Every finding on record at Evan Terrace Post Acute

Based on interviews and record review it was determined the facility failed to report an injury of unknown origin to the State Agency for 1 of 7 sampled residents (#1) reviewed for safety. This placed residents at risk for a delay in the investigation and continued injuries. Findings include: Resident 1 was admitted to the facility in 4/2026 with diagnoses including Parkinsons with hand tremors and dementia.Resident 1's 4/17/26 Admissions Care Plan indicated the resident required a two-person assist with their ADLs and had meals in the assisted dining room. Resident 1's 4/21/26 MDS revealed a BIMS score of 7 which indicated severe cognitive impairment. On 7/16/26 at 2:21 PM, Witness 1 (Resident 1's Spouse) spouse stated she had arrived after breakfast and observed swelling and blistering on Resident 1's right hand, and informed Staff 4 (LPN). Witness 1 stated that Staff 4 assessed Resident 1's right hand and found red discoloration in the palm of the resident's hand. Witness 1 requested the resident be sent to the hospital for evaluation. A 4/21/26 emergency room record indicated Resident 1 was treated for a second degree burn to her/his right hand. On 7/16/26 at 1:12 PM, Staff 3 (LPN) stated she assessed Resident 1's right hand and found it warm, with blisters and tender when touched. Staff 3 stated Resident 1 was not aware of what had happened. Staff 3 stated Resident 1 had no complaints of hand pain or swelling or blisters the previous night on 4/20/26. Staff 3 stated she would have reported the incident to the State Agency.On 7/16/26 at 1:15 PM, Staff 10 (CNA) stated she had assisted Resident 1 back to her/his room around 9:00 AM and had not noticed any injury to Resident 1's right hand. On 7/16/26 at 1:34 PM, Staff 4 (LPN) stated she assessed Resident 1's right hand and thought it was inflammation with redness. Staff 4 stated she was trained to report a burn of unknown origin to the State Agency. She stated that because the injury did not appear to be a burn, it was not reported.On 7/17/26 at 10:10 AM, Staff 2 (DNS) stated an injury of unknown injury should be reported to the State Agency and the facility failed to report it.

Based on observations, interviews and record review it was determined the facility failed to provide ADL assistance for 1 of 5 sampled residents (# 7) reviewed for ADLs. This placed residents at risk for not receiving ADL assistance for hygiene care.Resident 7 was admitted to the facility in 6/2026 with diagnoses including a stroke with right sided hemi-paralysis and aphasia (the inability to speak). Resident 7's 6/29/26 Care Plan indicated Resident 7 was dependent on staff for all ADLs. Resident 7's 6/2026 MDS Assessment indicated the resident was severely impaired. Resident 7's 6/2026 and 7/2026 Point of Care record indicated the resident was dependent for brushing teeth, washing face, combing hair, and shaving. On 7/15/26 at 10:07 AM, Staff 6 (CNA) charted in the Point of Care document she had provided oral care and a warm washcloth to Resident 7 on 7/15/26. Staff 6 stated she had charted in the wrong chart and stated she did not provide oral care or give a warm washcloth to Resident 7. On 7/15/26 at 10:18 AM, Resident 7 was observed lying in bed. Resident 7's spouse was present. Resident 7 appeared disheveled, hair was unbrushed and her/his eyes had dried eye discharge, and her/his nails were long and appeared to have dirt underneath them. Resident 7's spouse stated no one had provided the resident with a warm washcloth to wipe her/his face. The spouse also stated the resident did not have their teeth brushed. On 7/15/26 at 11:03 AM, Staff 2 (DNS) stated she expected staff to provide nail care, grooming and warm washcloths in the morning. Staff 2 acknowledged Resident 7 did not receive a warm washcloth or oral care on this day.

Based on interview and record review it was determined the facility failed to ensure a resident's indwelling urinary catheter had a clinical indication for use for 1 of 3 sampled residents (#8) reviewed for indwelling catheter use. This placed residents at risk for infection. Findings include: Resident 8 admitted to the facility in 8/2025 with diagnoses including schizophrenia. Resident 8's 8/8/25 admission Evaluation indicated Resident 8 had an indwelling urinary catheter. Resident 8's admission Orders did not include an order for a urinary catheter. Review of Resident 8's clinical record found no documented evidence for a clinical indication for the use of an indwelling urinary catheter. On 3/16/26 at 9:16 AM, Staff 5 (LPN/RCM) verified Resident 8 was admitted with an indwelling urinary catheter with no indication for its use.

Based on interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 3 sampled residents (#2) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube. Findings include:The facility's incident report dated 7/29/25 indicated Staff 12 entered Resident 2's room and observed feeding tube formula was running at a rate of 300 ml/hr and observed the resident's formula was coming out of the resident's trach area.Resident 2's Physician Order dated 7/18/25 noted, enteral feed every shift, diet Jevity (liquid nutrition formula for tube feeding) 1.5, 66 ml/hr x 18 hours, on at 4:00 AM and off at 10:00 PM, feeding via pump for a total of 1206 ml. On 10/1/25 at 12:58 PM, Staff 12 (LPN) stated after receiving report from Staff 9 (LPN) she found Resident 2's feeding tube running at a rate of 300 ml/hour. She stated there was feeding tube formula bubbling out of Resident 2's tracheostomy site.On 10/2/25 at 9:11 AM, Staff 9 stated she had left Resident 2's feeding tube running at a rate of about 300 ml/hour by mistake during her shift on 7/28/25.On 10/2/25 at 9:52 AM, Staff 13 (LPN) stated Staff 12 found Resident 2's tube feeding running at 300 ml/hour on 7/29/25.On 10/2/24 at 10:48 AM, Staff 2 (DNS) stated she expected nurses to follow physician orders for feeding tubes.

Based on interview and record review it was determined the facility failed to provide pressure ulcer care consistent with professional standards of practice for 1 of 5 sampled residents (#6) reviewed for pressure ulcers. As a result, Resident 6 developed multiple facility-acquired pressure ulcers and placed residents at risk for new and worsening pressure ulcers. Findings include: The 2019 NPIAP (National Pressure Injury Advisory Panel) guidelines indicated when an individual had a pressure injury a comprehensive initial assessment should be completed, treatment goals with input from the individual's informal caregivers set, and a treatment plan developed. The wound was to be re-assessed at least weekly to monitor the progress toward healing. Resident 6 admitted to the facility in 1/2025, with diagnoses of dementia and a right lower leg fracture. Resident 6 discharged from the facility on 5/6/25. Resident 6's 1/13/25 Nursing admission Evaluation indicated she/he wore a splint on her/his right lower leg and had no open skin areas. The 1/20/25 admission MDS Assessment indicated Resident 6 had no pressure ulcers, was at risk for developing pressure ulcers, needed partial assistance with bed mobility and was dependent on staff for wheelchair mobility. Resident 6's Pressure Ulcer CAA indicated she/he had no pressure ulcers and was at risk for developing pressure ulcers. The assessment did not include any risk factors that could contribute to the development of pressure ulcers. There was no Baseline Care Plan for Resident 6 to address the resident's skin or risk for pressure ulcers upon admission. Resident 6's 2/7/25 Skin Care Plan indicated she/he was at risk for skin breakdown related to a healing fracture to the right lower leg and dementia. The care plan indicated Resident 6 had pressure ulcers to the right medial foot and bilateral heels. Interventions included to assist the resident to turn and reposition as indicated and as tolerated. Resident 6's Skin and Wound Evaluations indicated the resident had the following wounds: 1) Right medial (inner side) foot pressure ulcer identified on 1/23/25. The resident's Wound Evaluations for 2/14/25, 2/24/25 and 4/3/25 had inaccurate information related to the staging and description of her/his pressure ulcer and incorrectly identified the resident's pressure ulcer as being present on admission. There were 11 missing weekly wound assessments from 1/24/25 through 5/6/25. 2) Right heel pressure ulcer, no date provided for when pressure ulcer was identified. The resident's Wound Evaluations for 2/14/25, 2/21/25, and 4/9/25 had inaccurate information related to the staging and description of the her/his pressure ulcer. There were nine missing weekly wound assessments from 2/14/25 through 5/6/25. 3) Left heel pressure injury identified on 2/25/25. The resident's Wound Evaluations for 2/25/25 and 4/3/25 had inaccurate information related to the wound type and staging of her/his pressure ulcer. There were 8 missing weekly wound assessments from 2/25/25 through 5/6/25. 4) Left, third toe pressure injury identified on 2/25/25. The resident's Wound Evaluations for 4/3/25 indicated inaccurate information related to the wound type and location of the pressure ulcer. There were nine missing weekly wound assessments from 2/25/25 through 5/6/25. 5) Right foot, second toe pressure injury identified on 4/3/15. There were four missing weekly wound assessments from 4/3/25 through 5/6/25. 6) Right foot pressure injury identified on 4/22/25 by the wound clinic. There were two missing weekly wound assessments from 4/22/25 through 5/6/25. Resident 6's 4/2025 Wound Clinic Notes revealed her/his wounds were staged as follows: 1) Right medial foot, Stage 3 (full-thickness skin loss). 2) Right heel, Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). 3) Left heel, Stage 3. 4) Left, third toe, unstageable (obscured full-thickness skin and tissue loss). 5) Right, second toe, unstageable. 6) Right proximal, lateral, Stage 2 (partial-thickness skin loss). The facility did not have and did not request Resident 6's Wound Clinic notes until 6/12/25. Resident 6's 5/6/25 Discharge MDS indicated the resident discharged home with three Stage 3 pressure ulcers. The MDS incorrectly identified the number of pressure ulcers. Resident 6 discharged home with six pressure ulcers. Review of Resident 6's clinical record found no documented evidence the facility evaluated and assessed the development of the resident's pressure ulcers to determine causative factors, to evaluate current interventions or to determine if the pressure ulcers were avoidable or unavoidable. On 6/10/25 at 8:16 PM, Staff 29 (CNA) was unable to recall Resident 6. On 6/10/25 at 8:24 PM, Staff 28 (CNA) was unable to recall Resident 6. On 6/10/25 at 8:27 PM, Staff 27 (CNA) was unable to recall Resident 6. On 6/11/25 at 9:25 AM, Staff 25 (CNA) was unable to recall Resident 6. On 6/11/25 at 9:27 AM, Staff 26 (CNA) was unable to recall Resident 6. On 6/12/25 at 8:05 AM, Staff 19 (LPN) was unable to recall Resident 6. On 6/16/25 at 2:20 PM, Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional RN) and Staff 24 (MDS Coordinator) verified all six facility acquired pressure ulcers had inaccurate and/or missing weekly wound assessments and the Discharge MDS incorrectly identified the number of pressure ulcers upon discharge.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 25 and 26) reviewed for medications. This placed residents at risk for missed medications. Findings include: 1. Resident 25 admitted to the facility in 1/2025, with diagnoses including hypothyroidism (low thyroid hormone levels) and diabetes. A 1/17/25 admission Order for Resident 25 included an order for levothyroxine (a thyroid medication) 1 tablet by feeding-tube daily. A 1/20/25 Physician Progress Note indicated Resident 25 was ordered to have levothyroxine once daily but the order was erroneously entered as three times daily. The resident received three doses on 1/19/25 and two doses on 1/20/25. Resident 25's 1/2025 MAR included an order for levothyroxine, 50 mcg, via G-Tube before meals (or three times per day) for hypothyroidism. The order was transcribed incorrectly and should have been for once per day. The resident received three doses on 1/19/25 and two doses on 1/20/25. On 6/16/25 at 9:59 AM, Staff 1 (Administrator) was informed of the findings regarding not following physician orders for Resident 25's levothyroxine medication and provided no additional information. 2. Resident 26 was admitted to the facility in 9/2024, with diagnoses including orthopedic aftercare following above the knee surgical amputation, and diabetes with diabetic neuropathy (nerve damage). Resident 26's 11/28/25 Physician Orders included the following medication order: -Insulin Lispro Injection Solution, inject as per sliding scale subcutaneously with meals in addition to set dose. -Insulin Lispro Injection Solution, inject 8 units subcutaneously two times a day with breakfast and lunch. -Insulin Lispro Injection Solution, inject 6 units subcutaneously in the evening (5:00 PM). Resident 26's 11/2024 DAR revealed the following missed insulin medications: -On 11/29/24 - two doses of the resident's lispro sliding scale insulin were missed; -On 11/28/24 and 11/29/24 - three doses of lispro insulin 8 units were missed; and -On 11/28/24 and 11/29/24 - two doses of the lispro insulin 6 units were missed. On 6/16/25 at 12:24 PM, Staff 23 (LPN) stated she had discovered the resident was not administered her/his insulin medications during the day shift on 11/28/25 and on 11/29/25. Staff stated she reported the issue to Staff 2 (DNS). On 6/16/25 at 9:59 AM, Staff 1 (Administrator) was informed of the findings regarding not following physician orders for Resident 26's insulin medication and provided no additional information.

Based on interview and record review it was determined the facility failed to implement and maintain an effective tracheostomy training program for 1 of 1 sampled resident (#19) reviewed for respiratory care. This placed residents at risk for inappropriate tracheostomy care and the potential for a decline in respiratory status. Findings include: Resident 19 admitted to the facility in 4/2024, with diagnoses including acute respiratory failure and tracheostomy (a surgical opening through the front of the neck and into the windpipe, which a tube is placed into the hole to keep it open for breathing). A 5/5/25 Progress Note revealed Resident 19 was transferred to the hospital for vomiting. A 5/5/25 Fire District Incident Report revealed EMS (Emergency Medical Services) responded to the facility for Resident 19 and observed Resident 19's humidifier tubing taped to the resident's bed. EMS noted if Resident 19 had moved, the humidified oxygen would have disconnected. In addition, EMS observed the resident's humidifier to be partially filled with water (having water in a tracheostomy tube would be similar to having water poured directly into the lungs and provides less available oxygen for a resident to breath). On 6/10/25 at 8:23 PM, Staff 15 (Agency LPN) stated she had not received any tracheotomy training from the facility. On 6/10/25 at 8:31 PM, Staff 16 (CMA) stated only the 100 hall nurse worked with Resident 19 and no other staff. Staff 16 stated if the 100 hall nurse went to break or left the building he would not know who could assume care for the resident. On 6/11/25 at 11:53 AM, Staff 12 (Physician Assistant) stated he was unsure how well the staff were trained to care for a resident with a tracheostomy and questioned if the staff knew how to correctly suction Resident 19. Additionally, Staff 12 stated he would ask different staff the same question about Resident 19 and get different answers. On 6/12/25 at 8:05 AM, Staff 19 (Agency LPN) verified she was Resident 19's nurse the morning she/he was transferred to the hospital. Staff 19 stated the facility gave her no tracheostomy training prior to working with Resident 19 and had told the Resident Care Manager (RCM) she had not had any hands-on experience with tracheotomies for over 10 years and did not feel qualified to care for any resident with a tracheotomy. Staff 19 stated she was told the resident's CNA would tell her what to check and when to check it, which is what occurred. Staff 19 stated she knew she needed more training but there was no one in the building to help her. Staff 19 was unable to recall the set-up of the humidified oxygen tubing. On 6/12/25 at 11:07 AM, Staff 1 (Administrator) and Staff 2 (DNS) both stated they were unable to find any documentation to show staff were trained to care for a resident with a tracheotomy.

