Every finding on record at Creekside Health and Rehabilitation of Cascadia

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed. This placed residents at risk for living in an uncomfortable and un-homelike environment. Findings include: Resident 38 was admitted to the facility in 2023 with a diagnosis of quadriplegia.On 5/19/26 at 10:11 AM, Resident 38 stated the carpets were stained in several spots and needed to be replaced.On 5/21/26 at 10:12 AM, observation of all facility halls revealed multiple areas of stained and discolored carpeting throughout resident hallways. Large dark stains were observed on the carpeted walking surfaces. Multiple light-colored bleach stains were observed adjacent to resident room doorways. The carpets appeared worn, dingy and discolored, resulting in an unclean appearance.On 5/21/26 at 10:12 AM, Staff 7 (Maintenance Director) observed the 400, 600, and 700 halls confirmed the carpets were stained in multiple areas, large dark stains were observed in the carpet, and multiple light colored bleach stains were observed adjacent to resident rooms. The Maintenance Director acknowledged the carpeting was stained and discolored.On 5/21/26 at 11:03 AM, Staff 1 (CEO) acknowledged the carpets needed to be replaced.

Based on interview and record review it was determined the facility failed to provide timely lab services for 2 of 5 sampled residents (#s 6 and 11) reviewed for unnecessary medications. This placed residents at risk for delayed treatment. Findings include: Resident 6 was admitted to the facility on [DATE] with a diagnosis of acute pyelonephritis (severe kidney infection). Resident 6's 4/2026 BIMS Assessment indicated a score of 15 (cognitively intact). A review of the resident's clinical record revealed on 3/6/26 Resident 6 reported burning with urination for a couple of days to Staff 12 (NP). Staff 12 ordered a UA for Resident 6. Additional notes revealed the specimen was sent to the lab 3/6/26. No documentation was located in the clinical record of the lab results for the 3/6/26 urine sample. On 5/21/26 at 10:30 AM, Staff 4 (IP) stated the facility was notified by the lab on 3/10/26 the resident's name was not identifiable on the specimen. The clinical record revealed a new order was obtained for a UA on 3/12/26, and a new urine specimen was obtained and sent to the lab on 3/13/26. The resident's clinical record revealed she/he discharged [DATE]. Lab results were not returned to the facility until 3/17/26. The clinical record revealed Resident 6 returned to the hospital on 3/18/26 after a fall. Hospital records indicate the resident was diagnosed with a UTI while in the hospital. On 5/21/26 at 3:22 PM, Staff 10 (LPN) stated nurses are responsible for obtaining urine samples. Staff 10 stated when a resident was reporting symptoms of a UTI it would be imperative to obtain a new sample and send it to the lab. Staff 10 stated the nurse on duty when the lab notified the facility should have called the on-call provider for a new order. Staff 10 stated a sample should be obtained and sent to the lab the same day. On 5/21/26 at 3:33 PM, Staff 11 (LPN/Unit Manager) stated the lab generally sends an email within 24 hours if they can't process a specimen. Staff 11 stated the Unit Manager and IP should know when a urine culture was ordered and monitor for a result. On 5/21/26 at 3:45 PM, Staff 9 (NP) stated she expected a nurse to call for a new order for a UA the same day they learned the specimen could not be processed. On 5/22/26 at 8:18 AM, Staff 2 (DNS) stated the original UA was collected by the facility on 3/6/26 and sent to the lab the same day. Staff 2 stated it was rejected by the lab, and the facility was informed on 3/10/26. Staff 2 stated a new culture was obtained and sent to the lab on 3/13/26. She stated she expected facility staff to follow up. 2. Resident 11 was admitted to the facility in 4/2026 with a diagnosis of a shoulder fracture. Resident 11's 4/17/26 Provider Visit Note revealed she/he had a suspected UTI with urine retention and the orders included to send a urine sample to evaluate for infection. Resident 11's Final Diagnostic report revealed her/his urine sample was collected on 4/17/26 and was not received at the laboratory until 4/21/26. Resident 11's urine sample results indicated she/he had many bacteria in the urine and a culture was to be completed. Resident 11's culture notes indicated the specimen quality was inadequate, and the culture was not performed because the urine sample exceeded the stability required for the test. On 5/19/26 at 3:17 PM, Staff 4 (Infection Preventionist) stated on 4/17/26 (Friday) Resident 11's urine sample was collected and placed in the laboratory box for the laboratory currier to pick up, but the specimen was still in the box on 4/20/26 (Monday). Staff 4 stated this was likely the reason the sample was inadequate. On 5/21/26 at 10:46 AM, Staff 2 (Chief Nursing Officer) stated when a resident's urine sample was collected., staff were to call the laboratory and request a currier pick up. Staff 2 stated at times the laboratory did not pick up the sample and the sample would need to be recollected.

Based on observation, interview, and record review it was determined the facility failed to store medications properly for 1 of 3 medication refrigerators. This placed residents at risk for receiving ineffective medication. Findings include:The CDC requires medication refrigerators to always maintain a temperature between 36 and 46 degrees Fahrenheit (F).On 5/21/26 at 1:37 PM, Staff 2 (DNS/CNO) provided the temperature log for the facility's narcotic refrigerator for the last 30 days. The temperatures were as follows:-4/21/26 at 7:00 AM 25.16 degrees F-4/21/26 at 7:00 PM 28.04 degrees F-4/22/26 at 7:00 AM 30.2 degrees F-4/22/26 at 7:00 PM 28.58 degrees F-4/23/26 at 7:00 AM 28.4 degrees F-4/23/26 at 7:00 PM 27.68 degrees F-4/24/26 at 7:00 AM 25.88 degrees F-4/24/26 at 7:00 PM 27.5 degrees F-4/25/26 at 7:00 AM 25.34 degrees F-4/25/26 at 7:00 PM 27.5 degrees F-4/26/26 at 7:00 AM 24.08 degrees F-4/26/26 at 7:00 PM 29.48 degrees F-4/27/26 at 7:00 AM 25.16 degrees F-4/27/26 at 7:00 PM 27.86 degrees F-4/28/26 at 7:00 AM 26.42 degrees F-4/28/26 at 7:00 PM 24.98 degrees F-4/29/26 at 7:00 AM 27.5 degrees F-4/29/26 at 7:00 PM 25.7 degrees F-4/30/26 at 7:00 AM 28.58 degrees F-4/30/26 at 7:00 PM 31.1 degrees F-5/1/26 at 7:00 AM 25.7 degrees F-5/1/26 at 7:00 PM 26.6 degrees F-5/2/26 at 7:00 AM 26.6 degrees F-5/2/26 at 7:00 PM 31.1 degrees F-5/3/26 at 7:00 AM 30.74 degrees F-5/3/26 at 7:00 PM 31.64 degrees F-5/4/26 at 7:00 AM 25.88 degrees F-5/4/26 at 7:00 PM 26.42 degrees F-5/5/26 at 7:00 AM 31.1 degrees F-5/5/26 at 7:00 PM 27.14 degrees F-5/6/26 at 7:00 AM 31.1 degrees F-5/6/26 at 7:00 PM 28.4 degrees F-5/7/26 at 7:00 AM 27.5 degrees F-5/7/26 at 7:00 PM 27.86 degrees F-5/8/26 at 7:00 AM 29.12 degrees F-5/8/26 at 7:00 PM 23.9 degrees F-5/9/26 at 7:00 AM 30.56 degrees F-5/9/26 at 7:00 PM 30.02 degrees F-5/10/26 at 7:00 AM 25.88 degrees F-5/10/26 at 7:00 PM 28.76 degrees F-5/11/26 at 7:00 AM 29.3 degrees F-5/11/26 at 7:00 PM 25.16 degrees F-5/12/26 at 7:00 AM 26.24 degrees F-5/12/26 at 7:00 PM 25.52 degrees F-5/13/26 at 7:00 AM 28.4 degrees F-5/13/26 at 7:00 PM 30.02 degrees F-5/14/26 at 7:00 AM 30.02 degrees F-5/14/26 at 7:00 PM 25.34 degrees F-5/15/26 at 7:00 AM 26.78 degrees F-5/15/26 at 7:00 PM 28.04 degrees F-5/16/26 at 7:00 AM 24.8 degrees F-5/16/26 at 7:00 PM 25.34 degrees F-5/17/26 at 7:00 AM 29.48 degrees F-5/17/26 at 7:00 PM 29.3 degrees F-5/18/26 at 7:00 AM 28.04 degrees F-5/18/26 at 7:00 PM 27.5 degrees F-5/19/26 at 7:00 AM 26.42 degrees F-5/19/26 at 7:00 PM 25.52 degrees F-5/20/26 at 7:00 AM 26.06 degrees F-5/20/26 at 7:00 PM 26.24 degrees F-5/21/26 at 7:00 AM 25.88 degrees [NAME] 5/21/26 at 3:19 PM, Staff 2 stated medication refrigerator temperatures are taken automatically every 12 hours and when the temperature is out of range, she gets a notification on her phone. On 5/21/26 at 3:24 PM, the narcotic refrigerator was observed with Staff 2. The narcotic refrigerator contained an unopened bottle of liquid lorazepam (an antianxiety medication), an unopened vial of injectable lorazepam, and an open bottle of liquid lorazepam for a resident who discharged on 5/20/26. The resident received two doses of lorazepam, one dose on 5/19/26 and one dose on 5/20/26. Staff 2 stated the pharmacy was notified and the medications would be discarded. Staff 2 stated she expected if the temperature in the refrigerator was too low, the temperature would be turned up, and the medications in the refrigerator would be replaced. Staff 2 acknowledged this procedure was not followed and maintenance had not been notified of the low temperatures in the medication refrigerator.On 5/21/26 at 3:50 PM, Staff 14 (Pharmacist) stated lorazepam efficiency would be affected if kept in a refrigerator below freezing temperatures for that long.

