NAME] listed as an allergy. The report revealed the medication error did not cause harm to the resident. The factors that contributed to the error included the drug, by brand name, was not recognized as a drug on the allergy list. Staff involved with the med error included a CMA, LPN and RN. The recommendation listed to prevent further reoccurrence included to not administer a medication listed as an allergy unless the physician took the medication off the allergy list. On 12/30/10 Staff 2 (DNS) stated the facility staff sent a fax to the resident's physician to clarify if the resident should take [MEDICATION NAME] (a [MEDICATION NAME]) due to a [MEDICATION NAME] allergy. The facility staff should not have administered the [MEDICATION NAME] until the physician clarified the order. The facility staff should have called the physician to clarify the order regarding a medication allergy. On 12/30/10 at 11:50 am Staff 3 (CMA) stated the resident had an allergy to [MEDICATION NAME] and [MEDICATION NAME] was administered from the e-kit (emergency supply of medications). Staff 3 stated she did not realize [MEDICATION NAME] was a type of [MEDICATION NAME]. On 1/4/11 at 11:56 am Staff 5 (LPN) stated the resident was started on [MEDICATION NAME] (a [MEDICATION NAME]) after a physician office visit. The RN on duty sent a fax to the physician to clarify if [MEDICATION NAME] should be given with the resident's history of allergies [REDACTED]. On 1/4/11 at 12:36 pm Staff 8 (RN) stated she did not recall the resident having [MEDICATION NAME] listed as an allergy. The facility process to check newly prescribed medications for residents was to look at the allergy list located on the MAR or the front of the chart to ensure the resident did not have an allergy to the newly prescribed medication. On 1/4/11 at 12:00 pm Witness 1 (Director of Pharmacy) stated the pharmacy informed the facility nursing staff to not administer the [MEDICATION NAME] (a [MEDICATION NAME]) until the order was clarified by the physician. The pharmacy did not provide the [MEDICATION NAME] to the facility and the facility obtained the [MEDICATION NAME] from the e-kit. The resident developed a rash on 10/1/10 and the rash may have been caused by the [MEDICATION NAME] or the Keflex which was started on 9/30/10. On 1/4/11 at 1:16 pm Resident 1 stated he/she was admitted to the facility in September 2010 due to a broken ankle and the ankle swelling had to decrease before the resident could have surgery. Resident 1 informed the facility of the [MEDICATION NAME] allergy and wore a red bracelet that listed [MEDICATION NAME] as an allergy. The facility continued to give the resident the [MEDICATION NAME] (a [MEDICATION NAME]) and the resident developed a rash. The resident stated he/she had a "severe experience." The resident was admitted to the hospital for scheduled surgery on 10/4/10 but the surgery had to be canceled because of the resident's rash. Resident 1 stated while in the hospital he/she had a "heart incident" but does not know if the incident was directly related to the allergic reaction to the [MEDICATION NAME]. On 1/5/11 Witness 2 (Facility Consulting Pharmacist) stated she informed the facility of the resident's allergies [REDACTED]. On 1/4/11 a telephone call was placed to Staff 6 (RN), a return call was not received.