Based on interview and record review it was determined the facility failed to investigate allegations of sexual, physical, and verbal abuse for 4 of 6 sampled residents (#s 11, 43, 61, and 66) reviewed for abuse. This placed residents at risk for further abuse. Findings include: 1. Resident 11 was admitted to the facility in 8/2023 with diagnoses including depression and stroke. The 2/25/25 Quarterly MDS indicated Resident 11 had a BIMS score of 14 which indicated the resident was cognitively intact. Resident 20 was admitted to the facility in 9/2024 with diagnosis including dementia with behavioral disturbances. The 4/4/25 Quarterly MDS indicated Resident 20 had a BIMS score of 3 which indicated severe cognitive impairment. On 3/5/25 a public complaint was received by the State Agency which alleged Resident 11 was punched by Resident 20. On 5/30/25 at 4:39 PM, Resident 11 stated Resident 20 hit and swore at her/him in the dining room and also slapped Resident 11 a month earlier in the day room. Resident 11 stated she reported the issue to management. On 6/2/25 at 4:49 PM and 6/3/25 at 7:58 AM, Staff 1 (Administrator) acknowledged Resident 11 spoke to him about Resident 20 around 2/2025. Staff 1 stated Resident 11 asked, What are you going to do about the pervert, [Resident 20]? Staff 1 stated he spoke to one other resident about the incident who Resident 11 indicated was a witness but did not document interviews. Staff 1 stated there was no additional interviews or full investigation because the conversation with the alleged witness did not pan out. Staff 1 acknowledged he did not conduct a full abuse investigation to rule out abuse. On 6/3/25 at 8:27 AM, Staff 30 (CNA) confirmed an incident occurred in the dining room between Resident 11 and Resident 20 around 3/2025 or 4/2025. Staff 30 stated she heard yelling and saw fists, separated Resident 11 and Resident 20, and reported the incident to an agency nurse the same day. On 6/9/25 at 2:28 PM, Staff 21 (Regional Director of Clinical Services) acknowledged a comprehensive investigation was to begin the moment Staff 1 was aware which did not occur. 4. Resident 66 admitted to the facility in 10/2024 with diagnoses including Huntington's Disease (a genetic disorder which causes a progressive breakdown of nerve cells in the brain). An 10/18/24 admission MDS revealed Resident 66 had a BIMS of 10, which indicated her/his cognition was moderately impaired. On 6/2/25 at 12:30 PM Witness 4 (Complainant) stated in 11/2024 Resident 66 reported to her a staff member at the facility fondled her/him. Witness 4 did not indicate if this was reported to the facility and did not have additional information related to the allegation. Resident 66 was unable to be interviewed due to being discharged from the facility and poor cognition. A review of Resident 66's medical record revealed nothing related to an allegation of sexual abuse. On 6/02/25 at 1:02 PM Staff 2 (DNS) stated the facility did not have an investigation into an allegation of sexual abuse related to Resident 66. On 6/4/25 at 11:57 PM Staff 23 (CNA) stated she assisted Resident 66 with a shower and while she assisted her/him she unintentionally brushed Resident 66's breast and Resident 66 felt uncomfortable. Staff 23 stated facility management notified her after the shower that there was an allegation that she abused Resident 66. On 6/5/25 at 12:13 PM Staff 8 (Social Services) stated she recalled Resident 66 made an allegation related to care provided by Staff 23 and thought it was investigated. Staff 8 was unable to provide additional information. On 6/6/25 at 11:53 AM Staff 22 (Former Administrator) stated he recalled Resident 66 and the allegation of sexual abuse. Staff 22 stated Resident 66 was given a shower by Staff 23 and Resident 66 became upset. Staff 22 stated he did not know if the incident was investigated and was unable to provide addition information. On 6/9/25 at 9:44 AM during a joint interview Staff 20 (Regional Director of Clinical Services) and Staff 21 (Regional Director of Clinical Services) stated the facility did not complete an investigation into Resident 66's allegation of sexual abuse. 2. Resident 43 admitted to the facility in 2025 with diagnoses including schizophrenia (a brain disorder that affects a person's ability to think, feel, and behave clearly). Resident 43's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident had no cognitive impairment. On 6/2/25 at 1:56 PM Resident 43 stated her/his breasts were grabbed by an unidentified male caregiver one time. On 6/6/25 at 8:38 AM Staff 8 (Social Services Director) indicated she was aware Resident 43 alleged a male caregiver touched her/his breasts and it was reported to Staff 1 (Administrator) for further investigation. A record review on 6/6/25 revealed no evidence an investigation into the allegations made by Resident 43 was completed. On 6/6/25 at 11:12 AM Staff 1 (Administrator) confirmed an investigation into the allegations made by Resident 43 was not completed. 3. Resident 61 admitted to the facility in 2025 with diagnoses including a stroke. Resident 61's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident had no cognitive impairment. On 6/2/25 at 12:53 PM Resident 61 stated an unidentified male caregiver grabbed her/his breasts one time. On 6/6/25 at 8:38 AM Staff 8 (Social Services Director) indicated she was aware Resident 61 alleged a male caregiver touched her/his breasts and it was reported to Staff 1 (Administrator) for further investigation. A record review on 6/6/25 revealed no evidence an investigation into the allegations was completed. On 6/6/25 at 11:12 AM Staff 1 confirmed an investigation into the allegations made by Resident 61 was not completed.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 4 of 5 sampled residents (#s 20, 31, 44 and 56) reviewed for medications. This placed residents at risk for unnecessary medication. Findings include: A 4/2025 Drug Regimen Review Policy and Procedure indicated the pharmacy was to review each resident's medication regime to ensure that risk and problems were identified and acted upon in a timely manner. 1. Resident 20 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbances and fracture of the left hip bone. The 10/2/24 admission MDS indicated Resident 20 received psychotropic medications to manage the resident's agitation and aggressive behaviors related to her/his dementia and the pharmacist consultant was to review her/his medications quarterly. A 12/6/24 IDT (Interdisciplinary Team) Psychotherapeutic Review indicated Resident 20 was not scheduled for a GDR until 3/2025. A review of Resident 20's clinical record found no additional quarterly review completed related to Resident 20's psychotropic medications. The 4/4/25 Quarterly MDS revealed no GDR (Gradual Dose Reduction) was attempted for Resident 20. The 4/21/25 pharmacy Nursing Recommendations indicated Resident 20's fluoxetine (antidepressant medication) and quetiapine (antipsychotic medication) were due for a GDR and the notification was a repeated recommendation from 3/2025. Psychotropic IDT meeting notes on the form indicated no discussion related to Resident 20's GDR. The 5/25/25 pharmacy Nursing Recommendations indicated Resident 20's fluoxetine and quetiapine were due for a GDR and the notification was a repeated recommendation from 3/2025. On 6/5/25 at 9:55 AM and 6/6/25 at 9:14 AM, Staff 20 (Regional Director of Clinical Services) stated there was no indication all aspects of Resident 20's psychotropic medications were addressed quarterly as expected and pharmacy recommendations should be submitted to Resident 20's physician and resolved within 30 days once the notice was received. On 6/9/25 at 2:20 PM, Staff 32 (NP) confirmed she received no communication from the facility related to a need for a GDR for Resident 20's fluoxetine and quetiapine which should be addressed. 2. Resident 31 was admitted to the facility in 2022 with diagnoses including chronic diastolic congestive heart failure, hypertensive heart disease with heart failure and hyperkalemia (high potassium in blood). A review of pharmacy recommendations for 3/2025, 4/2025 and 5/2025 revealed on 4/25/25 and 5/25/25 the facility was notified the pharmacist recommended a periodic assessment of Resident 31's potassium level. There was no evidence in Resident 31's clinical record the facility responded to or followed-up on this recommendation. On 6/9/25 at 12:31 PM Staff 2 (DNS) stated 3/2025 and 4/2025 pharmacist recommendations were not responded to or followed-up on in error. 3. Resident 44 was admitted to the facility in 9/2024 with diagnoses including depression and PTSD (Post Traumatic Stress Disorder). a. A 2/25/25 Pharmacy review indicated the resident had three PRN pain opioid orders and the recommendation was to simplify the orders. There was no physician response. -A 3/24/25 Pharmacy review indicated it was a repeat recommendation from February 2025 due to no response. There was still no physician response. b. A 3/25/25 Pharmacy review indicated Resident 44 was on the following psychotropic regimen and was due for a GDR (gradual dose reduction): -buproprion (an Anti-depressant) 150 mg once a day for depression, start date of 9/2024. -escitalopram (an Anti-depressant) 5 mg once a day for depressing, start date 11/2024. -quetiapine (an Anti-psychotic) 50 mg in the morning and 250 mg at bedtime for bipolar, start date 11/14/24. -liothyronine (a thyroid medication) 12.5 mg once a day for adjunct depression, start date 12/2024. -propranolol (a beta blocker) 10 mg twice daily for headache and anxiety, start date 11/2024. There was no response from the physician. -A 4/21/25 Pharmacy review revealed it was a repeat recommendation from March 2025. There was still no response from the physician. -A 5/25/25 Pharmacy review revealed it was a repeat recommendation from March and April 2025 and there was no response from the physician. On 6/9/25 at 12:37 PM Staff 2 (DNS) stated pharmacy recommendations for February, March, April, and May 2025 were not sent to Resident 44's physician. 4. Resident 56 was admitted to the facility on [DATE] for surgical aftercare with diagnoses including spinal abscess and paralysis. Resident 56's 4/30/25 physician orders indicated the following active medications: -Oxycodone 10mg every 24 hours as needed for pain -Lidocaine 4% 2 patches every 24 hours for pain -Albuterol-Budesonide 2 puffs every 4 hours as needed for shortness of breath In Resident 56's 5/2025 Note To Attending Physician/Prescriber and Nursing Recommendations the following recommendations were made: -Oxycodone 10mg every 24 hours as needed for pain - specify if medication should be given a certain amount hours from the other PRN Oxycodone. -Lidocaine patch add to schedule: Lidocaine patch to be worn for 12 hours and patient is to be patch free for 12 hours. -Albuterol-Budesonide: Please confirm that the correct med is actually albuterol-budesonide and not supposed to be albuterol only. -Hydroxyzine (used to treat anxiety) PRN orders may be extended beyond 14 days if rationale is provided and duration for the PRN order is indicated. -Prochlorperazine (used to treat nausea and vomiting) PRN orders are limited to 14 days and cannot be renewed without a physical evaluation. Review of Resident 56's 5/2025 MARs revealed the pharmacy recommendations were not implemented. On 6/9/25 12:31 PM Staff 2 (DNS) stated the facility's regular pharmacist went on leave in late 1/2025 through early 5/2025 and the interim pharmacist did not send recommendations to the providers. Staff 2 acknowledged recommendations were not acted upon in that time and stated the facility discovered the problem about a week ago.

Based on observation, interview, and record review it was determined the facility failed to follow proper infection control protocols related to transmission based and enhanced barrier precautions for 2 of 4 sampled residents (#s 48 and 60) reviewed for feeding tube and infection control. This placed residents at risk for cross-contamination and infection. Findings include: 1. Resident 48 was admitted to the facility in 10/2024 with diagnoses including multiple pressure ulcers and contractures. A 6/2021 Center for Disease Control Consideration for Use of Enhanced Barrier Precautions (EBP) in Skilled Nursing Facilities identified that EBP was an approach of targeted gown and glove use for residents with wounds, regardless of the multidrug-resistant organism status of the resident, due to the common existence of organisms in nursing facilities. A 5/30/25 revised care plan indicated Resident 48 had a Stage 4 (full-thickness skin loss with exposed bone or tendons) pressure ulcer on her/his sacrum (bone at the base of the spine). On 6/2/25 at 1:32 PM, an EBP sign, with instructions to don gown and gloves, was observed in the hall and outside the door of Resident 48's room. No supply of gowns were observed near the sign. On 6/2/25 at 1:33 PM and 1:41 PM, Staff 37 (CNA) and an unidentified CNA donned gloves only and entered Resident 48's room to turn and adjust the resident in her/his bed. Staff 37 was unsure why Resident 48 was on EBP and stated a cart with a supply of gowns at the door was needed to alert staff to use gowns. Staff 37 confirmed she was to don both gloves and gowns to move Resident 48 in her/his bed. On 6/6/25 at 2:26 PM Staff 20 (Regional Director of Clinical Services/IP) confirmed staff were to don gown and gloves during all direct care for residents on EBP. 2. Resident 60 was admitted to the facility in 4/2025 with diagnoses including acute respiratory failure with hypoxia, pneumonia, nontraumatic subarachnoid hemorrhage from right middle cerebral artery (stroke) and tracheostomy status. A review of Resident 60's 5/1/25 care plan indicated: Isolation precautions: Resident requires droplet, enhanced standard precautions (ESP) single room isolation precautions due to MRSA infection, pneumonia. Maintain isolation droplet enhanced standard precautions. Requires strict single bed isolation due to infection. Staff will perform hand washing after completing care and leaving the room/ Use of PPE as recommended for type of infection. On 6/2/25 at 10:19 AM and throughout the survey a sign was observed outside of Resident 60's room that read: STOP Droplet Precautions Everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. a. On 6/2/25 at 10:19 AM Staff 34 (LPN) was observed to enter Resident 60's room without a mask or eye covering. On 6/6/25 at 8:36 AM Staff 34 (LPN) stated Resident 60 was on droplet precautions because she/he had MRSA in his/her tracheostomy and in wounds. She further stated she did not need an eye covering unless the resident was going to cough in her eyeballs. She said on 6/2/25 she entered Resident 60's room without PPE because the tube feeding alarm was sounding but she should have put on a mask and eye covering. b. On 6/3/25 at 10:17 AM Staff 33 (Agency LPN) was observed to enter Resident 60's room without a mask or eye covering. On 6/3/25 at 10:21 AM Staff 33 exited Resident 60's room, did not perform hand hygiene and used her computer. She re-entered without a mask or eye covering and put on gloves without using sanitizer. On 6/3/25 at 10:28 AM Staff 33 entered Resident 60's room with a glucometer and CBG supplies without performing hand hygiene, a mask or eye covering. On 6/3/25 at 10:39 AM Staff 33 stated she had not noticed the sign by Resident 60's door, was not aware Resident 60 was on droplet precautions, and had been in and out of Resident 60's room all day without using a mask or shield. c. On 6/4/25 8:50 AM Staff 35 (LPN) was observed providing care to Resident 60 without an eye covering. On 6/4/25 at 9:09 AM Staff 35 stated staff and visitors were to use a mask and eye covering to enter the room. She stated she took her face shield off while she was in the room because she couldn't see what she was doing with it on due to fog. She explained the mask and eye covering was to protect Resident 60 and staff. On 6/6/25 at 11:36 AM Staff 20 (Regional Director of Clinical Services and Infection Preventionist) stated for residents on droplet precautions staff were to use a mask and shield to prevent the spread of diseases through respiratory droplets. She stated she was aware some staff did not wear a mask and face shield in Resident 60's room and staff needed education on what precautions were. She also stated staff were to encourage and educate Resident 60's visitors to use PPE because it would put them at risk of infection. On 6/9/25 at 9:30 AM Staff 2 (DNS) stated staff were to follow contact precautions.

3. Resident 66 admitted to the facility in 10/2024 with diagnoses including Huntington's Disease (a genetic disorder which causes a progressive breakdown of nerve cells in the brain). An 10/18/24 admission MDS revealed Resident 66 had a BIMS of 10, which indicated her/his cognition was moderately impaired. On 6/2/25 at 12:30 PM Witness 4 (Complainant) stated in 11/2024 Resident 66 reported to her a staff member at the facility fondled her/him. Witness 4 did not indicate if this was reported to the facility and did not have additional information related to the allegation. Resident 66 was unable to be interviewed due to being discharged from the facility and poor cognition. No evidence was found to indicate the incident was reported to the state agency. On 6/2/25 at 1:02 PM Staff 2 (DNS) stated the facility did not have an investigation into an allegation of sexual abuse related to Resident 66. On 6/4/25 at 11:57 PM Staff 23 (CNA) stated she assisted Resident 66 with a shower and unintentionally brushed Resident 66's breast and Resident 66 felt uncomfortable. Staff 23 stated the facility management notified her at that time there was an abuse allegation related to the incident. On 6/6/25 at 11:53 AM Staff 22 (Former Administrator) stated he recalled Resident 66 and the allegation of sexual abuse. Staff 22 stated Resident 66 was given a shower by Staff 23 and Resident 66 became upset. Staff 22 stated he did not know if the incident was investigated and was unable to provide additional information. On 6/9/25 at 9:02 AM Staff 1 (Administrator) confirmed the sexual abuse allegation was not reported to the state agency. Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported to the State Agency within two hours for 3 of 6 sampled residents (#s 43, 61 and 66) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: 1. Resident 43 admitted to the facility in 2025 with diagnoses including schizophrenia (a brain disorder that affects a person's ability to think, feel, and behave clearly). Resident 43's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident had no cognitive impairment. On 6/2/25 at 1:56 PM Resident 43 stated her/his breasts were grabbed by an unidentified male caregiver one time. On 6/6/25 at 8:38 AM Staff 8 (Social Services Director) indicated she was aware Resident 43 alleged a male caregiver touched her/his breasts and it was reported to Staff 1 (Administrator) for further investigation. A record review on 6/6/25 revealed no evidence the allegation was reported to the State Agency. On 6/6/25 at 11:12 AM Staff 1 (Administrator) confirmed he was aware of the allegation made by Resident 43 and did not report it to the State Agency. 2. Resident 61 admitted to the facility in 2025 with diagnoses including a stroke. Resident 61's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident had no cognitive impairment. On 6/2/25 at 12:53 PM Resident 61 stated an unidentified male caregiver grabbed her/his breasts one time. On 6/6/25 at 8:38 AM Staff 8 (Social Services Director) indicated she was aware Resident 61 alleged a male caregiver touched her/his breasts and it was reported to Staff 1 (Administrator) for further investigation. A record review on 6/6/25 revealed no evidence the allegation was submitted to the State Agency. On 6/6/25 at 11:12 AM Staff 1 (Administrator) confirmed he was aware of the allegations made by Resident 43 and did not report it to the State Agency.