Based on interview and record review, it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 sampled residents (#16) reviewed for abuse. This placed residents at risk for lack of dignity and respect. Findings include: Resident 16 was admitted to the facility in 3/2025, with diagnoses including anxiety. An admission MDS dated [DATE] indicated Resident 16 was cognitively intact. The Baseline Care Plan dated 3/28/25, indicated Resident 16 used anti-anxiety medications, with interventions including she/he could become overwhelmed. Staff could assist with one-on-one support. Resident 16 required moderate assistance of one staff member for stand pivot transfers and toileting. A 3/29/25 facility investigation was initiated after two residents complained about Staff 5 (Former CNA). Multiple grievances against Staff 5 led to him being placed on administrative leave. Resident 16 filed a grievance on 3/29/25, which detailed an incident on 3/28/25 during the evening or night shift. Resident 16 reported she/he had requested a female CNA to assist with her/his shower, to which Staff 5 responded one was not available and you're not my type. During assistance with toileting and assisting Resident 16 into bed a call light fell off the bed. Resident 16 reported Staff 5, with clenched teeth and after getting close to her/his face stated, I don't understand you fucking people leaving your shit on the bed. Resident 16 also stated Staff 5 folded her/his walker and threw it in the corner of the room. Resident 16 reported Staff 5 was angry about her/him needing to use the potty, and Staff 5 refused to deal with her/him. Staff 5 got a urinal and stated, fucking tired of this, then told Resident 16 to put her/his legs on the bed. Resident 16 was too slow; Staff 5 reportedly grabbed her/his legs and roughly tossed them on the bed. While Resident 16 used the urinal, Staff 5 kept ranting. An item dropped behind the bed, and Staff 5 became scary, clenching his teeth and getting into Resident 16's face saying, what's wrong with you fucking people. You put your personal shit all over your bed. Staff 5 then pulled the bed out and found the call light. Resident 16 was crying, and Staff 5 stated she/he did not need to cry and patted her/his hand. The investigation indicated Staff 5 reported he was in a hurry on 3/28/25 and felt he may have been short but never intended to be. On 6/12/25 at 9:19 AM, Staff 5 (Former CNA) stated he did not remember Resident 16. Staff 5 denied throwing the walker, though he conceded he might have inadvertently moved a walker quickly, causing it to hit a wall. Staff 5 also admitted he might have inadvertently used profanity in a resident's room and not intentionally moved a resident's legs roughly. Staff 5 mentioned numerous complaints from multiple residents at the facility and stated he resigned as there was no resolution. On 6/12/25 at 10:12 AM, Staff 6 stated she heard residents complain about Staff 5, describing him as gruff with the residents and was rough around the edges. On 6/12/25 at 10:38 AM, Resident 16 stated on the night of 3/28/25 a male CNA came into her/his room to assist her/him with toileting. Resident 16 stated she/he asked for a female caregiver and Staff 5 informed her/him there was no female CNA available and stated, you are not my type. Resident 16 stated Staff 5 assisted her/him with toileting and getting into bed. Staff 5 folded up the walker and he threw it, and it hit hard. Resident 16 stated she/he was frightened. Staff 5 stated he did not have time for this bull shit and picked Resident 16 up and plopped her/him on the bed. Resident 16 stated he picked her/him up from underneath the arm pits and he was very strong. During the time he put her/him into the bed an object fell behind the bed. Staff 5 was very close to her/his faced and stated, I am so fucking sick of you guys putting stuff on the end of the bed. Resident 16 stated it scared her/him. Staff 5 picked up the items behind the bed, patted Resident 16 on the back and told her/him everything was okay. On 6/12/25 at 11:53 AM, Staff 2 (DNS) and Staff 3 (Regional RN Consultant) stated the facility ruled out abuse and neglect as Resident 16's story would go back and forth with her/his statement. Staff 2 stated she felt everything was resolved with Resident 16. The deficient practice was identified as Past Noncompliance based on the following: On 3/31/25, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures in the identification of potential abuse and neglect. The Plan of Correction included: *On 3/31/25, Staff 7 (RN) was educated on abuse and neglect policies, along with grievances which could potentially rise to the level of an allegation of abuse or neglect which should be reported to the Administrator immediately. *Ten additional residents were interviewed. All indicated they felt safe at the facility and vocalized no concerns regarding staff care and services. *Staff 5 was provided education regarding communication and perception of communication by others. Staff 5 was provided a work plan which included access to counseling services and offered additional time off. Staff 5 was assigned training, which included Stress Management and Building up Emotional Intelligence. This training must be completed prior to returning to the facility along with abuse and neglect training. *All staff educated on grievances and understanding that grievances could potentially rise to the level of alleged abuse or neglect along with the facility's reporting abuse and neglect policy.

Based on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 5 sampled residents (#313) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 313 was admitted to the facility in 1/2025 with diagnoses including anxiety. A 1/23/25 Nutrition Evaluation indicated Resident 313 had difficulty grasping a fork related to hand tremors and the RD recommended adaptive ware (flatware in foam tubes to make it easier to grip) for all meals. A 1/23/24 order indicated Resident 313 was to have adaptive flatware for all meals. On 2/10/25 at 12:52 PM Resident 313 was observed eating in the dining room, no adaptive ware was observed. On 2/11/25 at 1:38 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Staff 18 (Dietary Aide) stated adaptive ware are added to the trays during the tray line in the kitchen based on what the tray tickets indicated. On 2/13/25 at 2:52 PM Staff 13 (RD) stated she met with Resident 313 on 1/23/25 and she/he had a hard time holding her/his fork so, with Resident 313's agreement, she put in orders to use adaptive ware with meals. On 2/13/25 at 3:16 PM Staff 14 (Culinary Manager) stated the order for adaptive ware for Resident 313 was in the orders but was not on the tray tickets.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 residents(#50)reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include: Resident 50 was admitted to the facility in 11/2024 with diagnoses including congestive heart failure. A 12/20/24 physician order for Enestro (a heart and blood pressure medication) indicated to hold the medication if Resident 50's systolic blood pressure(SBP)was less than 120. A review of the 1/2025 MAR revealed on 1/2/25 the PM dose of Enestro was given with a SBP of 118 and on 1/4/25 the PM dose of Enestro was given with a SBP of 110. A review of the 2/2025 MAR revealed on 2/1/25 the PM dose of Enestro was given with a SBP of 104. On 2/14/25 at 11:58 AM Staff 2(DNS)acknowledged Resident 50 received Enestro on 1/2/25, 1/4/25, and 2/1/25 when the medication should have been held per orders. On 2/14/25 at 2:19 PM Staff 10(LPN)stated he gave Enestro on 2/1/25 when it should have been held based on the blood pressure parameter order. On 2/14/25 at 2:30 PM Staff 16(RN)stated she gave Enestro on 1/4/25 when it should have been held based on the blood pressure parameter order. On 2/14/25 at 2:47 PM Staff 17(CMA)stated she gave Enestro on 1/2/25 when it should have been held based on the blood pressure parameter order.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 18 was admitted to the facility in 2023 with diagnoses including diabetes. Resident 18's current physician orders indicated the resident had an order for MiraLAX (a laxative) once daily for constipation. The medication was to be held for loose stools. Bowel elimination records from 9/20/23 through 10/17/23 revealed Resident 18 had loose stools or diarrhea documented on the following dates: - 9/20/23, 9/28/23, 9/29/23, 10/4/23, 10/6/23, 10/13/23, and 10/17/23. Resident 18's MARs from 9/20/23 through 10/17/23 indicated the scheduled MiraLAX was not held for the loose stools. On 10/18/23 at 2:20 PM Staff 5 (LPN) stated Resident 18's MiraLAX should have been held on the days the resident had loose stools. On 10/19/23 at 12:09 PM Staff 2 (DNS) verified Resident 18 was administered MiraLAX with documented loose stools and stated her expectation was for medications to be administered according to the physician's orders.

Based on observation, interview and record review it was determined the facility failed to implement care planned interventions related to fall safety for 1 of 2 sampled residents (#36) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. A review of an incident report, dated 10/1/23, indicated Resident 36 had an unwitnessed fall and was found next to her/his bed on 10/1/23. The resident indicated she/he attempted to reposition herself/himself in bed, slid off the bed and onto the floor. The resident was assessed and not injured from the fall. Review of Resident 36's Care Plan, initiated 9/29/23, revealed the resident was at risk for falls related to visual impairment and impaired functional mobility. A revision on 10/6/23 revealed the resident had a non-injury fall out of bed on 10/1/23 and interventions included a fall mat at bedside, bed in a low position and the resident was placed on the falling star program (more frequent checks). The Admission MDS dated [DATE], revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and the bed was approximately two feet from the floor with a fall mat next to her/his bed. On 10/18/23 at 6:24 AM Staff 4 (CNA) stated Resident 36 had a non-injury and stated Resident 36's bed was to be in the lowest position. Staff 4 acknowledged Resident 36's bed was not in the lowest position. On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 was a fall risk and her/his bed was to be in the lowest position. Staff 14 acknowledged the bed was approximately two feet from the floor and was not in the lowest position. On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a non-injury fall out of bed and staff were expected to follow the care plan and ensure her/his bed was in the lowest position while the resident was in bed.

Based on observation, interview and record review it was determined the facility failed to update resident care plans for 2 of 2 sampled residents (#s 6 and 36) reviewed for accidents. This placed residents at risk for lack of ADL care needs and safety. Findings include: 1. Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. Review of Resident 36's Care Plan initiated 9/29/23, revealed the resident had an ADL self-care performance deficit related to blindness, decreased mobility and wounds. The resident required one or two-person extensive assist with toileting, substantial/maximum assistance for repositioning, personal hygiene and dressing. The resident was encouraged to use her/his pressure sensitive call device to ring for assistance. The Admission MDS, dated [DATE], revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. Random observations from 10/16/23 through 10/18/23 revealed Resident 36 was in bed and whistled until staff entered her/his room and her/his call light was not activated. On 10/18/23 at 6:24 AM Staff 4 (CNA) and 6:45 AM Staff 3 (RN) stated Resident 36 was legally blind and had a touch pad alarm but whistled for assistance. Staff 4 and Staff 3 stated Resident 36 did not use the touch pad alarm. On 10/18/23 at 6:43 AM Resident 36 stated she/he did not use the call device but whistled for help. On 10/18/23 at 11:01 AM Staff 14 (RN) stated Resident 36 never used her/his touch pad alarm and whistled when she/he needed assistance with her/his ADL care needs. On 10/18/23 at 7:41 PM Staff 13 (CNA) stated Resident 36 was dependent for all ADL care needs and had a difficult time using her/his touch pad alarm and whistled to get staff attention. On 10/19/23 at 12:22 PM Staff 12 (LPN/Resident Care Manager) stated Resident 36 had a touch pad alarm but whistled to alert staff when she/he needed assistance. Staff 12 acknowledged this was not on the care plan and needed to be updated to reflect Resident 36's ADL care needs. 47005 2. Resident 6 was admitted to the facility in 8/2019 with diagnoses including severe protein calorie malnutrition and osteoporosis. An 8/28/23 Quarterly MDS indicated Resident 6 was cognitively intact. On 10/16/23 and 10/17/23 between 2:30 PM and 4:15 PM Resident 6 was observed driving her/his power wheelchair in the facility parking lot towards the street. A Care Plan last updated on 10/16/23 revealed Resident 6 had unsafe community behaviors. The care plan did not include any interventions regarding her/his unsafe community behaviors. On 10/17/23 at 2:10 PM Staff 18 (RN) stated Resident 6's typical behavior was to get into her/his power wheelchair around 2:00 PM or 3:00 PM, leave the facility, and return around 3:30 AM. Staff 18 stated she was unsure of where Resident 6 went, but per other staff Resident 6 was either in the facility parking lot, at stores, or the two nearby parks. Staff 18 further stated Resident 6 did not tell staff where she/he went. On 10/17/23 at 11:47 PM Staff 17 (CNA) stated Resident 6 was out of the facility in her/his power wheelchair and did not expect her/him to return until 3:00 AM or 3:30 AM when she/he was ready to go to bed. On 10/20/23 at 9:00 AM Staff 2 (DNS) acknowledged Resident 6's care plan was not updated to reflect the resident's preference for being in the community all day and there were no interventions in place for safety.

Based on interview and record review it was determined the facility failed to ensure adequate RN charge nurse staffing for 15 of 28 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 10/24/22 through 11/20/22 revealed 15 days with no RN coverage for eight hours each day. On 11/21/22 at 10:56 AM Staff 1 (Administrator) confirmed the lack of RN staffing.

Based on interview and record review it was determined the facility failed to ensure adequate RN charge nurse staffing for 15 of 28 days reviewed for staffing. This placed residents at risk for unmet needs. Findings include: A review of the facility's Direct Care Staff Daily Reports from 10/24/22 through 11/20/22 revealed 15 days with no RN coverage for eight hours each day. On 11/21/22 at 10:56 AM Staff 1 (Administrator) confirmed the lack of RN staffing.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate and complete for 12 of 36 sampled days reviewed for staffing. This placed residents and visitors at risk for lack of staffing information. Findings include: Review of the Direct Care Staff Daily Report postings from 8/1/22 through 9/5/22 revealed the following: *Nine days (8/5/22, 8/8/22, 8/26/22, 8/27/22, 8/30/22, 8/31/22, 9/1/22, 9/2/22 and 9/4/22) the actual hours worked by the RN, LPN or CNAs were not documented as required for one or more of the shifts each day. *Four days (8/31/22, 9/1/22, 9/2/22 and 9/4/22) the resident census was not documented as required for one or more of the shifts each day. *Two days (8/28/22 and 8/29/22) the nursing staff signature and resident census were missing for one or more of the shifts each day. *One day (9/3/22) the night shift information was incomplete and the total number and the actual hours worked by the RN, LPN and CNAs and the total resident census were not documented as required. On 9/9/22 at 12:18 PM Staff 1 (Administrator) and Staff 2 (Interim DNS) acknowledged the Direct Care Staff Daily Reports reviewed were inaccurate or incomplete.

Based on interview and record review it was determined the facility failed to follow up regarding Advance Directives for 2 of 4 sampled residents (#s 4 and 5) reviewed for Advance Directives. This placed residents at risk for not having their healthcare wishes honored. Findings include: 1. Resident 4 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/7/22 at 8:13 AM Resident 4 was asked about Advance Directives. Resident 4 stated she/he did not have an Advance Directive and the facility did not ask about Advance Directives. Care Conference Notes from 9/2021 to current were reviewed. There was no information related to Advance Directives documented in the notes. Review of the medical record revealed no information related to Resident 4's desire to execute Advance Directives. On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and they were reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered. 2. Resident 5 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Care Conference Notes from 5/2021 to current were reviewed. There was no information to indicate advance directives were discussed with Resident 5. Review of the medical record revealed no information related to Resident 5 having an advance directive or her/his desire to execute an Advance Directive. On 9/8/22 at 2:15 PM Staff 1 (Administrator) stated the facility asked about an Advance Directive upon admission and reviewed at every care conference. Staff 1 added if information related to Advance Directives was not in the care conference notes, it was not reviewed or offered.

Based on interview and record review it was determined the facility failed to assess and care plan a restraint for 1 of 1 sampled resident (#9) reviewed for accidents. This placed residents at risk for restraint use. Findings include: Resident 9 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An investigation note for a fall on 8/7/22 recommended the use of a seatbelt in Resident 9's wheelchair. A review of the medical record indicated there was no information related to the addition of a seatbelt or who applied the seatbelt to Resident 9's wheelchair. There was no information related to seatbelt use for Resident 9 until 9/6/22. A Health Status note dated 9/6/22 indicated Resident 9 had a seatbelt. A Care Plan Change note dated 9/7/2022 indicated due to multiple falls Resident 9 would benefit from the use of a seatbelt. On 9/9/22 at 11:15 AM Staff 13 (CNA) was asked about the use of the seatbelt for Resident 9 and Staff 13 indicated Resident 9 used the seatbelt for approximately one month. On 9/9/22 at 11:42 AM Resident 9's seatbelt was reviewed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated they just found out Resident 9 used a seatbelt. Staff 1 added upon review of the medical record they identified there was no information or assessment for the use of the seatbelt for Resident 9.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to initiating [CONDITION(S)] medication for 1 of 5 sampled residents (#6) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 6 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/1/22 Quarterly MDS revealed Resident 6 had a BIMS score of 13, indicating she/he was cognitively intact. Resident 6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's 8/2022 and 9/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed no documentation of Resident 6's consent to receive [MEDICATION(S)]. On 9/9/22 at 9:40 AM Resident 6 stated she/he did not know what medications she/he received. On 9/9/22 at 11:11 AM Staff 2 (Interim DNS) stated there was no consent in the medical record for Resident 6 to receive [MEDICATION(S)].