Based on interview and record review it was determined the facility failed to obtain treatment orders and provided treatment for diabetic ulcers for 1 of 1 sampled resident (#8) reviewed for pressure ulcers. This placed residents at risk for lack of timely treatment. Findings include: Resident 8 was admitted to the facility in 2015 with diagnoses including diabetes and osteomyelitis (bone infection). A 1/10/25 Quarterly MDS revealed Resident 8 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Resident 8 had surgical wounds and 6 arterial ulcers (wounds due to lack of adequate blood flow) including diabetic foot ulcers. The 1/2025 TAR revealed the following treatment orders for Resident 8: -Between the first and second toes, cleanse wound vigorously to patient's tolerance with house wound cleanser, apply gauze and paint with betadine (solution to prevent infections). The order started on 12/11/24. -Right lower leg: wash lower leg with warm water, pat dry, apply ointment (except to surgical site) and apply two-layer compression every day shift. The order started on 11/8/24. A 1/28/25 wound clinic Physician Orders Details instructed the facility to: fax orders and progress notes to the clinic, not use compression wraps or wrap all the way up Resident 8's leg, and apply DriGo (skin protection textile to prevent bacterial growth) between the resident's toes to prevent moisture. A 1/29/25 Note Text revealed Resident 8 refused her/his diabetic foot ulcer treatment between her/his toes because the resident recently returned from the wound clinic where treatment was completed. The 2/2025 TAR revealed no additional implementation of the 1/28/25 wound care clinic orders related to Resident 8's toes and legs. On 6/4/25 at 9:13 AM Resident 8 stated she/he preferred the wound clinic for wound care and indicated orders from the wound clinic were not always implemented by the facility. On 6/4/25 at 3:34 PM, Staff 5 (RNCM) stated communication between the wound clinic and the facility was challenging, and indicated the wound clinic orders were at times requested and not received. On 6/5/25 at 12:42 PM, Staff 25 (Former LPN) stated Resident 8 had diabetic foot ulcers which were treated by an outside provider as early as 1/2025. Staff 25 stated, when Resident 8 returned from the wound clinic, the resident's new orders were to be scanned. On 6/5/25 at 3:57 PM, Staff 28 (LPN) confirmed nurses were to check for new treatments when Resident 8 returned from the wound clinic. Staff 28 stated the system to ensure new orders were implemented was not consistent and agency staff were not aware of the process. On 6/6/25 at 8:40 AM, Staff 32 (NP) stated she did not coordinate communication between Resident 8's multiple providers. On 6/9/25 at 10:24 AM, Staff 21 (Regional Director of Clinical Services) expected staff to verify wound care for Resident 8 was addressed timely and treatments orders were in place. On 6/9/25 at 1:51 PM, Witness 3 (Wound Clinic Program Director) stated the clinic was often unable to connect with the facility related to needed follow-up for Resident 8's leg and foot treatments.

Based on interview and record review it was determined the facility failed to provide the risk and benefits for the use of an antipsychotic medication to a resident/responsible party prior to administration for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 20 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbances and convulsions. A 9/26/24 Informed Consent-Psychoactive Medication form indicated Resident 20 gave verbal consent for the use of her/his psychotropic medications not including divalproex sodium (anticonvulsant medication). The 10/2/24 admission MDS indicated Resident 20 received psychotropic medications to manage the resident's agitation and aggressive behaviors related to her/his dementia. A 12/6/24 IDT (Interdisciplinary Team) Psychotherapeutic Review indicated Resident 20 received divalproex sodium (anticonvulsant medication use as an antipsychotic medication). A review of Resident 20's clinical record revealed no signed consent for the use of divalproex sodium. On 6/5/25 at 9:55 AM, Staff 20 (Regional Director of Clinical Services) and Staff 14 (MDS Coordinator) acknowledged a consent for the risks and benefits of divalproex sodium was not obtained as expected.

Based on observation, interview and record review it was determined the facility failed to promote self determination for 1 of 1 sampled resident (#44) reviewed for choices. This placed residents at risk for lack of honoring choices and room preferences. Findings include: Resident 44 was admitted to the facility in 9/2024 with diagnoses including a stroke and depression. The 9/12/24 admission MDS indicated Resident 44 was cognitively intact. On 6/2/25 at 1:51 PM Resident 44 stated she/he requested a room change as the roommate's television volume was loud and disrupted her/his sleep. The roommate's television was observed to be on and the volume was loud, which made it difficult to hear anything else in the room. Resident 44 stated she/he spoke with Staff 8 (Social Services Director) about the request and no follow up was provided. On 6/4/25 at 9:40 AM Resident 44 was observed in bed with a headphone set on and the roommate's television volume was loud. Resident 44 stated the headphones helped some with the noise, but her/his sleep was still disrupted. On 6/6/25 at 11:59 AM Staff 8 stated about one week ago Resident 44 expressed to her a desire to move rooms due to the roommate's television volume. Staff 8 stated she was more focused on the resident's discharge arrangements than a room move. On 6/6/25 at 1:01 PM Staff 1 (Administrator) stated he was not aware of Resident 44's request to move rooms and it should have been brought his attention.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 sampled residents (#56) reviewed for medications. This placed residents at risk for adverse side effects of medication. Findings include: Resident 56 was admitted to facility in 4/2025 for surgical aftercare with diagnoses including spinal abscess and lower body paralysis. Resident 56's medication orders upon admission indicated the following: - Prochlorperazine (used to treat nausea and vomiting) every 6 hours PRN. Resident 56's 5/2025 Note To Attending Physician/Prescriber revealed a letter was sent to the provider, advising that the PRN Prochlorperazine required the prescriber to provide a direct examination and rationale every 14 days. There was no evidence in Resident 56's medical record that indicated the physician reviewed, assessed or evaluated the resident within 14 days for the PRN antipsychotic, as required. On 6/9/25 at 11:44 AM Staff 18 (LPN Resident Care Manager) stated his understanding of regulations around antipsychotic orders included PRN orders were only allowed for 14 days at a time, and the prescriber was required to provide a face-to-face evaluation and rationale for continuing the medication. Staff 18 reviewed Resident 56's PRN Prochlorperazine orders and acknowledged the orders went beyond the 14 days without review and evaluation.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#43) reviewed for choices. This placed residents at risk for unmet needs. Findings include: Resident 43 admitted to the facility in 2025 with diagnoses including schizophrenia. Resident 43's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. A 4/30/25 Social History Assessment indicated the resident had trauma of rape/sexual assault/uncomfortable and unwanted sexual experience. A review of Resident 43's 6/2/25 updated comprehensive care plan revealed no evidence she/he was to receive care from females only. On 6/2/25 at 1:56 PM Resident 43 stated she/he experienced uncomfortable interactions with male caregivers. Resident 43 stated she/he did not want male caregivers coming into her/his room. On 6/5/25 at 9:36 AM Staff 38 (CNA) stated Resident 43 preferred female caregivers based upon conversations she had with the resident and believed this information was included in the resident's care plan. On 6/6/25 at 11:12 AM Staff 1 (Administrator) confirmed Resident 43's care plan was not updated to reflect female caregiving staff only.

Based on interview and record review it was determined the facility failed to complete a timely assessment after a fall and conduct a thorough investigation for 2 of 6 sampled residents (#s 20 and 66) reviewed for accidents. Findings include: 1. A 9/2024 facility Accident/Incident Policy and Procedure indicated persons with knowledge of events surrounding an incident were to complete a witness statement and to implement a plan to prevent re-occurrences after a thorough investigation was completed. Resident 20 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbances and fracture of the left hip bone. The 10/2/24 admission MDS indicated Resident 20 had a history of falls with injuries, was dependent on staff for toileting and transfers, and had a BIMS score of 6 which indicated the resident had severe cognitive impairment. A 11/5/24 revised care plan indicated Resident 20 required minimal assistance to transfer, to anticipate the resident's needs, and monitor the resident for complications after a fall. A 11/25/24 Un-witnessed Fall report, completed by Staff 26 (Former RN), indicated Resident 20 was found on the floor with her/his head towards the wall and an injury to her/his left hip. The report indicated a fall mat was in place and the floor in the resident's room was wet. The report revealed Resident 20 was assisted back to bed by three staff after vitals were obtained and her/his bed linens were changed. The report contained no additional staff interviews or conclusion to the investigation. A 12/11/24 revised care plan indicated to place a fall mat on the right side of Resident 20's bed. The 4/4/25 Quarterly MDS indicated Resident 20 had two or more falls during the previous quarter. On 6/3/25 at 11:11 AM, Staff 26 recalled Resident 20's fall on 11/25/24 and stated the floor was wet because there was urine on the floor since the resident refused toileting. Staff 26 stated she was surprised when Resident 20 stood up and urinated. Staff 26 indicated she had to complete the nightly medication pass and was unable to complete the fall report and protocol. On 6/5/25 at 1:48 PM, Staff 27 (Former CNA) stated she worked with Resident 20 on 11/25/24 but was in another room when she/he fell. Staff 27 stated no witness statement was requested related to the 11/25/24 incident. On 6/6/25 at 9:14 AM, Staff 20 (Regional Director of Clinical Services) expected the fall investigation to include witness statements and an updated care plan for Resident 20 after a root cause was determined. Staff 26 and Staff 1 (Administrator) acknowledged the 11/25/24 fall investigation for Resident 20 was not thorough and the revised care plan did not correctly address the correct fall prevention which could aid to reduce further falls. 2. Resident 66 admitted to the facility in 10/2024 with diagnoses including Huntington's Disease (a genetic disorder which causes a progressive breakdown of nerve cells in the brain). An 10/18/24 admission MDS revealed Resident 66 had a BIMS of 10, which indicated her/his cognition was moderately impaired. A 11/7/24 fall care plan revealed Resident 66 was at risk for falls due to medication side effects, Huntington's disease, incontinence, confusion, arthritis, and epilepsy. A Fall Risk Management dated 11/23/24, but completed on 1/6/25, revealed Resident 66 was found on the floor at 12:45 AM on 11/23/24. The fall investigation was not completed until 1/6/25 and no updates were made to the fall care plan. In interviews on 6/5/25 at 9:30 AM and 6/9/25 at 9:44 AM Staff 21 (Regional Director of Clinical Services) stated she completed the investigation into the fall late when the resident was discharging from the facility.

Based on observation, interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 1 sampled resident (#60) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube including bacterial growth. Findings include: According to Best Practices for Managing Tube Feeding, a Nurse's Pocket Manual published by [NAME] Nutrition in May 2015 an open system tube feeding container and tubing should be changed at least every 24 hours. Resident 60 was admitted to the facility in 4/2025 with diagnoses including acute respiratory failure with hypoxia, pneumonia, nontraumatic subarachnoid hemorrhage from right middle cerebral artery (stroke) and tracheostomy status. A review of Resident 60's 5/6/25 admission MDS revealed she/he had a feeding tube (TF) and received 51% or more of total calories through TF and an average fluid intake of 501 CC/day or more. A 5/25/25 physician order revealed Resident 60 was to receive [NAME] Farms 1.5 or equivalent at 67 mL/hr x 18 hours from 1600-1000 (providing 1206 mL total volume) house equivalent TF - Jevity 1.5 or Isosource 1.5 per RD two times a day for nutrition with new bag set-up daily when starting at 4:00 PM. On 6/3/25 at 9:51 AM a bag containing Resident 60's tube feeding formula was observed running and had a sticker-label dated 5/30/25. On 6/3/25 at 10:17 AM Staff 33 (Agency LPN) was observed re-filling the tube feeding bag with cartons of formula. On 06/3/25 at 10:39 AM Staff 33 confirmed the tube feeding bag was dated 5/30/25. On 06/6/25 at 8:19 AM Staff 34 (LPN) stated Resident 60's tube feeding bag and tubing was to be placed daily at 4pm. She further stated it was not changed on 5/31/25, 6/1/25 or 6/2/25 though she documented on the TAR it was completed. She explained the risks of not changing the bag as ordered were bacterial growth and the resident experiencing nausea or vomiting. On 6/6/25 at 12:20 PM Staff 18 (LPN RCM) stated the bag should be changed every 24 hours or when it doubt, change it out and the resident was at risk for infection, aspiration, pneumonia and sepsis if not completed. He further stated he was aware the tube feeding bag was not changed on 5/31/25, 6/1/25 and 6/2/25. On 6/9/25 at 9:24 AM Staff 2 (DNS) stated the tube feeding bag and tubing should have been changed every day at 4:00 PM and the risks associated with this not being done were bacterial growth in the bag, clogging and potential for gastro intestinal issues or sepsis.

Based on observation, interview, and record review it was determined the facility failed to comprehensively assess and revise a resident's care plan related to dementia for 1 of 1 sampled resident (#20) reviewed for dementia. This placed residents at risk for unaddressed dementia and behavioral needs. Findings include: Resident 20 was admitted to the facility in 9/2024 with diagnoses including dementia with behavioral disturbances. The 10/2/24 admission MDS indicated revealed a BIMS score of 6, which indicated Resident 20 had severe cognitive impairment. The MDS also indicated the resident received psychotropic medications to manage the resident's agitation and aggressive behaviors related to her/his dementia. A 12/23/24 Care Conference Meeting indicated Staff 8 (Social Services Director) met with Resident 20 and her/his representative to discuss facility and discharge goals. The 5/6/25 through 6/3/25 CNA Task: Focused Behaviors revealed Resident 20 kicked, yelled, rejected care, threatened or grabbed others on 16 of 32 days. A 5/8/25 revised care plan indicated to analyze and document key times, places, circumstances, and triggers related to what deescalated Resident 20's behavior. The care plan instructed staff to engage calmly with Resident 20 and explain care before care was provided to reduce tension. No additional behavior triggers were identified. On 6/3/25 at 8:27 AM, Resident 20 was observed to attempt to grab another resident's food tray. Staff 30 (CNA) redirected Resident 20 and stated the resident grabbed anything she/he wanted if not redirected. Staff 30 stated consistent CNAs and care for Resident 20 was helpful to reduce her/his behaviors. Staff 30 acknowledged Resident 20 became calm when her/his spouse visited and became angry and agitated when her/his spouse left. On 6/4/25 at 12:44 PM, Staff 24 (CNA) stated Resident 20 was less resistive to care when her/his spouse was present. Staff 24 indicated Resident 20 routinely hit female care givers if the approach was unexpected. On 6/6/25 at 9:14 AM, Staff 20 (Regional Director of Clinical Operations) and Staff 1 (Administrator) expected a more detailed resident-centered care plan for Resident 20, especially related to her/his spouse. On 6/6/25 at 10:56 AM, Staff 31 (LPN) stated Resident 20 often asked for her/his spouse. Staff 31 stated she calmed Resident 20 when she reassured her/him of the spouse's pending visit. On 6/9/25 at 11:16 AM Staff 8 stated she was responsible for Resident 20's dementia care plan. Staff 8 indicated she updated the resident's care plan based on her observations and relied on staff to come to her to provide additional insight. Staff 8 acknowledged additional staff feedback was necessary to addressed the behavioral and dementia needs for Resident 20.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#59) reviewed for rehabilitative and restorative services. This placed residents at risk for not receiving physical therapy services. Findings include: Resident 59 was admitted to the facility in 4/2025 with diagnoses including fracture of right and left heel bones, and multiple fractures of ribs. The 4/14/25 admission MDS identified Resident 59 with lower extremity impairment on both sides, and indicated resident was cognitively intact. On 6/5/25 at 1:08 PM the resident stated she/he went to a physician visit on 6/2/25 and received hard copy orders from the bone specialist for continued physical therapy, and she/he gave the orders to a nurse when she/he returned to the facility. Resident 59 stated she/he was not scheduled for more physical therapy yet. Resident 59's physical therapy order was observed and indicated physical therapy two times a week for eight weeks. A 6/2/25 physician order indicated Resident 59 was to receive physical therapy two times a week for eight weeks. A review of Resident 59's health record revealed no current order for physical therapy. On 6/5/25 at 12:35 PM Staff 19 (OT) reviewed Resident 59's health records and stated the resident did not have therapy orders. On 6/6/25 11:07 AM Staff 18 (LPN Resident Care Manager) stated when a resident returned from a physician visit with a new order, the charge nurse was responsible for entering the orders. Staff 18 confirmed there were no new orders for continued physical therapy communicated to him or entered in Resident 59's health record.