Based on observation, interview and record review it was determined the facility failed to provide routine dental services to meet resident needs for 1 of 2 sampled residents (#6) reviewed for dental care. This placed residents at risk for unmet dental needs. Findings include: Resident 6 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 6 was observed on 9/6/22 at 1:16 PM with many upper teeth missing. A 3/30/22 Oral Dental Assessment revealed Resident 6's last dental appointment was unknown and a dental appointment was to be scheduled the week of 4/4/22 through 4/8/22. At the time of this survey a review of the medical records revealed no documentation of a dental appointment after the 3/30/22 assessment. On 9/8/22 at 9:36 AM Staff 3 (RNCM) stated dental appointments were scheduled as needed and she did not know if Resident 6 saw the dentist. On 9/8/22 at 11:08 AM Staff 1 (Administrator) stated there was nothing in the chart indicating Resident 6 was seen by the dentist after the 3/30/22 Oral Dental Assessment.

Based on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include. Resident 9 was admitted to the facility in 2020 with diagnoses including [CONDITION(S)]. A Pharmacy Review conducted 6/2022 indicated the need to clarify an antibiotic order based on Resident 9's noted allergy to the antibiotic. A Pharmacy Review conducted 8/2022 repeated the recommendation to clarify the antibiotic allergy and review the need for continued use of a proton pump inhibitor (used to decrease stomach acid). A review of the medical record revealed there was no follow up to the pharmacy recommendations for Resident 9. On 9/9/22 at 11:42 AM Pharmacy Reviews were discussed with Staff 1 (Administrator) and Staff 2 (Interim DNS). Staff 1 stated she was not aware pharmacy reviews were conducted. Staff 1 provided no additional information.

Based on observation, interview and record review it was determined the facility failed to provide services related to ROM and splints for 2 of 3 sampled residents (#s 1 and 8) reviewed for positioning and mobility. This place residents at risk for ROM decline. Findings include: 1. Resident 1 admitted to the facility in 8/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 8/16/21 signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An 8/17/21 OT Plan of Care Evaluation revealed Resident 1 would benefit from bilateral resting hand splints for the prevention of contractures of the wrist/hand and without therapy Resident 1 was at risk for bilateral hand contractures. The 10/17/21 Annual MDS revealed Resident 1 had upper and lower extremity impairments to both sides and there was no indication splints or ROM services were provided. Resident 1's 8/23/22 revised care plan did not include information regarding her/his hand/wrist contractures, provision of restorative ROM or use of splints on either hand. On 9/6/22 at 5:29 PM Witness 1 (Family) stated hand/wrist splints were ordered for Resident 1 but the use of the splints were not mentioned during recent care plan meetings. On 9/7/22 at 12:12 PM and 9/8/22 at 12:39 AM Resident 1 was observed in her/his wheelchair with her/his hands resting on a pillow on her/his lap. All of Resident 1's fingers were curled into a fist and no splints were observed on either hand. On 9/7/22 at 1:29 PM Staff 4 (CNA) stated she worked with Resident 1 since 10/2021 provided ROM by stretching Resident 1's hands during bathing but did not document the information into Resident 1's medical record. Staff 4 acknowledged she did not see ROM services listed for Resident 1 in her/his care plan and had no knowledge of any hand/wrist splints for Resident 1. On 9/7/22 at 1:44 PM Staff 5 (Therapy Director) stated he believed the hand/wrist splints for Resident 1 were ordered but was unsure if they ever arrived. On 9/9/22 at 1:00 PM Staff 2 (Interim DNS) acknowledged there was no evidience the hand/wrist splints for Resident 1 were ordered or implemented. 2. Resident 8 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) A 7/15/22 Annual MDS revealed Resident 8 had limited ROM in her/his upper and lower extremities. An 8/3/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for ROM for Resident 8. An 8/12/22 Physical Therapy Daily Treatment Note revealed Resident 8 had a physical therapy evaluation and it recommended Resident 8 receive ROM from CNA staff three to five days a week on her/his hips, knees and ankles. A review of Resident 8's current care plan revealed no documentation related to ROM. The 8/2022 and 9/2022 Documentation Survey Reports revealed no documentation ROM exercises were completed with Resident 8. On 9/7/22 at 1:52 PM Staff 4 (CNA) stated she did ROM with Resident 8 by extending Resident 8's arms when getting dressed and in the showers. Staff 4 stated Resident 8's care plan did not indicate if ROM was to be completed. On 9/8/22 at 11:03 AM Staff 14 (CNA) stated she was unaware of ROM exercises for Resident 8. On 9/8/22 at 12:12 PM Staff 5 (Therapy Director) stated Resident 8 was evaluated for ROM and the CNAs were to complete ROM exercises. Staff 5 stated Resident 8 needed ROM to prevent contractures and it was best if ROM was completed daily. On 9/8/22 at 3:08 PM Staff 3 (RNCM) stated Resident 8's medical record did not have charting or orders to direct facility staff to do ROM, did not include what exercises were to be completed and did not include when the exercises were to be completed. Staff 3 further stated it was dependent on the CNAs or nurses to remember to do the ROM exercises and to know the residents and what they needed.

Based on observation, interview and record review it was determined the facility failed to ensure AGP (aerosol generating procedure) precautions were used according to CDC guidelines for 1 of 1 sampled resident (#10) reviewed for respiratory care. This placed staff and residents at increased risk for infections and contracting COVID-19. Findings include: A review of Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) policy and procedure dated 6/1/22 revealed the following: - AGP to reduce the risk of transmission during bronchoscopy, sputum induction, intubation and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways. -Procedure should be performed in an airborne isolation room if available (negative pressure) and door must be closed. -Limit the number of healthcare workers present. -Staff must wear a fit tested N95 or PAPR (powered air purifying respirator). -Eye protection (goggles or face shield) should be worn if not using a PAPR. -Gown and gloves. -A patient who underwent AGP must have the door closed two hours in a standard room. Resident 10 admitted to the facility in 11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive care plan dated 2/22/22 revealed Resident 10 had difficulty breathing related to obstructive sleep apnea and a [CONDITION(S)] (continuous positive airway pressure) machine was used each night when she/he slept. Staff were to assist Resident 10 at bedtime and remove the [CONDITION(S)] as she/he desired. Random observations from 9/6/22 through 9/9/22 revealed Resident 10 had a [CONDITION(S)] machine on her/his night stand. Resident 10 did not have any AGP or PPE precautions posted or supplies available outside her/his door identifying when the [CONDITION(S)] was in use. On 9/7/22 at 1:10 PM Resident 10 stated she/he used a [CONDITION(S)] machine at night because she/he had better quality of sleep. On 9/7/22 at 4:59 PM Staff 13 (CNA) stated Resident 10 utilized her/his [CONDITION(S)] machine at night and was not aware of any AGP or PPE precautions needed. On 9/8/22 at 11:03 AM Staff 3 (RNCM) stated Resident 10 used a [CONDITION(S)] machine at night. Staff 3 stated she was not aware AGPs were required for Resident 10's [CONDITION(S)] machine use. On 9/9/22 at 1:34 PM Staff 1 (Administrator) and Staff 2 (DNS) stated staff were expected to implement and follow AGP precautions for Resident 10.