Based on interview and record review it was determined the facility failed to ensure a resident had interventions in place to prevent pressure ulcers and update the plan of care to prevent worsening of pressure ulcers for 1 of 3 sampled residents (#12) reviewed for pressure ulcers. Resident 12 developed two stage 2 pressure ulcers (shallow partial thickness skin loss) to the coccyx and a deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration of intact skin due to damage of underlying soft tissue) to the heel which deteriorated to an unstageable ulcer (depth unable to be determined due to slough/nonviable tissue covering the base of the ulcer). Findings include: Resident 12 was admitted to the facility 1/13/23 with diagnoses including pneumonia. A 1/13/23 Scale for Prediction of Pressure Sore Risk form indicated Resident 12 was at risk for the development of pressure ulcers. A 1/13/23 Admission Nursing assessment indicated Resident 12 did not have skin impairments including pressure ulcers. The Skin Care Plan section was not marked as initiated on the form and goals were not selected which could have included to assist the resident to change position frequently and to float heels. A baseline care plan dated 1/14/23 did not include pressure ulcer prevention interventions. A Progress Note dated 1/24/23 indicated a 0.5 cm by 0.5 cm open area to the coccyx was identified. A 1/24/23 Skin investigation indicated a small open area was noted to the coccyx region. Predisposing factors included the resident was confused, incontinent, weak, had impaired memory and had a recent illness. On 2/13/23 at 12:19 PM Staff 6 (LPN Resident Care Manager) stated Resident 12 was admitted to the facility without pressure ulcers, was weak and was at risk for the development of pressure ulcers. Staff 6 acknowledged the baseline care plan did not have interventions for the prevention of pressure ulcers and the resident developed a Stage 2 pressure ulcer to the coccyx. A Progress Note dated 1/26/23 by the Advanced Registered Nurse Practitioner (ARNP) revealed the resident had a Stage 2 pressure ulcer to the coccyx which was 4.5 cm by 1.3 cm and a new deep tissue pressure injury to the left lateral heel which was 3.3 cm by 3.7 cm. The resident was assessed to have poor ability to reposition and was incontinent. Recommendations included off-loading boots, repositioning and off-loading pressure areas. A Care Plan for potential impairment to skin integrity, pressure injury to left lateral heel and coccyx was not initiated until 1/30/23, six days after the identification of the Stage 2 pressure ulcer to the resident's coccyx and four days after the identification of the deep tissue injury to the foot. Interventions added on 1/30/23 included encourage resident to change position frequently and an air bed. It did not include to float heals or to use off-loading boots as recommended by the ARNP. On 2/9/23 at 9:22 AM and 2/13/23 at 12:59 PM Resident 12 was observed in her/his wheel chair with shoes on. The resident's off loading boots were on her/his bed. On 2/9/23 at 10:32 AM during an interview with Witness 1 (ARNP) and Staff 3 (RN), Witness 1 stated she first assessed Resident 12 on 1/26/23. Witness 1 stated facility staff always went with her when she provided care to Resident 12. She provided verbal recommendations to staff and usually documented the recommendations in the resident's record. The coccyx ulcer was larger on 1/26/23 compared to 1/24/23 because a new Stage 2 ulcer developed right above the original ulcer which was identified on 1/24/23. It was standard of practice for her to combine the measurements of two ulcers if the two ulcers were in the same area and if the ulcers would likely merge into one. Witness 1 acknowledged the resident had shoes on when she entered the room to do Resident 12's assessment and on her previous visit she notified staff the resident was not to wear shoes when out of bed, except for transfers, to prevent pressure on the heel ulcer. Witness 1 indicated the heel ulcer progressed from a deep tissue injury to an unstageable pressure ulcer since her last visit. The 2/9/23 ARNP note indicated the resident was to wear NO shoes except to stand and was to wear heel protector booties while up in a chair. The coccyx wound was assessed as improved. On 2/13/23 at 12:19 PM Staff 6 stated she was not at the facility on 2/9/23 when Witness 1 assessed Resident 12. Prior to 2/9/23, Staff 6 indicated she recalled having a conversation with Witness 1 which included the resident was not to wear shoes to decrease pressure to the heel. Staff 6 acknowledged the care plan was not updated for staff to float heels or to use off-loading boots. Staff 12 was not able to provide a date when the boots arrived to the facility.

Based on observation, interview and record review it was determined the facility failed to thoroughly investigate and report allegations of sexual exploitation and sexual abuse for 1 of 3 sampled residents (#1) reviewed for allegations of abuse. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 experiencing the potential for ongoing sexual abuse and exploitation. Findings include: The facility Policy and Procedures for Abuse screening, training, identification, investigation, reporting and protection revised 2/2019 included the following: -Investigate allegations of Abuse. -Report allegations of Abuse to appropriate reporting authority. -Protect our residents from Abuse. -Incident investigation and reporting shall be completed following Abuse Reporting and Investigation, Guide for Providers, DHS 0818 (Rev. 10/05) issued by the state of Oregon. The Abuse Reporting and Investigation Guide for Providers, 4/2019 stated: Sexual abuse: Any time sexual abuse is witnessed or suspected, the incident(s) must be referred to the State Survey Agency. Resident 1 was admitted to the facility in 12/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's 6/14/22 MDS indicated the resident was cognitively intact and required extensive assistance with bed mobility. Resident 1's 6/20/22 Care Plan revealed: -Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident 1 required a two-person extensive assist with bed mobility, toileting and transferring. Staff used a mechanical lift to transfer Resident 1 out of the bed. Resident 1 was reported to be involved in two separate incidents involving allegations of potential sexual exploitation and sexual abuse. On 9/9/22 at 2:22 PM Staff 4 (CNA) stated the call bell system on the hallway where Resident 1 lived was wonky because the call light just blinked and did not stay on. a. Observations made on 9/9/22 at 2:00 PM revealed Resident 1's room was located at the short end of the 200 hall near the vacant 100 hall. Resident 1 was one of two residents who resided down a short corridor, around the corner, at the end of a long hallway of occupied rooms. On 9/9/22 at 2:22 PM Staff 3 (CNA) and Staff 4 (CNA) stated on 8/14/22 Resident 1 disclosed that her/his significant other (in the outside community) who Resident 1 referred to as Master, pressured the resident to perform sexual acts for money. This made Resident 1 feel intimidated and afraid of being beaten due to past experience. Staff 3 and Staff 4 stated they remembered the exact date because they were styling Resident 1's hair and Resident 1 requested pictures. Staff 3 and Staff 4 reported the allegation to Staff 7 (Charge RN). On 9/9/22 at 4:25 PM Resident 1 stated she/he referred to her/his significant other as Master. Resident 1 stated Master told her/him she/he owed money and the punishment was to provide sexual favors for money. Resident 1 stated this occurred on and before 8/14/22 and she/he informed Staff 1 (Administrator) at that time. Resident 1 stated this incident upset her/him. Resident 1 stated due to being sexually abused by family members in the past, she/he experienced [CONDITION(S)]. On 9/10/22 at 3:15 PM the facility submitted a FRI to the State Agency. Resident 1 reported Resident 4 came to her/his room to ask for sex for money. The facility placed a lock on Resident 1's door in attempt to protect Resident 1. Resident 1 stated the lock on the door made her/him feel safe. On 9/12/22 at 1:09 PM Staff 5 (CNA) stated Resident 1 told her the resident's significant other said she/he needed to start offering sexual favors for money. Staff 5 stated she spoke with Staff 1 (Administrator) about the conversation. Staff 5 stated Staff 1 told her, What [Resident 1] wants to do for money is her/his right. On 9/12/22 at 2:22 PM Staff 7 (Charge Nurse) stated in 8/2022, a CNA reported to him that Resident 1's significant other wanted Resident 1 to sell themselves. Staff 7 stated Resident 1 also confirmed the story to him about her/his significant other requesting Resident 1 provide sexual favors for money. Staff 7 stated he believed he mentioned the allegation to management and was not aware of any paperwork that needed to be filled out. Resident 1's medical records revealed no evidence the facility thoroughly investigated Resident 1's allegation her/his significant other pressured the resident into performing sexual acts for money. On 9/12/22 at 4:00 PM Staff 1 (Administrator) and Staff 2 (DNS) stated 9/10/22 was the first time they heard about a resident being pressured to provide sexual favors for money. Staff 1 stated we don't report everything, we don't want to cry wolf and report every little thing. b. Resident 2 was admitted to the facility in 5/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's 7/17/22 Quarterly MDS indicated the resident was cognitively intact and the resident's 7/27/22 Care Plan revealed Resident 2 was monitored by staff for behaviors due to inappropriate touching of female staff and inappropriate sexual comments to female staff. Observations made on 9/9/22 at 2:00 PM revealed Resident 1 and Resident 2's rooms were located diagonal to each other in the 200 hall near the vacant 100 hall. Resident 1 and Resident 2 were the only residents down a short corridor, around the corner, at the end of a long hallway of occupied rooms. On 9/9/22 at 2:22 PM Staff 3 (CNA) stated Resident 1 told her she/he previously allowed Resident 2 to touch her/his breasts. Resident 1 later asked Resident 2 to stop but Resident 2 continued to come to Resident 1's room and touch her/his breasts. Staff 3 and Staff 5 (CNA) reported the allegation to Staff 1 (Administrator) on 8/31/22. On 9/9/22 at 3:55 PM Staff 4 (CNA) stated she asked Staff 7 (Charge RN) if she should document that Resident 2 touched Resident 1's breast, which she considered sensitive information. Staff 7 stated he would document it. Staff 4 stated the situation was a big red flag for her and she was concerned because Resident 2 was not moved to a different room and she felt nothing was done to prevent the situation from reoccurring. On 9/12/22 at 1:09 PM Staff 5 (CNA) stated Resident 1 told her she/he previously allowed Resident 2 to touch her/his breasts. Resident 1 then told Resident 2 she/he didn't want to do this anymore and to stop it. Staff 5 stated Resident 1 told her Resident 2 came to her/his room recently and she/he told the resident to leave. Staff 5 stated she reported this allegation to Staff 1 (Administrator) and Staff 1 stated she was aware of the situation and was taking care of it. On 9/12/22 at 4:00 PM Staff 2 (DNS) stated she spoke with Resident 1 regarding Resident 2 touching her/his breasts. Staff 2 did not document the conversation. Staff 2 was unable to show Resident 1's allegation was thoroughly investigated, and interventions were implemented to protect the resident and prevent future encounters from occurring. Staff 2 stated the allegation was not reported to the State Agency. On 9/15/22 at 12:57 PM Staff 10 (Nurse Practitioner) was aware that Resident 2 touched Resident 1's breasts despite Resident 1 telling Resident 2 to stop. Staff 10 stated Resident 1 reported Resident 2 came to her/his room every day for three days. Resident 1's medical records revealed no documentation the facility thoroughly investigated the allegation of sexual abuse. On 9/16/22 at 8:54 AM Staff 1 (Administrator) stated she was aware of Resident 2 fondling Resident 1's breasts on 8/31/22 and discussed it with Staff 9 (SSD). Staff 1 was unable to produce documentation or evidence of an investigation related to the incidents. The facility was found to be in an Immediate Jeopardy (IJ) situation in the areas of: CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. On 9/13/22 at 4:17 PM the facility administrative staff, including Staff 1 (Administrator) and Staff 2 (DNS), were notified of the immediate jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to investigate and report allegations of sexual abuse. The facility's failure to investigate resulted in the likelihood for Resident 1 to be sexually exploited, potential for serious disease and illness, and potential for Resident 1 to be affected by psychosocial harm. An immediate plan of correction (POC) was requested. On 9/13/22 at 6:30 PM the facility submitted a Plan of Correction (POC). On 9/13/22 at 8:37 PM the Administrator was notified the immediacy was removed based on onsite verification that the IJ removal plan was implemented. Following the removal of the immediacy; noncompliance remained at isolated with no actual harm with potential for more than minimal harm that is not IJ. The IJ immediacy Removal Plan included: -Resident #1 - Resident has been interviewed regarding her/his safety within the facility to ensure they are not being pressured to perform any non-consensual sexual acts. Resident has been interviewed to ensure all outside contact is consensual with significant other. Resident #1 care plan updated to reflect her/his wishes to maintain this relationship. Resident #1 states she/he feels safe at the facility. -Resident #2 - relocated to another area of the building, away from Resident #1. Current residents have been interviewed regarding their safety and if there had been any unwanted sexual interactions with other residents. All stated they felt safe and had no unwanted sexual interactions. -Staff will be educated regarding abuse and abuse reporting before beginning of their shift. No staff will work prior to receiving their education. All staff currently at the facility have received this education. Staff education will be completed by 9-16-22. Staff on time off will be educated immediately upon return. Administrator and DNS were educated regarding the need to investigate all allegations timely and thoroughly and to document all investigation findings. -DNS or designee will audit to ensure that all allegations have been appropriately investigated and reported according to regulation. Audits to be done weekly for four weeks, then every two weeks for one month. Results of audits to be presented to QAPI to determine substantial compliance and need for ongoing audits. Administrator is responsible to ensure compliance. Date of compliance 9-16-22.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#14) reviewed for medications; and failed to follow physician orders [REDACTED].#5) reviewed for non-pressure wounds. This placed residents at risk for missed or delayed medications, treatments and nutritional supplements. Resident 5's surgical debridement and administration of appropriate antibiotic treatment was delayed, the resident developed a deep tissue infection which required additional dressing changes, two surgical procedures and six weeks of IV (intravenous) antibiotic therapy. Findings include: 1. Resident 5 was readmitted to the facility 9/18/19 after surgical repair of a [MEDICAL CONDITION]. The 9/18/19 hospital Patient Discharge Information form revealed Resident 5 was to be seen by the orthopedic surgeon on 10/28/19. The orders also indicated the facility was to Watch for signs of infection. If there is wound drainage occurring after pOD (sic) (POD/Post-Operative Day) #10 (9/25/19) call the Orthopaedic office. The 12/22/19 faxed response from Witness 5 (Orthopedic Surgeon) revealed post-operative wounds with prolonged drainage have a higher risk of infection. If the drainage was noted and treated usually with irrigation and debridement the risk of a deep wound infection can be thwarted (prevented). The Progress Notes indicated the surgical incision was monitored daily from 9/18/19. The notes revealed the hip did not have signs of infection and was healing through 9/27/19. The 9/28/19 note by Staff 21 (RN) indicated the left hip incision had an area of slight dehiscence (surgical wound reopens) and had scant amount of serous drainage (pale transparent fluid). A dressing was placed over the incision. There was no note to indicate the surgeon was notified of the dehiscence or drainage per hospital discharge orders. On 12/13/19 at 10:30 AM Staff 21 stated the floor nurses administered medications, treatments, completed assessments, documented assessments and informed the unit manager if there were resident related concerns. Staff 21 indicated the house physician was in the facility at least weekly, was easily reached and the unit manager would notify the house physician if a resident's incision had drainage. Staff 21 acknowledged she wrote the 9/28/19 note and believed she notified the unit manager. Staff 21 further indicated the surgeon would be notified if the incision did not improve for additional orders such as blood tests. The Progress Notes revealed the following: -9/29/19 and 9/30/19 incision without signs of infection -10/1/19 slightly pink incision, no warmth or drainage -10/2/19 Staff 22 (LPN) indicated the incision was closed, no inflammation, warmth or foul odor. Scant off-white/yellowish odorless drainage from bottom most point of incision. The area was cleaned and antibiotic ointment was applied. There was no note to indicate the surgeon was notified. On 12/11/19 at 3:20 PM Staff 22 indicated he worked the night shift from 6:00 PM to 6:00 AM. Staff 22 acknowledged he wrote the 10/2/19 note and stated the drainage was likely pus. Staff 22 stated if a resident had drainage to a surgical incision the surgeon and the medical physician should be notified. Staff 22 also stated if there was more drainage and odor he would have called the physicians, but instead informed the oncoming nurse. The Progress Notes revealed the following: -10/2/19 hip incision was healing without signs of infection and had scant pale drainage to the distal incision. There was no note to indicate the surgeon was notified. -10/3/19 there was no description of the incision -10/4/19 Staff 23 (LPN) documented the hip incision was red and tender to the bottom of the incision. With light palpation purulent drainage was observed secreting from the incision. The note indicated the physician was notified of the drainage, the physician would be in the facility to assess the resident and the resident was prescribed Keflex (antibiotic). On 12/16/19 at 12:19 PM Staff 23 acknowledged she wrote the 10/4/19 Progress Note. Staff 23 indicated it was early in the morning when she saw the incision and she reported the drainage to Staff 24 (Facility Physician). Staff 23 was not sure if Staff 24 saw the resident on 10/4/19. Staff 23 acknowledged she did not call the surgeon. On 12/16/19 at 12:36 PM Staff 24 stated he was informed by the staff on 10/4/19 the resident's incision had drainage. Staff 24 indicated he saw the resident's incision on 10/4/19 and the incision was slightly red and he did not see drainage, therefore a culture was not able to be obtained. Staff 24 indicated he was not aware the facility had orders to call the surgeon if the wound had drainage. Staff 24 indicated when he assessed the resident's incision, the incision looked like a local infection. On 12/12/19 via email a request was made to Staff 5 (DNS) for the 10/4/19 physician visit assessment. Staff 5 indicated the physician gave verbal orders and a documented assessment was not found in the resident's record. The 12/22/19 faxed response from Witness 5 (Orthopedic Surgeon) revealed she was not notified of the drainage which was identified by the facility staff on 9/28/19, 10/2/19 and 10/4/19 until the orthopedic staff called the facility on 10/30/19 to arrange Resident 5's follow-up appointment. If notified of the drainage Witness 5 would have performed an irrigation and drainage and would have started IV antibiotics. The 12/22/19 faxed response also revealed Keflex could be an appropriate antibiotic for some post-operative infections, however; the typical practice was to perform an irrigation and drainage of the prosthetic joint. The Progress notes revealed the following: -10/5/19 and 10/6/19 incision had purulent drainage -10/7/19 Staff 18 (LPN Unit Manager) indicated she and Witness 9 (Former DNS) looked at the hip incision 10/6/19 and there was no purulent drainage and there was reddened areas where the surgical staples were located. Staff 18 updated the physician (Staff 24) and the physician indicated the incision improved and advised it was likely a local irritation and there was no need to call the Orthopedic doctor. On 12/13/19 at 2:38 PM Witness 9 indicated Staff 24 (Facility Physician) treated Resident 5 for an incisional infection on two occasions, the physician saw the resident in the facility and staff monitored the resident's incision. Witness 9 indicated she was not aware of the order to notify the orthopedic surgeon if the incision developed incisional drainage after 9/25/19. The Progress Notes revealed the following: -10/7/19 incision had scant sanguineous drainage (contains blood) -10/8/19 incision had serosanguinous drainage (light pink) -10/9/19 incision had minimal serous drainage -10/10/19 incision had scant purulent and serous drainage -10/11/19 no incision drainage -10/12/19 some serous drainage and antibiotic therapy was completed -10/13/19 no signs of infection -10/14/19 incision healing -10/15/19, 10/16/1910/17, 10/18/19, 10/19/19, 10/21/19, no drainage but slight scabbing to incision There were no progress notes related to the incision on 10/22/19, 10/23/19 10/24/19 or 10/25/19. The 10/26/19 Progress Note indicated the resident had purulent drainage at the top and to the bottom of the incision and Staff 24 (Facility Physician) prescribed an additional ten days of Keflex. There was no documentation to indicate the facility notified the orthopedic surgeon or obtained a culture and sensitivity of the wound to determine if Keflex would be effective against the infection. The Progress Notes revealed the following: -10/27/19 the resident did not have a fever, the incision line had a moderate amount of purulent drainage and the distal portion of the incision opened up. -10/28/19 incision with scant amount of drainage and the resident did not have a fever -10/29/19 scant drainage to incision -10/30/19 there was no drainage -10/31/19 no drainage, warmth and swelling. Slight pink. The 11/1/19 Orthopedic Surgery Encounter note indicated the resident had a surgical repair of a [MEDICAL CONDITION] and was in the clinic for a follow up visit. The orthopedic clinic staff called the facility on 10/30/19 and the facility informed the clinic staff the resident had a draining incision. The note indicated the facility physician (Staff 24) prescribed antibiotics on 10/26/19. The exam revealed the left incision had three areas which were not healed completely. The distal aspect of the incision had serous drainage. The central aspect of the wound had three small areas of eschar (dead tissue) which were three millimeters in diameter, the proximal aspect of the incision had a one cm long by four millimeter wide area of eschar and the areas were tender to touch. Unfortunately the resident's treatment was delayed for a draining hip incision. The resident's laboratory results showed an infection and was taken to surgery for [REDACTED]. The 11/22/19 Orthopedic Surgery note indicated Resident 5 had delayed drainage of the wound and was taken to surgery on 11/1/19 for irrigation and debridement. The resident was initially [MEDICATION NAME](antibiotic) and Keflex. The resident's wound was cultured and it was determined the infection was not susceptible to Keflex and the Keflex was changed to [MEDICATION NAME] (antibiotic). On 12/11/19 at 3:45 PM Witness 8 (Orthopedic Surgeon Medical Assistant) reported when Resident 5 was discharged from the hospital after hip surgery there were specific orders for the facility to notify the orthopedic surgeon if the surgical wound developed drainage after post-operative day ten. If the surgeon would have been notified the surgeon would have requested the resident be seen before the tenth week post surgery and would have obtained a wound culture. The facility physician did not perform a culture and the antibiotic the facility physician prescribed was not effective against the infection. The 12/22/19 faxed response from Witness 5 (Orthopaedic Surgeon) revealed the following: -A wound culture was not always standard of care for ten day post-operative drainage. A wound culture could be contaminated without obtaining a intra-operative culture which would be done at the time of the irrigation and drainage. The missed opportunity here was not having the opportunity on doing and I & (and) D. -It was possible if the wound would have been treated earlier with an I and D, followed by appropriate antibiotics determined by intraoperative cultures we could prevent this infection from being a deep prolonged infection. The 11/27/19 Short Stay Discharge Post Op Instructions for Witness 5 revealed Resident 5 required BID dressing changes and IV antibiotics for six weeks. The resident also required periodic blood draws to ensure the antibiotic dose was therapeutic. Resident 5's 9/18/19 post-operative orders directed staff to call the orthopedic surgeon if the resident's surgical incision had drainage after the tenth day post operatively; specifically 9/25/19. Resident 5's incision was first identified to have drainage on 9/28/19 and the facility did not notify the orthopedic surgeon for 32 days after the incision first developed drainage and only when the orthopedic surgical staff called the facility to arrange for the first post-operative follow-up examination. The resident required two I and Ds and on 11/27/19 was started on a six week course of IV antibiotics. 2. Resident 14 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 11/5/19 admission orders [REDACTED] * Aspirin 81 mg (supplement) every morning * Check blood pressure daily * cyanbalamin chewable 2500 mcg (supplement) tablet daily *[MEDICATION NAME] 125 mcg (heart failure medication) daily * [MEDICATION NAME] Allergy Relief Suspension 50 mcg (allergy medication) daily * [MEDICATION NAME] 20 meq (potassium supplement) daily * [MEDICATION NAME] 40 mg (diuretic medication) daily * [MEDICATION NAME] 10 mg (cholesterol medication) every evening * [MEDICATION NAME] 1 teaspoon (bowel medication) daily * Vitamin D3 2000 units (supplement) daily * [MEDICATION NAME] 12 hour 600 mg (mucus [MEDICATION NAME]) twice daily * 2.0 Calorie Med Pass 90 ml (nutritional supplement) three times daily The (MONTH) 2019 MARs revealed no scheduled medications were administered on 11/14/19. Additionally Resident 14's blood pressure was not checked and the 2.0 Calorie Med Pass was not administered per physician orders. The 11/14/19 Progress Note revealed during a chart review it was noted Resident 14's medications were placed on hold when Resident 14 transferred to the hospital on [DATE] and the medications were not re-activated when Resident 14 returned to the facility in the late evening of 11/13/19. On 12/11/19 at 8:50 AM Staff 11 (LPN Resident Care Manager) verified Resident 14's medications, blood pressure and nutritional supplement were not administered as ordered on [DATE] and stated this was considered a medication error.