Based on interview and record review it was determined the facility failed to address a resident's change in condition, failed to ensure provision of care and services for wounds and failed to follow physicians' orders for 4 of 6 sampled residents (#s 1, 4, 5 and 11) reviewed for wounds and medications. Resident 11 required acute care intervention due to [CONDITION(S)] (infection that causes life-threatening injury to the body's own tissues and organs) and amputation. Findings include: 1. Resident 11 admitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/13/21 orthopedic clinic note revealed amputations of Resident 11's right third toe, and left fourth and fifth toes were completed. The 1/2022 TAR revealed wound care orders for Resident 11 were as follows: -Pack right toe with strips moistened with Dakin's (an antiseptic solution containing bleach) solution and if the wound vac (a device used to conduct negative pressure to promote wound healing) on the left toe dislodged the procedures for the right toe should be followed for the left toe. A 1/5/22 orthopedic clinic note revealed Resident 11 was to receive wound care two times each week. A 1/24/22 Wound Care Provider Note revealed Resident 11's wound vac fell off during her/his sleep over the weekend and her/his wounds were dressed by the facility using iodosorb (an antiseptic containing iodine) packing on the left foot and hydrafera (a blue colored antiseptic) packing on the right foot. A 1/28/22 orthopedic clinic note revealed Resident 11 had no signs of infection and the surgical wound was healing. A 1/28/22 facility Wound RN Assessment revealed Resident 11 had a non-pressure related wound to her/his left toes. No other information was documented. A 1/31/22 FAX Communication to Physician revealed Staff 12 (Nurse Practioner) was informed Resident 11 had decreased mobility and there were no changes at that time. A 2/1/22 progress note revealed Staff 2 (DNS) reported Staff 3 (RN Care Manager) observed Resident 11 had increased weakness and Witness 7 (clinic physician) was informed. The progress note revealed additional orders for Resident 11 would only be sent if orders for Resident 11 needed to occur before her/his upcoming appointment. A 2/4/22 facility Wound RN Assessment revealed Resident 11 had a surgical wound on her/his left toes with partial thickness loss and the depth of the wound had increased. On 3/26/22 at 3:05 PM Staff 3 stated Resident 11 slept more according to an unidentified CNA and staff reported this information to her since they knew Staff 3 was aware of Resident 11's history with infection. Staff 3 stated because of Resident 11's weak condition and infection history she intended for Staff 12 to assess Resident 11 but was unsure if the request was completed. Review of Resident 11's medical record revealed no ongoing assessment and monitoring after increased weakness was noted on 2/1/22. A 2/4/22 progress note revealed Resident 11 was scheduled for an appointment with the wound clinic on 2/7/22. A 2/7/22 progress note revealed transportation did not arrive for Resident 11's appointment. The 2/2022 facility appointment calendar revealed an appointment for Resident 11 with the orthopedic clinic on 2/10/22 was canceled since no transportation was scheduled. On 3/25/22 at 3:24 PM Witness 4 (Clinic LPN) stated Resident 11 often arrived to appointments with wound care not completed or done incorrectly. Witness 4 also stated on 2/11/22 Resident 11 was not seen but was sent directly to the hospital because she/he had a fever and was unable to communicate. On 3/29/22 at 2:05 PM Staff 11 (receptionist) stated there was a period of time when Witness 6 (former Social Services Director) was gone and resident transportation was a little chaotic. Staff 11 stated she helped facilitate resident transportation during the week of 2/7/22 through 2/11/22 when Witness 6 was out of the facility. On 3/29/22 at 11:23 AM Witness 5 (wound clinic receptionist) stated Resident 11 was scheduled routinely for wound care appointments, had a wound care appointment on 2/4/22, was scheduled for appointments on 2/7/22 and 2/9/22 and those appointments were canceled (one week without wound care). On 2/11/22 Resident 11 arrived for wound care and was immediately sent to the hospital. A 2/11/22 History and Physical revealed Resident 11 was positive for [CONDITION(S)] (a bacteria resistant to antibiotics) and presented with a wound infection complicated by septic shock which required a central line access for blood pressure management. A 2/16/22 hospital Consultation revealed Resident 11 had a new [CONDITION(S)] bacteremia (bacteria in the blood stream) infection of the right foot fourth digit after amputation of the third digit (in 12/2021) and septic shock which required admission to intensive care. A 2/23/22 Operative Note revealed Resident 11 was admitted to the hospital with [CONDITION(S)] and additional amputation occurred to her/his right and left toes due to infection. On 3/18/22 at 4:57 PM Staff 2 (DNS) stated she should have advocated more for a physician visit based on the observation and infection history of Resident 11 provided by Staff 3. Staff 2 confirmed there was no additional charting related to Resident 11's increased weakness and monitoring did not occur. Staff 2 also stated she recently provided wound care for Resident 11 and she/he informed Staff 2 she/he wanted the alternative wound dressing other nurses provided and not what was ordered. Staff 2 confirmed wound dressing should be provided as ordered. On 3/29/22 at 5:00 PM and 3/30/22 at 1:15 PM Staff 1 (Administrator) confirmed there was no evidence rides for the missed appointments for Resident 11 were scheduled and it was an ongoing issue that needed to be addressed. 2. Resident 1 admitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/31/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2022 Facility Narcotic Book revealed no morning [MEDICATION(S)] was dispensed on 2/15/22, 2/16/22, 2/17/22, 2/18/22, 2/22/22, 2/23/22 and 2/24/22. On 3/17/22 at 4:01 PM Staff 7 (RN) stated Staff 6 (LPN) informed her that Resident 1's [MEDICATION(S)] was not administered based on her observation of the narcotic book. Staff 2 (DNS) was informed. On 3/22/22 at 5:52 PM Staff 2 stated an investigation was initiated and confirmed Witness 3 did not administer Resident 11's medication as ordered. 3. Resident 4 admitted to the facility in 2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident 4's clinical record revealed no indication why the [MEDICATION(S)] was held or that the physician was notified. On 3/28/22 at 5:28 PM Staff 2 (DNS) confirmed there was no indication in the clinical record why Resident 4's [MEDICATION(S)] was not administered, the physician should have been notified and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Resident 5 admitted to the facility in 2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/24/22 Order Audit Report for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 3/1/22 Order Audit Report of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/2022 TAR revealed Resident 5's wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 5's clinical record revealed no indication why wound treatment was not provided on 3/7/22 or 3/15/22 or physician was notified. On 3/23/22 at 3:52 PM and 3/24/22 at 1:15 PM Staff 4 (LPN) stated nurses were not able to view tasks of the previous shift that were not provided. Staff 2 (DNS) was informed any time care for a resident was not provided but the reason for any lapse in treatment might not be documented. Staff 4 also stated she informed Staff 7 (RN) Resident 5's wound care was not done. On 3/24/22 at 3:11 PM Staff 5 (CNA) stated Resident 5 sometimes refused treatment on shower days but nurses were to document and address any refusals. On 3/28/22 at 5:28 PM Staff 2 stated no entry for a scheduled treatment indicated the order was not provided. Staff 2 confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review it was determined the facility failed to ensure residents with major mental health [DIAGNOSES REDACTED].#15) reviewed for behavioral and emotional health. This caused the resident pyschosocial harm related to decreased social interaction and increased depressive behaviors. Findings include: Resident 15 admitted to the facility directly from her/his home as per physician orders [REDACTED]. The 6/15/18 MDS assessment indicated the resident was alert and oriented, had a [DIAGNOSES REDACTED]. The assessment further indicated the resident did not experience any signs of depression or have any documented behaviors during the seven day look-back period. The assessment further indicated it was very important for the resident to get outside and get fresh air when the weather was good, do things with groups of people and have pet visits. Review of Resident 15's 6/15/18 CAAs revealed no comprehensive assessment to indicate the history of trauma, target behaviors related to, medications used to treat or non pharmacological interventions related to the resident's [DIAGNOSES REDACTED]. The ADL CAA indicated the resident had an ADL self care performance deficit related to her/his anxiety, depression and [MEDICAL CONDITION]. The ADL CAA further indicated the resident's care plan would direct staff to monitor and report of changes in her/his functional abilities, outside of her/his current baseline level of functioning. Review of Resident 15's current undated Kardex (CNA care plan) did not indicate the resident had a major mental health [DIAGNOSES REDACTED]. The Kardex further did not indicate the resident to have occasional incontinence of bowels, or to wear briefs. The Kardex indicated the resident's favorite activities were crosswords, watching TV and reading, and indicated for staff to invite her/him to activities related to food. Review of Resident 15's 6/15/18 Care Plan indicated the following: Use of antidepressant and antianxiety medications were in use due to a history of depression, anxiety disorder and [MEDICAL CONDITION]. There was no information to indicate the resident's baseline behaviors, and no information related to person centered non-pharmacological interventions related to the [DIAGNOSES REDACTED]. The ADL care plan, last updated on 6/30/18 did not direct staff to monitor and report changes in Resident 15's functional abilities outside of her/his current baseline level of functioning. The care plan did not indicate if the resident was continent of bowels and if she/he was care planned to wear briefs. The activities care plan, last updated on 6/14/18 indicated the resident had an alteration in activity involvement related to a preference for unstructured free time, preferring time in room, resting daily, adjusting to the facility, anxiety and depression. The care plan further indicated the resident wished not to participate in facility group activities. The care plan indicated the resident would offered pet visits as available. Signed physician orders [REDACTED]. Review of the 7/30/18 through 8/4/18 activities calendar revealed the following: Monday: 10 AM bible study with no other planned activities. Tuesday: 10 AM outdoor gardening activity and 12:30 PM activity in the dining room. Wednesday: 10 AM worship service and 12:30 PM activity in the dining room. 1:1 activities to be offered at 2:30 PM. Thursday: 10 AM Spiritual gathering and 12:30 PM activity in the dining room. Friday: 10 AM exercise program and 12:30 PM activity in the dining room. 2: 00 PM bingo. Saturday: 10:30 AM bingo and 2:30 pm coloring activity. Sunday: No planned activities. Progress Notes completed by the physician and various nurse practitioners (NPs) from 6/12/18 through 7/30/18 revealed the following: * 6/12/18 -- Resident 15 was noted to have [MEDICAL CONDITION] and long term anxiety. The resident indicated to the physician she/he had been hospitalized for [REDACTED]. *6/18/18 -- Resident 15 was noted to have increased anxiety related to her/his history of [MEDICAL CONDITION] and her/his current social situation. Resident 15 indicated she/he would like to have her PRN [MEDICATION NAME] (antianxiety medication) changed to a scheduled dose to help prevent anxiety. Attached orders indicated the medication was changed to a scheduled dose BID. *7/3/18 -- Nurse practitioner discussed with the resident a need to ask for assistance related to her/his toileting needs. The resident stated she/he had continued anxiety. *7/16/18 -- Nurse practitioner noted the resident to be rather independent and thus a good candidate for a lower level of care, noted the resident's history of anxiety and [MEDICAL CONDITION], and educated the resident on her/his use of [MEDICAL CONDITION] medication and the increased risk for falls. The resident stated she/he wanted to continue these medications. The assessment and plan portion of the progress note indicated the resident's LCSW (licensed clinical social worker) should be contacted to schedule an appointment. *7/30/18 -- The resident stated on 7/29/18 she/he wanted to kill her/himself. She/he had frustration regarding family situations and she/he had been depressed. The resident currently denied she/he wanted to hurt her/himself and reiterated she/he had feelings of depression. The resident's history of [MEDICAL CONDITION] was noted by the NP to be managed with her/his current use of [MEDICATION NAME] and [MEDICATION NAME]. Progress notes completed by facility staff from 6/12/18 through 8/1/18 revealed the following: *6/12/18 -- Care plan update note: every 2 hour toileting while awake to promote continence initiated. *7/3/18 -- Resident behavior of swearing at CNA staff was documented, resident denied the behavior. *7/10/18 -- Resident behavior of crying for twenty minutes before she/he could be consoled, following by another episode of crying shortly thereafter. *7/18/18 -- Noted referral to resident's LCSW for counseling services by Staff 10 (Director of Social Services). *7/29/18 -- Resident stated to CNA staff at 2:30 PM she/he wanted to kill her/himself. Nursing staff talked with the resident who stated she/he was depressed. At 5:30 PM the resident left the facility for an outing with a friend, no additional suicidal statement made following the resident's return. *7/30/18 -- Physician was notified of the resident's suicidal statement, and hourly checks by staff were initiated for 24 hours. *7/31/18 -- Staff 3 (LPN Unit Care Manager) noted he received NP communication from the 7/30/18 visit the NP had with the resident regarding her/his suicidal statement. Staff 3 noted the NP discussed no further concern regarding the suicidal ideation, as per resident statement that she/he was not currently suicidal, rather was just depressed. *8/1/18 -- Staff 10 (Director of Social Services) documented a report on 7/30/18 regarding the resident making suicidal ideation on 7/29/18. Staff 10 stated the NP met with the resident on 7/30/18 and ruled out the suicidal ideation, as the resident stated she/he had just had a bad day and felt better. Staff 10 stated she followed up with the resident on 7/31/18 to see how the resident was doing. Resident 15 verbalized she/he had been depressed, and asked Staff 10 if she/he could have an increase in antidepressant medication. Staff 10 informed the resident she was not responsible for that, and the NP or MD would be the ones for that and she already had that conversation with the NP . The resident was noted to state she did not remember meeting with the nurse practioner recently. Multiple observations across day and evening shift from 7/30/18 through 8/2/18 revealed Resident 15's door to be closed, regardless if resident care was being provided. On 7/30/18 at 11:56 AM Resident 15 stated her/his depression had increased since her/his admission to the facility. The resident further stated she/he had been on antidepressant medication for some time, but that her/his body may just be too used to the drug by now. Resident 15 stated she/he had seen a therapist before admitting to the facility, but had not seen her/him since her/his admission. The resident stated she/he would like to think about seeing either her/his previous therapist or a new one. The resident indicated she/he believed it was her/his responsibility to set up a visit with the therapist. On 7/30/18 at 12:14 PM Resident 15 stated she/he felt staff could do more to encourage her/him to attend activities or to give her/him reminders about events. Resident 15 stated she/he would like to get out of bed more frequently, to be social, but that she/he would have needed more motivation to do so. On 8/2/18 at 9:16 AM Staff 10 confirmed Resident 15 had a [DIAGNOSES REDACTED]. Staff 15 acknowledged there was a suicidal ideation verbalized by Resident 15 on 7/29/18. Staff 10 further stated the suicidal ideation documented in the resident record was a new behavior for the resident and further stated shortly after the incident the resident had denied being suicidal and stated she/he was just depressed. Staff 10 stated a nurse practioner followed up with the resident the following day on 7/30/18 and stated she herself (Staff 10) followed up with the resident regarding the incident on 7/31/18. Staff 10 stated the resident asked her about having her/his antidepressant medication/s increased, and Staff 10 indicated she told the resident that would be something the resident would need to address with her/his nurse practioner. Staff 10 further stated the resident had no recollection of meeting with the nurse practioner the day before. On 8/2/18 at 12:39 PM an activity was observed to occur in the 400 hall dining room. At that time Resident 15 was observed to be seated on the side of her/his bed and a lunch tray on the table in front of her/him. The resident stated she/he usually ate meals in her/his room and the meals were typically served at this time during the later part of the noon hour. Resident 15 stated staff did invite her/him to the current activity but stated the timing for the activity did not work for her lunch meal schedule. The resident further stated that due to her/his religious beliefs, the three mornings a week when religious/spiritual events occurred were not an option for her/him. On 8/2/18 at 10:37 PM Staff 11 (Activity Director) stated Resident 15 did not come out of her/his room often but would attend bingo if she happened to already be out of her/his room. Staff 15 confirmed there were no scheduled activities on Sundays, there were no activities on Monday the resident could attend and further acknowledged the resident was unable to attend social activities two additional mornings a week due to the her/his religious beliefs. Staff 15 stated she/he did not visit resident rooms to remind them of activities and did not have an activities assistant, but relied on CNA staff to remind residents of group activities. Staff 15 stated there was a volunteer who visited the facility about once per week to provide animal visits with residents, and further stated the volunteer typically did not knock on resident doors when they were closed. Staff 15 acknowledged Resident 15 may not have had her/his activity and social needs met. On 8/2/18 at 12:45 PM Resident 15 stated her/his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The resident stated her/his symptoms included increased anxiety and depression, which she/he stated is what she/he had been experiencing recently. Resident 15 further stated she/he still felt her/his antidepressant medications needed to be reviewed for a potential increase, and further stated she/he would still like to know if she/he was able to see a therapist while in the facility. On 8/2/18 at 1:43 PM Staff 5 and Staff 6 (CNAs) were interviewed. Staff 5 stated Resident 15's typical mood was high anxiety, and could change from one minute to the next. She stated the resident could go into manic crying episodes, and Staff 5 stated she would try to distract the resident which would sometimes work. Staff 5 further stated although the resident was continent of bowels, she would sometimes not physically get up to use the bathroom because of her anxiety and depression. Staff 5 stated the resident wore briefs due to her/his inability to get out of bed to use the toilet, and indicated she/he felt this was by choice. Staff 5 stated over time her/his need for staff assistance had increased. Staff 6 further confirmed the resident typically would eat lunch in her/his room, and trays were served between 12:15 PM and 12:30 PM. Staff 5 confirmed this was the time when afternoon activities occurred in the dining room, and acknowledged the resident was not able to attend afternoon activities due to the timing. On 8/2/18 at 1:50 PM Staff 6 (CNA) stated the resident's mood and motivation would affect her/his decision to get out of bed to use the bathroom. Staff 6 further stated her/his behaviors varied dramatically from day to day and her/his reliance on staff for ADL assistance would fluctuate depending on her/his mood or behaviors. Staff 6 further stated at one point in time, the resident was care planned for scheduled assistance to the toilet every two hours, and that intervention had failed. On 8/2/18 at 1:51 PM Staff 23 (CNA) acknowledged the resident's ADL abilities would fluctuate from day to day depending on her/his mood or behaviors. On 8/2/18 at 1:52 PM Staff 5 and Staff 6 both stated Staff 2 (Interim DNS) recently mentioned to them the resident had some form of mental illness. Both staff stated they were made aware of Resident 15's mental illness following her/his episode of suicidal ideation on 7/29/18, and confirmed they were not made aware of her/his [DIAGNOSES REDACTED]. On 8/2/18 at 2:11 PM Staff 3 (LPN Unit Manager) acknowledged the resident's mood and behavior would fluctuate from day to day. Staff 3 further stated the resident's ADLs had declined since her admission to the facility, including episodes of incontinence which he believed were due to her not wanting to get out of bed because of depression and anxiety. Staff 3 stated the resident's behaviors had increased since admission, and further stated he believed Staff 10 had been involved in her/his care related to these behaviors. Staff 3 indicated he was never notified by Staff 10 the resident indicated she/he noted increased anxiety and depression, and indicated she/he would like to increase her antidepressant dosage. Staff 3 stated the resident's target behaviors included increased reliance on staff for ADLs she/he can physically do her/himself, cursing at staff on one occasion and voicing suicidal ideation on one occasion. On 8/2/18 at 2:22 PM Staff 10 stated she was unaware of the resident's fluctuations in staff assistance with ADLs, and her/his increased reliance on staff assistance for toileting needs. Staff 10 acknowledged she did not notify Staff 3 (LPN Unit Care Manager) of the resident request to increase her antidepressant, following her episode of suicidal ideation. Staff 10 additionally stated she had attempted to contact the resident's LCSW and had not heard back from the provider. On 8/3/18 at 8:25 AM Staff 2 (Interim DNS) confirmed she was currently unaware of how long the resident had been diagnosed with [REDACTED]. Staff 2 acknowledged the resident had become increasingly withdrawn, had less social interaction and had verbalized she/he did not feel like getting out of bed. Staff 2 stated she believed this was due to the resident's anxiety and depression, which were likely due to her/his [MEDICAL CONDITION]. Staff 2 acknowledged the resident was not comprehensively assessed related to her/his [DIAGNOSES REDACTED]. Staff 2 stated the resident had recently stated when she/he was having a bad day and needed extra help with her/his ADLs, she/he had been told by staff she could do it for herself and stated this felt like a refusal of care. Staff 2 stated this was when she/he notified Staff 5 and 6 the resident had a mental health condition. Staff 2 stated Resident 15 was housed on a floor with long term residents, who had very different care needs than Resident 15. Staff 2 acknowledged facility staff needed training related to the care of a resident with major mental health [DIAGNOSES REDACTED]. On 8/3/18 at 9:49 AM Staff 16 (LPN) and Staff 5 both stated the resident now seemed to have daily episodes of crying, hyperventilating and needed to be redirected frequently. Staff 5 stated it was now unusual for the resident to want to perform any of her/his own ADLs, and stated the resident had both verbally and observably become more socially withdrawn. On 8/3/18 at 9:54 AM Staff 3 acknowledged there was a lack of communication regarding the resident's display of behaviors from CNA staff to nursing staff. Staff 2 acknowledged a lack of monitoring of the resident's behaviors, and how this may have contributed to the lack of communication of the resident's care needs related to [MEDICAL CONDITION].

Based on interview and record review it was determined the facility failed to discontinue an anticoagulant medication and obtain labs as ordered for 1 of 5 sampled residents (#90) for whom medications were reviewed. The resident experienced a significant bleeding episode and need for transfusion. This placed residents at risk for complications associated with the use of anticoagulant medication. Findings include: Resident 90 was admitted to the facility in August 2015 for rehabilitation following surgical repair of a [MEDICAL CONDITION]. The resident had [DIAGNOSES REDACTED]. On 9/4/15 Resident 90 was diagnosed with [REDACTED]. Prior to this [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] or [MEDICATION NAME] (generic name), an anticoagulant to treat the [MEDICAL CONDITION] in early September 2015. The [MEDICATION NAME] was to be held while the resident was receiving [MEDICATION NAME]. Review of Nurse Practitioner progress notes dated 9/14/15 and 9/21/15 revealed frequent order changes to ensure therapeutic anticoagulation. Review of discontinued care plans on 4/7/16 at 10:47 am with Staff 13 (RNCM) revealed the following item added on 11/19/15, approximately two months after initiation of anticoagulant therapy. The resident is on anticoagulant therapy related to [MEDICAL CONDITION] (a chronic abnormal heart rhythm.) Interventions included monitoring for adverse side effects and avoid the use of aspirin. Staff 13 indicated no other care plan related to anticoagulant therapy was completed. The resident did not have a [DIAGNOSES REDACTED]. Resident 90's Care Plan was not updated with an accurate problem statement related to the initiation of short-term anticoagulant therapy. Orders dated 11/15/15 included, start [MEDICATION NAME] 75 mg po daily 12/20/15. A Pharmacy Review dated 12/2/15 advised facility to, clarify with PCP if both [MEDICATION NAME] and aspirin are to continue when [MEDICATION NAME] starts 12/20/15. physician's orders [REDACTED]. Review of Physician orders [REDACTED]. A PT/INR (The [MEDICATION NAME] time (PT) and international normalized ratio (INR) - are used to determine the clotting tendency of blood, in the measure of [MEDICATION NAME] dosage) was done on 12/8/15 and subsequent orders dated 12/9/15 were obtained to adjust the [MEDICATION NAME] dose to alternating 3.5 mg and 3 mg doses of [MEDICATION NAME] with PT/INR to be checked again on 12/16/15. According to the December 2015 MAR indicated [REDACTED]. In an interview on 4/7/16 at 12:53 pm Staff 3 (RN) confirmed there was no evidence the INR was obtained on 12/16/15 as ordered. On 4/7/16 at 2:31 pm Staff 1 (DNS) stated a triple check system was currently in place for orders. One nurse enters the order, a second nurse verifies it and the RNCM is the third check. Staff 1 stated the 12/9/15 order was found to have been entered incorrectly. On 04/7/16 at 4:14 pm Staff 15 (LPN) stated when the order from 12/9/15 was entered the stop date dropped off the previous order. She noticed it on 12/31/15 when the previous shift reported seeing bruising on the resident. She reviewed the resident's medication and discovered the resident was receiving [MEDICATION NAME], aspirin and [MEDICATION NAME]. She recalled the previous order to discontinued the [MEDICATION NAME] when [MEDICATION NAME] started and notified the physician who discontinued the [MEDICATION NAME] on 12/31/15. Resident 90 was admitted to hospital 1/1/16 for abdominal pain and distension. Review of the hospital History and Physical dated 1/1/16 and Discharge Summary dated 1/6/16 revealed the primary [DIAGNOSES REDACTED]. Significant acute blood loss [MEDICAL CONDITION] due to the urinary bleeding requiring a total of 5 units PRBC (packed red blood cells) and under secondary Diagnoses: [REDACTED]. On 4/8/16 at 1:51 pm the findings were discussed with Staff 1 (DNS) who acknowledged the administration of [MEDICATION NAME] ([MEDICATION NAME]) past 12/20/15 was related to a transcription error on 12/9/15.