Based on the lack of effective systems for ensuring adequate staffing levels, appropriate storage, administration and disposal of narcotic medication, appropriate pressure ulcer treatment and effective pain management the facility administration failed to utilize its resources effectively and efficiently to ensure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. This failure resulted in Resident #s 2 and 3 experiencing unrelieved pain and Resident 30 experiencing delayed wound healing. The failure also placed residents at risk for lack of timely assistance and drug diversion. Findings include: 1. Deficient practice was identified regarding the facility's failure to ensure sufficient nursing staff were available to meet resident needs. On 2/25/19 at 11:32 AM Staff 2 (DNS) acknowledged the facility administration was aware of a lack of sufficient staffing to ensure residents received timely assistance. Staff 2 stated the administration discussed a plan to add additional staff members at specified times, but the plan was not yet implemented. Refer to F725 and F727. 2. Deficient practice was identified regarding the facility's failure to ensure appropriate storage, administration and disposal of narcotic medication. On 2/24/19 at 3:15 PM and 2/25/19 at 8:36 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged irregularities on the facility's narcotic logs and indicated the facility administration did not audit the narcotic logs. Refer to F755. 3. Deficient practice was identified regarding the facility's failure to ensure pressure ulcer treatment was implemented as ordered. On 2/22/19 at 10:56 AM Staff 2 (DNS) acknowledged pressure ulcer treatments were not completed as ordered even after facility administration was informed of the failure to properly implement pressure ulcer treatments. Refer to F686. 4. Deficient practice was identified regarding the facility's failure to ensure effective pain management. On 2/26/19 at 9:45 AM Staff 2 (DNS) acknowledged additional interventions to treat pain were not implemented despite facility administration's knowledge of a resident's pain. Refer to F697.