Based on observation, interview and record review it was determined the facility failed to provide adequate assessment and interventions related to bowel care for 1 or 6 residents (#90) for whom medication regimen was reviewed. This resulted in hospitalization and treatment for [REDACTED]. Resident 90 was admitted to the facility in August 2015 for rehabilitation following surgical repair of a fractured femur. The resident had [DIAGNOSES REDACTED]. The ADL CAA dated 8/26/15 revealed the resident was non-ambulatory and at risk for constipation. The admission Care Plan dated 8/20/15 included interventions under a problem statement for pain instructing staff to observe for constipation. Review of Progress Notes from 8/27/15 through 9/7/15 revealed Resident 90 required multiple interventions including oral laxative, rectal suppositories and enemas. The resident was identified as frequently incontinent of bowel, able to use a commode or request a bed pan but was incontinent of urine. Nursing notes indicated the resident's abdomen was assessed daily and the Nurse Practitioner was notified of abnormal findings. An abdominal X-ray on 9/7/15 revealed fecal impaction. The resident required digital removal of rectal stool impaction before constipation resolved. Resident 90's care plan was not updated with a problem statement of impaired bowel function related to history of impaction and need for frequent bowel care. On 9/15/15 Resident 90 was discharged from skilled services and on 9/16/15 was transferred to the 400 hall for long-term care. The resident continued to use PRN narcotic pain medication and had an order for [REDACTED]. Contact provider/practitioner if there are three days without a significant BM (bowel movement). Other orders included [MEDICATION NAME] suppositories and enema PRN. Review of Nursing Notes from night shift on 9/26/15 revealed documentation Resident 90 was agitated and calling out. Notes from the following day shift documented administration of MOM for no BM for three days. Nursing notes dated 9/27/16 revealed increased behaviors of calling out, the MOM was documented as ineffective and another dose was administered. Review of notes between 9/27/15 and 10/3/15 indicated the MOM was not effective and was followed up with a suppository, documented as effective on 10/3/15. There was no documentation of bowel assessment and no revision of plan of care during this time. Review of Nursing notes from November 2015 revealed two episodes of constipation [MEDICATION NAME] over 3 days with administration of PRN laxatives. No bowel assessment was documented. Review of the 12/2015 MAR indicated [REDACTED]. The MOM was documented as effective although review of the Bladder and Bowel record for December indicated the resident did not have a BM on 12/1/15. MOM was discontinued by the Nurse Practitioner on 12/2/15. [MEDICATION NAME] ([MEDICATION NAME] supplement) bid, Senna with [MEDICATION NAME] (Senna Plus, Stool softener) was ordered bid PRN constipation and [MEDICATION NAME] 1 tbs daily with water was ordered. According to the 12/2015 MAR indicated [REDACTED]. Bowel records revealed only three large bowel movements during the month on December 2015 on 12/19/15, 12/20/15 and 12/30/15. All other documentation was of small medium or No bowel movement. Nurses Notes dated 12/31/15 at 8:28 pm revealed Resident 90 was observed by Staff 15 (LPN) to have a distended, firm abdomen, painful upon touch. Bowel tones were active, last BM was 12/31/15 medium soft. Does not appear to be constipation related. Informed oncoming nurse and will continue to monitor for not resolving or worsening. There were no further nursing notes regarding the abdominal distension until 1/1/16 at 10:29 am when Staff 15 was next on shift. Staff 15 documented the resident's abdomen appeared more distended since last seen by this nurse yesterday evening, very firm, primarily right sided. (Resident) calls out in pain when I touch the area. Phoned to inform on call physician. An order was received to send Resident 90 to the hospital for evaluation. The resident was transported to the hospital at approximately 11:00 am on 1/1/16. Review of the Hospital History and Physical dated 1/1/16 revealed a [DIAGNOSES REDACTED]. On 4/5/16 at 11:08 am Witness 1 stated Resident 90 complained at times she/he had to go to the bathroom. The resident was wearing a brief and was told by Witness 1 she/he could just go in the brief. Resident 90 told Witness 1 she/he tried, but could not go. When Witness 1 talked to the nurses they said the resident had diarrhea. Witness 1 asked if the diarrhea could be an impaction and asked if the resident was voiding but did not get an answer. On 12/31/15 Witness 1 was visiting and Resident 90 was in her/his wheelchair tipped back. Witness 1 noticed the resident's abdomen was distended and had a big hard lump. Staff 15 checked Resident 90 and said that's not right and wanted to call the doctor. Witness 1 said she wasn't sure but the nurse insisted. At the ER they discovered the lump was the resident's distended bladder was she/he was found to have a fecal impaction as well. Witness 1 stated she/he was told by the physician at the hospital the impaction may have caused the bladder obstruction. On 4/6/16 at 11:13 am Resident 90 was observed to refuse [MEDICATION NAME]. Staff 6 (LPN) stated the resident had a suppository the night before and had two large BMs so far that day. She took care of Resident 90 on the Skilled Unit and knew the resident had significant problems with constipation and had to be disimpacted at least once. In an interview on 4/7/16 at 10:23 am Staff 4 (LPN) stated Resident 90 had problems with her/his bowels, we need to stay on top of that. Bowel assessments are not on the TAR but she tried to do one anytime she helped transfer the resident. Staff 4 stated Resident 90 had an extra large BM that morning. On 4/7/16 at 10:46 am Staff 13 (RNCM) confirmed the care plan was not updated with a specific problem statement related to constipation and recent history of fecal impaction. The December TAR instructed staff to stay on top of bowel care. Pt prone to constipation. On 4/7/16 at 4:17 pm Staff 15 (LPN) stated she recalled the resident's abdomen was visibly distended and painful on palpation. She reviewed the bowel records but since the resident was documented to have had a BM the day before, she did not think it was bowel related but knew something was not right. She further stated three days without a BM will trigger on Nursing Dashboards in the electronic record. Nurses are supposed to check it every shift. Staff 15 recalled no specific pain behaviors or anything out of the ordinary prior to the abdomen distention noted on 12/31/15.