Based on observation, interview and record review it was determined the facility failed to provide appropriate pain management for 4 of 7 sampled residents (#s 2, 3, 17 and 91) reviewed for pain and medication. The failure resulted in Resident 2 experiencing unrelieved pain, increased sleepiness and depression. The failure also resulted in Resident 3 experiencing unrelieved pain, caused the resident emotional distress and limited functional activities during physical therapy. Findings include: 1. Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 11/16/18 Admission MDS Pain CAA indicated Resident 2 had bilateral lower extremity [MEDICAL CONDITION] and received pain medication. The pain disturbed the resident's sleep and limited day-to-day activities. The LN was to notify the physician if the pain regimen was ineffective and referral to the pain clinic was possible. A 1/3/19 physician order [REDACTED]. A 1/17/19 physician order [REDACTED]. During interviews on 2/19/19 at 10:54 AM and 11:26 AM Resident 2 stated she/he had [MEDICAL CONDITION] on both legs and had pain in the left foot which caused the resident to cry on a daily basis. The resident expressed her/his pain was so bad that sometimes the resident did not want to be alive. She/he stated dressing changes were completed daily. The resident stated she/he received PRN [MEDICATION NAME] (pain medication) every eight hours but continued to have unrelieved pain. Resident 2 stated she/he previously received [MEDICATION NAME] every four hours but Staff 2 (DNS) wanted the resident off of the [MEDICATION NAME]. Resident 2 sobbed when discussing her/his pain. On 2/20/19 at 2:25 PM Resident 2 stated her/his pain level was currently a seven out of ten. The resident stated her/his pain level was an eight out of ten earlier that morning when the resident asked for the PRN [MEDICATION NAME]. Resident 2 stated the medication was not received until an hour and a half later. The resident further stated when she/he received [MEDICATION NAME] every four hours instead of every eight hours the pain was better managed. a. Wound Clinic notes indicated the following: -1/16/19: The resident had a lot of pain, particularly in the foot. -2/6/19: The resident continued to complain of excruciating pain in her/his left foot. This information was reported to staff who indicated the PCP would be notified. -2/13/19: The resident continued to complain of excruciating pain in her/his left foot. This information was reported to staff who indicated the PCP would be notified. No diagnostics were performed over the previous week. X-rays were ordered. The narcotic log indicated Resident 2 received PRN [MEDICATION NAME] at 2:02 PM. On 2/19/19 at 3:12 PM Staff 32 (RN) was observed to complete a dressing change for Resident 2. The resident was in pain wincing and jerking her/his left leg around during the dressing change. Resident 2 complained of pain when Staff 32 touched her/his left foot. b. On 2/20/19 at 2:25 PM Resident 2 stated she/he was not able to take [MEDICATION NAME] prior to therapy if it had not been eight hours since the previous dose. The resident further stated she/he had increased pain when participating in therapy. A review of Resident 2's therapy notes indicated the following: -2/22/19: nine out of ten pain in bilateral lower extremities. -2/21/19: eight out of ten pain in the left lower extremity. -2/20/19: eight out of ten pain in the left lower extremity and pain limited functional activities for the resident. -2/19/19: nine out of ten pain in the left lower extremity, requested pain medication from nursing and pain limited functional activities for the resident. -2/16/19: eight out of ten pain in the left lower extremity. -2/15/19: eight out of ten pain in the left lower extremity. -2/14/19: eight out of ten pain in the left lower extremity. -2/13/19: eight out of ten pain in the left foot. On 2/26/19 at 8:56 AM Staff 31 (Physical Therapist) stated Resident 2's left leg pain was constantly a seven or eight out of ten. She stated it was important the resident received pain medications prior to therapy as the resident's pain skyrocketed when putting weight on the heel. c. The 1/2019 physician order [REDACTED]. The 2/8/19 physician order [REDACTED]. The narcotic logs indicated [MEDICATION NAME] was administered late on 39 of 94 occasions between 1/3/19 and 2/18/19. On 2/25/19 at 2:24 PM Staff 2 (DNS) acknowledged the physician orders [REDACTED]. Staff 2 acknowledged it was important to administer pain medication on time in order to manage pain. d. A 2/8/19 physician visit note indicated Resident 2's pain was poorly controlled, not covered by current medications and was described as burning. The note indicated a plan to start [MEDICATION NAME] twice daily. A 2/8/19 progress note indicated Resident 2 refused the [MEDICATION NAME] due to a bad reaction to it in the past. The physician was notified and the medication was discontinued. A review of the clinical record revealed no evidence a replacement pain medication was offered to Resident 2. A 2/11/19 progress note indicated Resident 2 had continued pain to the left lower extremity. A 2/20/19 Care Conference Report indicated Resident 2 still had left foot pain. On 2/21/19 at 4:00 PM and 2/22/19 at 1:21 PM Staff 2 (DNS) stated Resident 2's pain was horrific. She stated the resident currently received [MEDICATION NAME] and [MEDICATION NAME] daily. She further stated Resident 2's other pain medications were not as effective as the [MEDICATION NAME]. Staff 2 acknowledged Resident 2's order for [MEDICATION NAME] was decreased from every four hours to every eight hours and the resident continued to report seven or eight out of ten pain. She stated it would be a disservice to discharge the resident addicted to narcotics. On 2/25/19 at 2:04 PM Staff 2 stated Resident 2 was not referred to a pain clinic because the pain clinic did not accept the resident's insurance. On 2/26/19 at 8:45 AM Resident 2 stated she/he had a care conference and informed Staff 30 (RNCM) she/he had unrelieved pain but the pain was not addressed. On 2/26/19 at 9:37 AM Staff 30 stated she attended Resident 2's care conference when the resident informed her of her/his uncontrolled pain. Staff 30 acknowledged there was no follow up with the resident regarding her/his pain. 2. The 2/2018 Medication and Treatment Order Policy indicated the following: -The medication order would be communicated to the pharmacy. -In the event that a fax was received back from the pharmacy, that a medication is not covered by the insurance company, a fax will promptly be sent to the physician to receive authorization to change order to medication which was covered by the insurance provider. -The Administrator and DNS would be notified expediently of this action, and would authorize a limited amount of the original medication ordered, until the order could be received to change a medication which was authorized by the insurance provider, to ensure that the resident did not miss any of the prescribed medication. Resident 3 was readmitted to the facility in 2019 with [DIAGNOSES REDACTED]. The 2/8/19 physician order [REDACTED]. On 2/20/19 at 1:12 PM Resident 3 stated her/his [MEDICATION NAME] was discontinued the day before and she/he did not have a replacement medication. The resident further stated she/he was started feeling weird and tingly and was less active today than usual. She/he stated Staff 2 was aware of the medication was discontinued and the insurance did not cover the medication. The resident stated this was the second time this happened recently. She/he stated it made a big difference and did not feel well after the [MEDICATION NAME] was discontinued. On 2/20/19 at 1:53 PM Staff 20 (CMA) acknowledged Resident 20 did not currently have [MEDICATION NAME] available due to insurance issues. She stated on 2/19/19 she informed Staff 29 (LPN) that Resident 3 did not have [MEDICATION NAME]. She further stated Staff 29 then informed her the medication was being put on hold. She stated this was the second time the resident ran out of the medication recently. She further stated when the resident was not receiving [MEDICATION NAME] she/he was more sleepy, depressed and had uncontrolled pain. On 2/21/19 at 3:48 PM Staff 2 (DNS) stated Resident 3 had taken [MEDICATION NAME] for pain but it was discontinued on 2/19/19 due to insurance issues. She further stated no alternative medication was put in place when the [MEDICATION NAME] was discontinued. Staff 2 stated it was the physician's responsibility to address the residents pain needs following the discontinuation of [MEDICATION NAME]. The 2/2019 MAR indicated [REDACTED]. On 2/22/19 at 1:39 PM Resident 3 stated she/he started taking the [MEDICATION NAME] again. The resident stated the short time she/he was off of the [MEDICATION NAME] she/he experienced the following feelings: extra burning and tingling during the night, an electrical shock like feeling in her/his hands, a feeling of being shocked or poked with a hot iron and she/he was uncomfortable. The resident further stated these symptoms were common when she/he stopped taking [MEDICATION NAME]. On 2/25/19 at 9:36 AM Staff 29 stated Resident 3's [MEDICATION NAME] was no longer being covered by insurance and was recently discontinued. She acknowledged the [MEDICATION NAME] was effective for managing Resident 3's pain. 3. Resident 17 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 12/20/18 Quarterly MDS indicated Resident 17 was cognitively intact. The 2/20/19 care plan for pain indicated the resident had complaints of chronic pain in her/his lower back. Goals included the resident would verbalize a reduction of pain. Signed physician orders [REDACTED]. -[MEDICATION NAME] for pain every 12 hours at 9:00 AM and 9:00 PM -[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) for low back back every eight hours at 5:00 AM, 1:00 PM and 9:00 PM. Review of the 1/1/2019 through 2/21/19 MARs indicated Resident 17 received late administrations of [MEDICATION NAME] 12 times and [MEDICATION NAME] 14 times. On 2/25/19 at 9:35 AM Resident 17 stated she/he had chronic low back pain and received multiple late doses of pain medications over time which had caused her/his pain level to increase. On 2/25/19 at 10:03 AM and on 2/26/19 at 10:55 AM Staff 2 (DNS) acknowledged the multiple late administrations of pain medication for Resident 17. Staff 2 further acknowledged the program to manage Resident 17's pain was reliant upon the resident receiving her/his medications on time. 4. Resident 91 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/15/19 Admission Nursing Database indicated Resident 91 was alert and oriented and able to make her/his needs known. The 2/20/19 In Room Care Plan indicated the resident had chronic pain. On 2/21/19 at 3:53 PM Resident 91 stated it was important to receive her/his pain medications on time, as it was more difficult to control her/his pain if these medications were administered late. Resident 91 further indicated she/he received late doses of her medication which caused her/him near unbearable pain. The 2/2019 MAR indicated [REDACTED]. Review of the 2/2019 MAR indicated [REDACTED]. The AM dose was administered by Staff 2 (DNS). On 2/26/19 at 10:48 AM Staff 2 confirmed the late administration of Resident 91's HS dose of [MEDICATION NAME] on 2/22/19 and indicated the resident was still in pain in the early morning hours of 2/23/19 when she administered the AM dose of scheduled [MEDICATION NAME] to the resident earlier than the regular AM medication administration hours.

Based on observation, interview and record review it was determined the facility failed implement pressure ulcer treatment for 1 of 1 sampled resident (#30) reviewed for pressure ulcers. This resulted in delayed healing of Resident 30's pressure ulcer. Findings include: Resident 30 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. The National Pressure Ulcer Advisory Panel defined a Stage 4 Pressure Injury as, Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The 1/28/19 Admission MDS pressure ulcer CAA indicated Resident 30 admitted with an existing Stage 4 pressure ulcer to the right hip. The pressure ulcer was debrided at the hospital and the resident admitted to the facility with a wound vac (negative pressure vacuum wound therapy to promote healing in acute or chronic wounds) in place. The 2/5/19 revised Care Plan indicated Resident 30 had a chronic Stage 4 pressure ulcer to the right hip. Interventions included to provide treatment as ordered and a wound nurse followed the pressure ulcer status weekly and indicated new treatments. The 1/2019 and 2/2019 TARs indicated the following: -Wound vac dressing was to be changed three times a week (Monday, Wednesday, Friday) with a start date of 1/22/19 and end date of 2/8/19. -Wound vac dressing was to be changed two times a week (Wednesday and Saturday) with a start date of 2/8/19. The (MONTH) and (MONTH) TARs did not include instructions of how to pack Resident 30's pressure ulcer. The weekly Skin Grid indicated Resident 30's pressure ulcer was identified on 1/21/19, present on admission and a wound vac was in place. The Skin Grid indicated the following measurements: -1/23/19: 3.7 x 2.0 x 6.8 cm. -1/30/19: 5 x 4 x 2.6 cm with tunneling of 5.4 cm and undermining of 1.6 cm. -2/6/19- 5 x 3 x 5 cm with tunneling at 2 and undermining of 7.5 cm. -2/13/19- 4.5 x 5 x 5 with tunneling at 2 and undermining of 5 cm. Review of wound documentation from the wound clinic dated 1/23/19 through 2/20/19 indicated the following: -1/23/19: Resident had a wound vac in place covering a debridement site. Ligaments and tendons were seen at the deepest part of the wound. -1/30/19: The wound vac was removed and noted the wound was not packed with foam. There was only a piece of foam covering the opening of the wound. Extensive education was given to staff regarding proper placement of the materials and the importance of wound healing. -2/6/19: Wound vac was restarted. Tendon was visible at bottom of wound bed with undermining continued to be present. Wound measured at 5 x 3.4 x 5 cm with an area of 17sq cm. Undermining noted at 10:00 ends at 2:00 with a maximum distance of 7.5 cm. - A 2/6/19: A treatment order indicated it was vitally important the entire wound cavity was packed with the black foam, not just placed on top of the wound and to be changed twice weekly. -2/20/19: No change to resident's wound. Continued concern about the wound being completely and thoroughly packed with wound vac application. The wound measured at 4.5 x 4 x 4.5 with tunneling noted at two o'clock with a maximum distance of 5 cm. On 2/20/19 at 2:05 PM an observation was made of Resident 30's right hip pressure ulcer with Witness 3 (Wound Nurse), Staff 3 (RN) and Staff 2 (DNS) present. The wound was round in shape, deep and had underlying tissue visible with slough (dead tissue). Witness 3 stated the wound needed to be packed to the bottom of the wound tunnel. Staff 22 (RN) stated nursing staff needed re-education on packing Resident 30's wound. Witness 3 stated there was a continued issue with the tunneling of the wound due to facility staff not packing the wound as ordered. On 2/20/19 at 2:30 PM Witness 3 stated Resident 30's wound did not change from the previous week. Witness 3 stated facility staff were not demonstrating the best techniques related to the packing of the pressure ulcer and confirmed the lack of appropriate treatment impacted the healing process of the wound. Witness 3 stated she previously demonstrated how the wound was to be packed to nursing staff and this was the second time she discussed the issue with facility staff. Witness 3 stated both Staff 22 and Staff 30 (RNCM) were present during 1/30/19 discussion when the black foam was placed only at the opening of the wound with no packing at all. On 2/21/19 at 9:00 AM and 9:24 AM Staff 22 stated she was trained on how to pack wounds by Witness 3 and confirmed she completed the dressing change on 2/16/19 and she did not pack the wound as ordered. Staff 22 stated there was no order on the TAR related to wound packing. Staff 22 stated the packing materials came with the wound vac and therefore needed to be used. She further stated she used nursing intuition to complete the treatments. On 2/22/19 at 10:56 AM Staff 2 (DNS) stated she was not aware Resident 30's wound treatment was not completed as ordered. She confirmed there was no oversight to ensure nursing staff were correctly packing Resident 30's pressure wound. Staff 2 also confirmed instructions for packing the pressure ulcer were not on the TAR.

1. Based on interview and record review it was determined Staff 2 (DNS), Staff 22 (RN) and Staff 30 (RNCM) failed to ensure pressure ulcer treatment and services met professional standards of practice for 1 of 1 sampled resident (# 30) reviewed for pressure ulcers. This resulted in delayed healing of Resident 30's pressure ulcer. Findings include: The Oregon Nurse Practice Act includes: Oregon Administrative Rule [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined Conduct that adversely affects the health, safety, and welfare of the public, 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; * Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs. Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling. Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Registered Nurses: * Be knowledgeable of the professional nursing practice and performance standards and adhere to those standards; * Be accountable for individual RN actions, maintain competency in one's RN practice role and ensure unsafe nursing practices are addressed immediately. * Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established. Resident 30 was admitted to the facility in 2019 with a Stage 4 pressure ulcer on the right hip and had a wound vac in place (negative pressure vacuum wound therapy to promote healing in acute or chronic wounds). Review of Resident 30's medical record revealed a lack of appropriate treatment for [REDACTED]. - The 1/2019 and 2/2019 TARs indicated the resident's wound vac was to be changed twice a week and did not indicate instructions on how the wound was to be packed. - Wound notes from 1/23/19 to 2/20/19 from Witness 3 (Wound RN) indicated the wound was not packed correctly and education was given on 1/30/19. On 2/20/19 the wound was noted with no change and there was continued concern with how the wound was packed. - Treatment related to wound packing was completed by Staff 22 (RN) and another charge nurse. On 2/20/19 at 2:30 PM Witness 3 confirmed Resident 30's wound had not changed and the lack of appropriate packing techniques delayed the healing of the wound. Witness 3 stated Staff 22 (RN) and Staff 30 (RNCM) were present during the 1/30/19 discussion when the pressure ulcer was not packed correctly. On 2/21/19 at 9:00 AM and 9:24 AM Staff 22 confirmed she received training by Witness 3 on how to pack Resident 30's wound. Staff 22 stated she did the packing prior to the 2/20/19 treatment and did not do it correctly. She acknowledged the TAR did not include instructions on how the wound was to be packed. On 2/22/19 at 10:56 AM Staff 2 (DNS) confirmed there was no oversight to ensure nursing staff correctly packed Resident 30's wound and there were no instructions on how the wound was to be packed on the TAR. Refer to F686. 2. Based on interview and record review it was determined Staff 2 (DNS), Staff 33 (LPN) and other unidentified nursing staff failed to ensure professional standards were followed for narcotic administration, storage and disposition for 2 of 3 facility narcotic books reviewed for narcotic medication management. This placed residents at risk for inaccurate records and drug diversion. Findings include: Oregon Administrative Rule [PHONE NUMBER] - Conduct Derogatory to the Standards of Nursing is defined as: 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: (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (b) Failure to document nursing interventions and nursing practice implementation in a timely, accurate, thorough, and clear manner. This includes failing to document a late entry within a reasonable time period; (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; (B) Documenting the provision of services that were not provided; (C) Failing to document information pertinent to a client's care; (D) Documenting someone else's charting omissions or signing someone else's name; (E) Falsifying data; (F) Altering or changing words or characters within an existing document to mislead the reader; (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. A review of the facility's narcotic drug books indicated numerous irregularities including the following: - Unknown staff member signed narcotics out of two books at the same exact date and time. - Staff 33 (LPN) documented disposal of medication without a second signature and the documentation did not indicate the method or date of the disposition. - Staff 33 administered medication without legible documentation of the times of the administration and with irregularities concerning the volume of remaining narcotic medication and/or the disposition of the remaining narcotic medication. - Staff 33 administered narcotic medication in excess of the order. - Staff 33 administered narcotic medication to residents who did not normally require narcotic medication. - Unknown staff members changed the times, dosing and remaining balance of prior narcotic medication administration documentation. - Unknown staff members signed out narcotics from the book without documentation of a corresponding medication administration. Staff 33 was unavailable for interviews with survey staff due to being terminated from employment on 2/19/19. On 2/22/19 at 3:15 PM and 2/25/19 at 8:36 AM Staff 2 (DNS) acknowledged the irregularities in the narcotic drug books. Staff 2 stated the facility had no process in place to audit the books and did not have a system in place to identify nursing staff signatures. Refer to F755.

Based on observations, interviews and record review it was determined the facility failed to provide adequate number of CNAs to meet the needs of the residents. Resident 2's peri area was red and excoriated from exposure to urine and feces due to insufficient CNA staffing. Findings include: 1. On 4/3/18 the facility completed a Facility Incident Self-Report Form and sent the information to the local protective services agency. The report indicated Resident 2 was left up in her/his wheelchair, had a bowel movement and her/his peri area was red and excoriated. The resident's skin remained intact with no open areas. The facility investigation determined five CNAs were scheduled to work on the evening shift. One CNA did not show up for work and one CNA left the floor at 8:30 PM instead of 10:00 PM. According to the census the state minimum CNA staff required was 4 CNAs and there were three CNAs for the last hour and a half of the shift. The facility had two admissions during the evening shift and the CNAs were required to assist with the admissions. The investigation determined Resident 2 was normally up in her/his wheelchair for a few hours during the day and after eating her/his dinner was to be assisted into bed. The facility determined the resident had an incontinent brief change after lunch and was seated in her/his wheelchair from 12:30 PM until 8:30 PM after the resident called Witness 2 (Complainant). The facility determined the root cause of the incident was not enough CNAs and the evening charge nurse did not report the short staffing when discovered at the start of the shift. Witness 6 (Agency LPN) stated she worked from 6:00 PM on 3/26/18 through 6:00 AM on 3/27/18. Witness 6 stated she knew the facility was short one CNA on the evening shift. Witness 6 stated Witness 7 (Former Administrator) and Staff 6 (Staffing Coordinator) were aware of the shortage and a replacement CNA was not provided. Witness 6 stated the CNAs were required to assist with two admissions and one readmission during the shift. Witness 6 stated all of the admissions arrived when dinner was served. Witness 6 stated at 7:30 PM she was called to Resident 2's room. Witness 6 stated Resident 2's family member was in the facility and was very upset. The family member stated Resident 2 called and complained she/he was in pain from being in the wheelchair all day. Witness 6 stated the CNAs assisted the resident into bed and she/he was assessed to be fiery red and excoriated. Witness 6 stated it was consistent with condition of sitting in urine and feces. It appeared to be a burn from the acid in urine and feces. 2. Interviews were conducted on 4/30/18 from 9:28 AM through 11:20 AM with eight of fifteen residents identified by the facility as alert and oriented. Six residents stated they had to wait for the call lights to be answered on the day and evening shifts. The residents stated the call light response time fluctuated between 5 minutes to up to an hour for the call light to be answered. Three residents stated there were occasions when they had the call light on when on the toilet or bed pan and waited between 20 and 30 minutes for a CNA to assist them. They stated it was uncomfortable to wait in the position. The residents stated they felt the CNAs tried their best though there not enough staff to care for all of the residents. On 4/30/18 at 3:51 PM Witness 7 (former Administrator) stated the facility conducted call light audits and the facility had a PALs system where Administrative staff members were assigned residents to interview and work to resolve issues the residents discussed. 3. Resident Council meeting minutes were reviewed for (MONTH) through (MONTH) (YEAR) revealed there were concerns regarding call lights being answered in a timely manner during (MONTH) and (MONTH) (YEAR) meetings. During the (MONTH) (YEAR) Resident Council meeting minutes two of four residents complained call lights were not being answered in a timely manner during the evening shift. Staff 8 (RN Corporate Consultant) documented a response to the Resident Council to indicate the facility monitored the call lights through their PALs program. Staff 8 indicated because the complaints about call lights were made by two specific residents there needed to be a grievance filled out by the specific residents so it was fully documented and resolved instead of same generic concern every month. 4. Periodic observations of call lights were conducted on 4/30/18, 5/2/18, 5/8/18 and 5/15/18 from 8:00 AM through 6:00 PM. Call lights were observed to be answered between 5 and 20 minutes. The facility had a visual and audible call light system and call lights were registered at the nurses station. 5. Interviews conducted from 4/30/18 11:15 AM through 5/16/18 10:07 AM with Staff 3, 4, 7, 19, 20, 21, 22 and 23 (CNAs) Staff 11, 12, 13 and 14 (Licensed Nurses) stated there were many residents who required the assistance of 2 CNAs for care. The staff stated there were two residents who required an hour of CNA care for dressing and eating. The staff stated there were many residents who needed a lot of reassurances so used their call lights many times during the shift. The staff stated there were many occasions when the facility knew when there were not enough CNAs and were unable to replace the CNAs. The Licensed Nurses stated they tried to assist with answering call lights though they needed to provide nursing care as well. 6. On 5/17/18 at 3:30 PM Staff 18 (Interim DNS) stated Residents 6 and 7 received their medications late due to a shortage of CNAs so the CMA was needed to work as a CNA. The nurses were then responsible for the medication pass along with their other nursing duties. 7. On 5/2/18 the facility provided documentation there were 18 residents of a census of 35 who required the assistance of 2 CNAs for transfers and/or care in bed. 8. Review of Direct Care Staffing Report including census, staff schedules and payroll records reviewed from 3/22/18 through 4/22/18 revealed the facility did not maintain state minimum CNA staff ratios on thirteen occasions. The payroll records revealed there were 184 occasions the Licensed Nurses and CNAs were unable to take rest or meal breaks.

Based on interviews and record review it was determined the facility failed to provide incontinent care for 1 of 3 sampled residents (#2) reviewed for incontinent care. The resident was not provided incontinent care and sustained red and excoriated skin and required additional pain medication. Findings include: Resident 2 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 1/6/18 In Room Care Plan indicated the resident was incontinent and required extensive assistance of one person for toileting. The resident was also provided with pull up incontinent briefs. The 1/14/18 comprehensive care plan indicated the approaches for the resident's incontinence were included on the In Room Care Plan. The 2/20/18 progress notes written at 7:31 PM documented the resident's State case manager asked the facility to offer the resident toileting every two hours instead of an incontinent brief check. There was no documentation the request was included on the In Room Care Plan. The (MONTH) (YEAR) TAR documented a weekly skin check was conducted on 3/26/18 with no new skin impairment. The bowel and bladder record indicated on 3/26/18 at 12:12 PM Staff 7 (CNA) documented Resident 2 had a medium bowel movement with a large amount of urine. There was no documentation the resident was provided incontinent care until 9:39 PM. The 3/26/18 Skin Grid completed by Witness 6 (Agency LPN) assessed the resident with red excoriation to her/his peri area, inner thighs and rectal areas. The measurements were 19 cm in length and 9 cm wide. The inside of the resident's inner buttocks were assessed with [REDACTED]. The skin issue was identified as a new skin issue and the resident was assessed to be in pain. The 4/2/18 Skin Grid assessed the excoriation resolved with pink and normal skin. On 4/3/18 the facility provided a Facility Incident Self-Report Form to the local protective services agency. The report indicated Resident 2 was left up in her/his wheelchair, had a bowel movement and her/his peri area was red and excoriated. The resident's skin remained intact with no open areas. The facility's documentation indicated Witness 2 (Complainant) completed a grievance report to indicate on 3/26/18 Resident 2 was left in her/his wheelchair in messy pants so long she/he was swollen red. The investigation determined Resident 2 was normally up in her/his wheelchair for a few hours during the day and after eating her/his dinner was assisted into bed. The facility determined the resident had an incontinent brief change after lunch and was seated in her/his wheelchair from 12:30 PM until 8:30 PM after the resident called Witness 2. The facility determined the root cause of the incident was not enough CNAs and the evening charge nurse did not report the short staffing when discovered at the start of the shift. Interviews conducted 4/30/18 at 4:15 PM through 5/7/18 at 9:05 AM revealed the following: Witness 2 (Complainant) stated on 3/26/18 Resident 2 called at 7:50 PM and asked her to come to the facility. Witness 2 stated when she arrived at the facility she found Resident 2 sitting in her/his wheelchair with an incontinent brief soiled with urine and feces. Witness 2 stated the resident's peri area was blistered from her/his incontinent brief not being changed. Staff 7 (CNA) stated she usually worked on the evening shift though would work whenever there was a need for a CNA. Staff 7 stated the day shift ended at 2:00 PM so the evening shift would need to provide incontinence care around 4:00 PM. Staff 7 stated the CNAs usually try to provide toileting or provide an incontinent brief change every two hours. Staff 7 stated she was familiar with Resident 2 and the resident would be checked or changed at 5:30 PM. Staff 2 (CNA) stated he was not usually not the CNA for Resident 2 though on 3/26/18 he assisted Staff 3 (CNA) at 3:00 PM to check on the resident. Staff 2 stated the resident refused to be changed at the time. Staff 2 stated Resident 2's family member arrived at the facility at 7:00 PM and asked Staff 2 if he would assist Resident 2 into bed. Staff 2 stated the resident was unusually upset. Staff 2 stated he assisted to lay down the resident and changed her/his brief. Staff 2 stated there was feces all over and her/his peri area was very red and raw. Staff 2 stated he (Staff 2) started to cry when he assisted in cleaning the resident because the resident complained because it hurt so much. Staff 2 stated the resident's skin condition was very bad and her/his peri area was bright red as if the resident sat in feces for awhile. Staff 2 stated he cleansed Resident 2's peri area and went to get Witness 6 (Agency LPN) to assess her/him. Staff 2 stated the resident's family member was very upset. Staff 2 stated it broke my heart and this should not have happened. Staff 2 stated they were one CNA short on the evening shift on 3/26/18. Staff 3 (CNA) stated she accompanied Staff 2 and checked the resident at 3:00 PM on 3/26/18. Staff 3 stated the resident refused to be changed at the time. Staff 3 stated she came back from break and Resident 2's family member was screaming because the resident was still up in the wheel chair. Staff 3 stated she also accompanied Staff 2 to transfer Resident 2 into bed. Staff 3 stated the resident was wet and had feces all over her/his peri area. Staff 3 stated the resident's peri area was very red. Staff 3 stated Staff 4 (CNA) was the resident's assigned CNA. Staff 3 stated they were one CNA short on the evening shift of 3/26/18. Staff 4 (CNA) stated she was Resident 2's CNA on the evening shift of 3/26/18. Staff 4 stated the facility was one CNA short on the evening shift of 3/26/18. She stated she thought she did the best she could to provide incontinent care for the resident though there was not enough time for everyone. Witness 6 (Agency LPN) stated she worked from 6:00 PM on 3/26/18 through 6:00 AM on 3/27/18. Witness 6 stated she knew the facility was short one CNA on the evening shift. Witness 6 stated Witness 7 (Former Administrator) and Staff 6 (Staffing Coordinator) were aware of the shortage and a replacement CNA was not provided. Witness 6 stated the CNAs were required to assist with two admissions and one readmission during the shift. Witness 6 stated all of the admissions arrived when dinner was served. Witness 6 stated at 7:30 PM she was called to Resident 2's room. Witness 6 stated Resident 2's family member was in the facility and was very upset. The family member stated Resident 2 called and complained she/he was in pain from being in the wheelchair all day. Witness 6 stated the CNAs assisted the resident into bed and she/he was assessed to be fiery red and excoriated. Witness 6 stated it was consistent with condition of sitting in urine and feces. It appeared to be a burn from the acid in urine and feces. Witness 6 stated she called Witness 7 (Former Administrator) because Resident 2's family member was very upset. Witness 6 stated Witness 7 stated Staff 8 (RN Corporate Consultant and Interim DNS in (MONTH) (YEAR)) would deal with the concerns on 3/27/18. Witness 6 stated she was very upset Witness 7 did not take responsibility for the issues and talk with Witness 2. Staff 8 (RN Corporate Consultant) verified she completed the Facility Self Report and determined the root cause of the resident's condition was due to the fact the facility had one CNA short for the evening shift.

1. Based on observation, interview and record review it was determined the facility failed to ensure staff followed standard precautions or have a thorough understanding of infection control practices for 6 of 6 staff (#s 10, 11, 12, 13, 14 and 16) observed or interviewed for infection control. This failure, determined to be an immediate jeopardy situation, resulted from staff not using PPE (personal protective equipment), not performing hand hygiene and subsequently making direct physical contact with another resident potentially contaminating her/him with an antibiotic resistant microorganism. Findings include: Resident 32 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. On 7/28/17 at 10:37 am Staff 10 (CNA) was observed to exit Resident 32's room with a meal tray in hand. A contact precautions cart was noted outside the room with signs posted on the door to see the nurse before entering. Staff 10 was not wearing any PPE and was not observed to perform hand hygiene. Staff 10 took the meal tray to the dining room and placed it in a meal tray cart. Staff 10 then walked over to Resident 25 and put both his hands on the resident's shoulders and gave them a gentle rub while talking to the resident. Staff 10 acknowledged he did not use PPE, or perform hand hygiene. On 7/28/17 at 10:39 am Staff 4 (Interim DNS) was informed of this surveyor's observations and interview with Staff 10 and was asked to identify the resident who was contacted in the dining room but was now self-propelling her/himself down the hall. Staff 4 identified the resident as Resident 25. She stated she would get the resident cleaned up. Staff 4 stated Resident 32 had an uncontained MRSA infection. On 7/28/17 at 10:50 am Staff 15 (Kitchen Manager) stated he was not aware there was a tray in the tray cart which came from a room with contact precautions. He stated usually the tray from a room with precautions would be bagged up and placed in the bottom of the cart. On 7/28/17 at 10:50 am Staff 16 (LPN) stated Resident 32 had a contained MRSA infection. On 7/28/17 at 10:56 am Staff 4 acknowledged the tray should have been bagged up before it went to the kitchen. On 7/28/17 at 11:45 am With Staff 4 and Staff 16 Resident 32 was observed in bed on her/his back. The resident's gown was observed to have an approximately 6 cm dark red stain which appeared to be blood on the lower left. The resident stated it was blood from her/his wound care this morning. The resident then rearranged her/his gown pulling it down while touching it near the blood. Staff 4 told the resident she would have someone come clean the resident up. Five CNA staff were interviewed on 7/28/17 regarding infection control practices for Resident 32. Four staff interviewed (#s 10, 11, 12 and 13) were not knowledgeable of the source of the resident's infection. Four staff interviewed (#s 10, 11, 12 and 13) reported the resident's wound drained on the bedding and/or gown. Five staff interviewed (#s 10, 11, 12, 13 and 14) were inconsistent in how they applied gloves and gowns when providing care including answering call lights and provision and removal of the resident's meal tray. A hospital History & Physical dated 5/28/17 indicated the resident was started on antibiotics for infections including pseudomonas and MRSA. An acceptable Plan of Correction was submitted and implemented on 7/28/17. 2. Based on observation, interview and record review it was determined the facility failed to implement and sustain a plan of correction related to the Immediate Jeopardy regarding infection control practices and the use of Personal Protective Equipment (PPE) for 1 of 1 staff (#17) randomly observed. This resulted in residents at continued risk for infection by an antibiotic resistant organism. Findings include: On 8/4/17 at 10:36 am Staff 17 (Agency CNA) was observed to exit room [ROOM NUMBER] while still wearing gloves and enter room [ROOM NUMBER], an isolation room related to uncontained MRSA (methicillin-resistant Staphylococcus aureus), wearing the same gloves. Posted instructions outside of Resident 226's room indicated hand hygiene and the application of gloves and a gown before entering the room. The PPE was available just outside of room [ROOM NUMBER]. Staff 17 was not observed to perform hand hygiene, apply new gloves or a gown before entering room [ROOM NUMBER]. On 8/4/17 at 10:37 am Staff 17 (Agency CNA) acknowledged she did not perform hand hygiene or apply new gloves or a gown prior to entering room [ROOM NUMBER]. On 8/4/17 at 11:27 am Staff 17 stated she was not in-serviced about room [ROOM NUMBER]'s infection control and the use of PPE. On 8/4/17 at 11:30 am Staff 18 (CNA) stated she was not in-serviced about room [ROOM NUMBER]'s infection control and use of PPE. On 8/4/17 at 10:44 am Staff 4 (Interim DNS) stated Staff 17 should have removed her gloves and performed hand hygiene before she exited room [ROOM NUMBER] and should have performed hand hygiene, donned gloves and a gown before she entered room [ROOM NUMBER]. Staff 4 acknowledged Staff 17 was not in-serviced regarding infection control and the use of PPE as per the plan of correction provided by the facility for the abatement of Immediate Jeopardy on 7/28/17. 3. Based on observation, interview and record review it was determined the facility failed to implement standard infection control practices related to a catheter bag and glucometer disinfection for 2 of 2 sampled residents (#s 11 and 36) reviewed and observed for infection control. This placed residents at risk for infection. Findings include: a. On 8/1/17 at 9:34 am Resident 36's catheter bag was observed to hang from the bed. The bottom half of the catheter bag sat on top of a fall mat next to the resident's bed. The fall mat was covered with dusty footprints. On 8/1/17 at 9:46 am and 9:59 am Staff 44 (CNA) and Staff 14 (CNA) stated the catheter bag should not be touching the fall mat. On 8/3/17 at 3:33 pm the observation of the catheter bag on the fall mat was reviewed with Staff 4 (Interim DNS). Staff 4 acknowledged it was not acceptable practice, the catheter bag was to be elevated and not in contact with the fall mat. b. On 8/1/17 at 12:11 pm Staff 20 (RN) obtained Resident 11's CBG, returned to the treatment cart and cleaned the glucometer with an alcohol pad. She acknowledged she did not clean the glucometer with the proper disinfecting wipes. The facility policy and procedure indicated glucometers were to be wiped down with EPA (Environmental Protection Agency) approved disinfectant wipe after each use and before leaving the resident room where the item was used or immediately, at the cart parked directly outside the point of care room. On 8/1/17 at 1:03 pm Staff 4 (Interim DNS) stated her expectation was staff use the approved wipes to clean glucometers.