Based on observations, interviews and record review it was determined the facility failed to ensure a resident received timely and correct use of an air mattress for 1 of 4 sampled residents (#6) with pressure ulcers. Resident 6 experienced multiple recurring stage 2 pressure ulcers. Findings include: Resident 6 was readmitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of a Pressure Ulcer Care Area assessment dated [DATE] revealed the resident was at risk for pressure ulcers due to a history of ulcers, decreased mobility and incontinence. The assessment indicated the resident did not have any wounds at that time. The resident's skin was fragile and there had been issues with the resident refusing to be compliant with bathing and changing. Review of a Wound Flow Sheet dated 2/19/11 revealed the resident had two "purple spots 1 either side of coccyx." The wound was described as 0.5 cm in diameter, minimum drainage and the resident had slight pain. The assessment indicated the wound was not progressing towards healing and did not indicate the use of an air mattress as a "support surface." The form also indicated the wound was assessed again on 2/28/11 and measured 0.2 cm in diameter with minimum drainage and no pain. The assessment indicated the wound was not progressing towards healing and did not indicate the use of an air mattress as a "support surface." Review of a Wound Flow Sheet dated 2/28/11 revealed the resident had a stage 2 pressure ulcer on the right buttock measuring 5.5 cm in diameter with minimum drainage and slight pain. The form also indicated the wound was assessed again on 3/3/11 and 3/6/11. The form did not indicate the resident used an air mattress as a preventative intervention. Review of the Treatment Record for March 2011 revealed a physician's orders [REDACTED]. Review of the care plan updated 3/4/11 revealed staff were to encourage the resident to let CNAs do peri care to prevent skin breakdown. The care plan indicated the resident had a history of [REDACTED]. There was no documentation the resident used an air mattress to reduce the chance of developing a pressure ulcers. Review of a Hospice note dated 3/7/11 revealed the resident had an alteration in skin integrity on the right buttock with a stage 2 pressure ulcer. The plan of care included assessing the resident's skin every visit and teaching the resident and care givers preventative care, skin care and use of pressure reducing devices. Review of a Wound Flow Sheet dated 3/8/11 revealed the resident had an unstaged open area measuring 2 cm in diameter and 0.5 cm in depth to the left buttock. The form indicated there was minimum drainage and the edges were macerated (excessive moisture as evidenced by white appearance of the skin). Review of a fax to hospice dated 3/8/11 revealed the resident had a 4 cm circular wound to the right buttock and a two cm circular wound to the left buttock. Observations on 3/8/11 at 8:17 am revealed the resident was lying in bed awaiting breakfast. The resident's was lying on an Airdyne Alternating and Low Air Loss Therapy mattress (Airdyne are flotation therapy mattresses providing a pressure management surface for the prevention and treatment of [REDACTED]. Observations on 3/9/11 at 9:30 am by an RN surveyor revealed the resident had a clean and intact dressing over the coccyx. Observations on 3/9/11 at 3:15 pm revealed the resident was lying in bed and the resident's air mattress was functioning. The resident was lying on top of one fitted mattress sheet, two quilted cloth pads and a non-breathable "chucks" pad. Observations on 3/11/11 at 8:50 am by an RN surveyor revealed the resident was lying in bed and had a cloth draw sheet, breathable "chucks" pad and a sheet on the air mattress. The resident had a stage 1 pressure ulcer on the left buttock and a stage 2 pressure ulcer on the left buttock measuring 4 cm by 3 cm. The resident also had a stage 2 pressure ulcer on the right buttock measuring 4 cm by 1.5 cm and two stage 1 pressure ulcers on the right buttock. In an interview on 3/8/11 at 8:55 am Staff 12 (CNA) said the resident had a special air mattress brought in by hospice and did not know when the resident received the air mattress. Staff 12 had not noticed the air mattress was not functioning. Staff 12 was then observed entering the resident's room, discovered the air mattress electric plug was loose, adjusted the plug and the air mattress started functioning. In an interview on 3/8/11 at 11:30 am Staff 8 (RNCM) said the resident used a bariatric bed provided by hospice and had a stage 2 pressure ulcer on the left thigh. Staff 8 said the resident was able to make decisions and had refused wound treatments at times. Staff 8 did not know when the air mattress was brought in by hospice and acknowledged use of the air mattress was not on the resident's care plan. In an interview on 3/9/11 at 1:44 pm Witness 2 (RN/Air Mattress Consultant for Dynamix) indicated that in order for the air mattress to provide any therapeutic benefit in reducing pressure ulcers there could be no more than one sheet and a breathable "chucks" pad on top of the air mattress and under the resident.