Based on observation, interview and record review it was determined the facility failed to ensure staff adhered to professional standards of practice for 4 of 4 facility staff (#s 6, 10, 17 and 38) related to [MEDICAL CONDITION] care, random observation and medication administration. This failure, determined to be an immediate jeopardy situation, resulted in Staff 6 instructing aides to restrain a resident while attempting to insert or reinsert a [MEDICAL CONDITION] cannula without clinical justification and refusing to honor a resident's right to refuse treatment, Staff 10 and Staff 17 failing to wear PPE (personal protective equipment) potentially exposing other residents to an antibiotic resistant microorganism and Staff 10 commiting physical abuse. Additionally this placed residents at risk for medication errors and adverse side effects to medications. Findings include: OAR 851¿045¿0040 indicated: Scope of Practice Standards for All Licensed Nurses Advocates for the client's right to receive appropriate care, including person ¿centered care and end ¿of ¿life care, considerate of the client's needs, choices and dignity; Communicates client's choices, concerns and special needs to other members of the healthcare team; Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner; OAR 851¿045¿0070 indicated: Conduct Derogatory to the Standards of Nursing Defined Developing, modifying, or implementing standards of nursing practice/care which jeopardize patient safety. Assigning persons to perform functions for which they are not prepared or which are beyond their scope of practice/scope of duties. Conduct related to other federal or state statute/rule violations: Abusing a client. The definition of abuse includes, but is not limited to, intentionally causing physical or emotional harm or discomfort, striking a client, intimidating, threatening or harassing a client, wrongfully taking or appropriating money or property, or knowingly subjecting a client to distress by conveying a threat to wrongfully take or appropriate money or property in a manner that causes the client to believe the threat will be carried out. Neglecting a client. The definition of neglect includes, but is not limited to, carelessly allowing a client to be in physical discomfort or be injured. Engaging in other unacceptable behavior towards or in the presence of a client such as using derogatory names or gestures or profane language. OAR 851¿063¿0030 indicated: Authorized Duties and Standards for Certified Nursing Assistant 1 (CNA 1) Under the supervision and at the direction of a licensed nurse, the CNA may provide care and assist clients with the following tasks: - Implementing precautions associated with communicable and infectious diseases; - Utilizing personal protective equipment. Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: - Apply standard precautions according to the Centers for Disease Control and Prevention guidelines; - Use hand hygiene between episodes of care; OAR 851¿063¿0090 indicated: Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established; 1. Resident 39 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. A Progress Note dated 4/23/17 by Staff 6 (LPN) indicated Gums appear to have no sign of bleeding, resident minimally cooperative with oral care this shift. Resident started grinding teeth and shaking (her/his) head when I approached to do oral care x2 attempts. A Progress Note dated 7/1/17 at 9:30 pm indicated the resident's [MEDICAL CONDITION] popped out during cares. Staff 6 (LPN) was attempting to replace it and the resident was trying to hit her. An aide restrained the resident's hand and Staff 6 told the resident her/his combative behavior was inappropriate. The resident flipped the nurse off and allowed her complete the treatment. At 3:00 am aides went in to change residents(sp) brief and found (her/him) crying. A Progress Note by Staff 6 dated 7/8/17 at 12:30 pm indicated At approximately 0800 this shift this nurse was called down from other hall to assist LN with getting [MEDICAL CONDITION]. Patient had pulled (her/his) [MEDICAL CONDITION] completely. This nurse attempted x2 to replace [MEDICAL CONDITION] and met resistance, failed x2. Resident attempted to hit me multiple times while I was attempting to replace the airway. This nurse had CNA contact 911 to have patient sent to hospital while myself and other nurse ensured airway was still open. SP 02 stayed at 93% with [MEDICAL CONDITION] place, blow by 02 was set at 8L per minute as patient refused to keep 02 mask on (her/his) face. Resident out of facility by EMTs at 0815. This nurse called the family to give them update and let them know (she/he) had been sent to the ER for immediate treatment. An edited Progress Note dated 7/8/17 at 12:37 pm by Staff 7 (Agency RN) indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I asked CNa's to hold (her/his) arm as I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. An Incident Investigation report dated 7/8/17 indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. The report recommended the resident be transported to the hospital to replace [MEDICAL CONDITION] stabilize behaviors. The Progress Notes and the incident report failed to provide rationale for the medical necessity to restrain the resident on 7/1/17 and 7/8/17. On 7/14/17 at 10:08 am Staff 6 acknowledged the CNAs were told to hold the resident down on 7/1/17 and 7/8/17 while the nurses attempted to reinsert the resident's [MEDICAL CONDITION]. She acknowledged the resident was able to breathe on her/his own without the [MEDICAL CONDITION] in place. On 7/27/17 at 10:22 am Staff 8 (CNA) acknowledged she was told to restrain the resident on 7/8/17 while Staff 6 and Staff 7 unsuccessfully attempted to forcefully reinsert the resident's [MEDICAL CONDITION] for several minutes. Staff 8 stated the resident clearly did not want it, was struggling and turning red. She stated it was gruesome to watch. Staff 8 stated the resident's oxygen saturation was steady 95% so there was plenty of time to call 911 and have them take care of the resident. Staff 8 stated the resident was able to communicate with hand gestures and a white board but no one attempted to communicate to the resident what they were doing or why. Staff 8 stated on another occasion Staff 6 instructed her to restrain the resident while Staff 6 placed a piece of equipment labeled Respironics on the resident. Staff 6 stated the resident did not have the right to refuse it and to hold her/him down. She was unable to recall the date of that incident. Refer to F-221 example 1 2. Resident 32 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. On 7/28/17 at 10:37 am Staff 10 (CNA) was observed to exit Resident 32's room with a meal tray in hand. A contact precautions cart was noted outside the room with signs posted on the door to see the nurse before entering. Staff 10 was not wearing any PPE and was not observed to perform hand hygiene. Staff 10 took the meal tray to the dining room and placed it in a meal tray cart. Staff 10 then walked over to Resident 25 and put both his hands on the resident's shoulders and gave them a gentle rub while talking to the resident. Staff 10 acknowledged he did not use PPE, or perform hand hygiene. On 7/28/17 at 10:39 am Staff 4 (Interim DNS) was informed of this surveyor's observations and interview with Staff 10 and was asked to identify the resident who was contacted in the dining room but was now self-propelling her/himself down the hall. Staff 4 identified the resident as Resident 25. She stated she would get the resident cleaned up. Staff 4 stated Resident 32 had an [MEDICAL CONDITION] infection. On 7/28/17 at 10:50 am Staff 15 (Kitchen Manager) stated he was not aware there was a tray in the tray cart which came from a room with contact precautions. He stated usually the tray from a room with precautions would be bagged up and placed in the bottom of the cart. On 7/28/17 at 10:50 am Staff 16 (LPN) stated Resident 32 had a [MEDICAL CONDITION] infection. On 7/28/17 at 10:56 am Staff 4 acknowledged the tray should have been bagged up before it went to the kitchen. On 7/28/17 at 11:45 am in the presence of Staff 4 and Staff 16 Resident 32 was observed in bed on her/his back. The resident's gown was observed to have an approximately 6 cm dark red stain which appeared to be blood on the lower left. The resident stated it was blood from her/his wound care that morning. The resident then rearranged her/his gown pulling it down while touching it near the blood. Staff 4 told the resident she would have someone come clean the resident up. Five CNA staff were interviewed on 7/28/17 regarding infection control practices for Resident 32. Four staff interviewed (#s 10, 11, 12 and 13) were not knowledgeable of the source of the resident's infection. Four staff interviewed (#s 10, 11, 12 and 13) reported the resident's wound drained on the bedding and/or gown. Five staff interviewed (#s 10, 11, 12, 13 and 14) were inconsistent in how they applied gloves and gowns when providing care including answering call lights and provision and removal of the resident's meal tray. A hospital History & Physical dated 5/28/17 indicated the resident was started on antibiotics for infections including pseudomonas [MEDICAL CONDITION]. An acceptable Plan of Correction was submitted and implemented on 7/28/17. Refer to F-441 example 1 3. On 8/4/17 at 10:36 am Staff 17 (Agency CNA) was observed to exit room [ROOM NUMBER] while still wearing gloves and enter room [ROOM NUMBER], an isolation room related to [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) wearing the same gloves. Posted instructions outside of Resident 226's room indicated hand hygiene and the application of gloves and a gown before entering the room. The PPE was available just outside of room [ROOM NUMBER]. Staff 17 was not observed to perform hand hygiene, apply new gloves or a gown before entering room [ROOM NUMBER]. On 8/4/17 at 10:37 am Staff 17 (Agency CNA) acknowledged she did not perform hand hygiene or apply new gloves or a gown prior to entering room [ROOM NUMBER]. On 8/4/17 at 11:27 am Staff 17 stated she was not in-serviced about room [ROOM NUMBER]'s infection control and the use of PPE. On 8/4/17 at 11:30 am Staff 18 (CNA) stated she was not in-serviced about room [ROOM NUMBER]'s infection control and use of PPE. On 8/4/17 at 10:44 am Staff 4 (Interim DNS) stated Staff 17 should have removed her gloves and performed hand hygiene before she exited room [ROOM NUMBER] and should have performed hand hygiene, donned gloves and a gown before she entered room [ROOM NUMBER]. Staff 4 acknowledged Staff 17 was not in-serviced regarding infection control and the use of PPE as per the plan of correction provided by the facility for the abatement of Immediate Jeopardy on 7/28/17. Refer to F-441 example 2 4. Resident 31 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 6/19/17 Annual MDS Section C indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 4 (which indicated severe mental impairment). The 4/19/17 In Room Care Plan indicated the following for Resident 31: - Locomotion: extensive assistant of 1 person in wheelchair. - Cognition: some confusion and forgetfulness; communication. - Allow resident time to process and speak - may be slow. The 6/24/17 Behavioral Symptoms Care Plan indicated Resident 31 had a [DIAGNOSES REDACTED]. The resident required a simple explanation of needs and time to thought process and respond. Approach the resident with simple explanations of cares or treatments and medication needs prior to providing. Offer her/him time to thought process question/express any concerns or questions. Validate her/his decisions. Revisit at later time as safety and cares allow. Refer to charge nurse. Refer to RCM (Resident Care Manager) and or SSD as needed for further assessment of behaviors. Observe tone of voice when attempting to encourage her/his participation. Be aware that you are not causing resident to feel rushed into responding. The 6/24/17 Care Plan for Communication indicated Resident 31 had cognitive deficits with impaired comprehension and decision making abilities. Approaches included: - Support and validate resident decision making abilities. - Provide her/him with simple, clear, concise information and explanation of cares and directions. - Allow her/him time to thought process and respond/express self. The 6/24/17 Care Plan for Cognitive Loss/Dementia indicated: - Resident 31 had a [DIAGNOSES REDACTED]. - Required cues and reminders to maintain active involvement with daily cares and decision making. - Encourage resident with her/his participation in daily cares and acts with support and validation of decisions. - Provide her/him opportunity to express self and participate in decisions as needed. - Allow her/him time to thought process and express self. - Repeat and rephrase instructions and/or messages as needed. The 2/18/17 ADL Care Plan indicated Resident 31 had an alteration in ADL function secondary to [DIAGNOSES REDACTED]. Approaches included to see in room care plan for ADL needs and level of assistance. On 8/8/17 at 7:46 am Staff 10 (CNA) was observed to push Resident 31 down the 300 hallway in a wheelchair. The resident yelled no. Staff 10 stopped in the hallway attempted to place Resident 31's foot on the wheelchair foot rest, Resident 31 again yelled no. Staff 10 then stated I will just drag your feet then, God bless America. Staff 10 continued to push Resident 31 down the hall with the bottom of his/her foot dragging on the floor. Staff 10 was pushing the resident very fast down the hall toward the nurses station. Staff 10 told the resident 'here comes a bump' as he went through the double doors by the nurses station, Staff 10 continued down the hallway toward the dining room. When Resident 31 was observed in the hallway next to the elevator both feet were resting on the foot rest. On 8/8/17 at 8:02 am Staff 10 stated Resident 31 didn't want to put her/his foot up on the foot rest and told the resident if she/he didn't put her/his foot up we were going to have to drag it, then the resident had her/his foot down and I told her/him to put it up. She/he put her/his foot up when we went by the double doors by the nurses station since I told her/him there was a bump. On 8/8/17 at 8:17 am Staff 9 (CMA) stated she observed Staff 10 bring Resident 31 out into the hallway from the resident's room. Staff 9 told Staff 10 Resident 31's foot had fallen off the foot rest. Staff 10 attempted to put the residents foot back up on the footrest of the wheelchair, Resident 31 said no and Staff 10 stated then we will just push her/his foot on the ground and off he went down the hall. On 8/8/17 at 8:20 am Staff 10 stated Resident 31 could lift both feet onto the footrests of the wheelchair by herself/himself and the left side (foot) was slower. Refer to F-223 5. Resident 75 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 7/29/17 physician orders [REDACTED]. On 8/10/17 at 8:33 am Resident 75 breakfast tray and drinks were observed to be 100% empty. Staff 38 (RN) checked her/his CBG and it was 85. On 8/10/17 at 8:49 am Staff 38 stated Resident 75 had already ate 100% of her/his breakfast and drank 100% of her/his drinks. On 8/10/17 at 8:53 am Staff 38 was observed to administer 17 units of Humalog 75/25 mix to Resident 75. The 2018 Drug Handbook indicated Humalog mix 75/25 insulin was to be given within 15 minutes before a meal. On 8/10/17 at 1:44 pm Staff 38 acknowledged the Humalog mix 75/25 insulin was not given within 15 minutes before Resident 75's meal.

Based on multiple immediate jeopardy situations and numerous citations including abuse, restraints, infection control, staffing, resident rights, assessments, pressure ulcers, professional standards of practice, accidents, nutrition, special needs and dignity it was determined the facility was not managed in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: 1. A resident was observed being physically abused by a staff member. Refer to F-223 2. Residents were restrained for reasons other than to treat a medical condition or without adequate rationale for the use of restraints. Refer to F-221 3. Staff failed to follow standard infection control precautions related to isolation precautions for a resident with an uncontained antibiotic resistant infection. Refer to F-441 4. Residents were not treated with dignity by being excluded from activities, denied privacy, excluded from eating in the dining room, made to use paper and plastic eating utensils and restricted from having visitors or using the telephone. Refer to F-241 5. The facility failed to ensure adequate staffing to respond to resident needs. Refer to F-353 6. The facility failed to investigate, comprehensively investigate or operationalize policies and procedures related to abuse. Refer to F-225 7. The facility failed to ensure residents were able to exercise their rights and had the right to refuse treatments. Refer to F-151 and F-155 8. The facility failed to ensure residents functional capacity was comprehensively and accurately assessed in a timely manner. Refer to F-272, F-273, F-276 and F-278 9. The facility failed to ensure staff performed their duties according to professional standards of practice. Refer to F-281 10. The facility failed to prevent residents from developing pressure ulcers, prevent pressure ulcers from deteriorating or provide clinical justification for why they were unavoidable. Refer to F-314 11. The facility failed to ensure residents were free from accidents hazards. Refer to F-323 12. The facility failed to ensure residents did not incur severe weight loss. Refer to F-325 13. The facility failed to provide appropriate care for special needs including [MEDICAL CONDITION] and feeding tube care. Refer to F-328

Based on interview and record review it was determined the facility failed to ensure a resident received proper treatment and care for a [MEDICAL CONDITION] and a feeding tube for 1 of 1 sampled residents (#39) reviewed for [MEDICAL CONDITION] and feeding tube care. This failure, determined to be an immediate jeopardy situation, resulted in staff inserting or attempting to insert a [MEDICAL CONDITION] cannula without clinical justification. Findings include: Resident 39 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. 1. A Progress Note dated 4/23/17 by Staff 6 (LPN) indicated Gums appear to have no sign of bleeding, resident minimally cooperative with oral care this shift. Resident started grinding teeth and shaking (her/his) head when I approached to do oral care x2 attempts. A Progress Note dated 7/1/17 at 9:30 pm indicated the resident's [MEDICAL CONDITION] popped out during cares. Staff 6 (LPN) was attempting to replace it and the resident was trying to hit her. An aide restrained the resident's hand and Staff 6 told the resident her/his combative behavior was inappropriate. The resident flipped the nurse off and allowed her complete the treatment. At 3:00 am aides went in to change residents(sp) brief and found (her/him) crying. A Progress Note by Staff 6 dated 7/8/17 at 12:30 pm indicated At approximately 0800 this shift this nurse was called down from other hall to assist LN with getting [MEDICAL CONDITION]. Patient had pulled (her/his) [MEDICAL CONDITION] completely. This nurse attempted x2 to replace [MEDICAL CONDITION] and met resistance, failed x2. Resident attempted to hit me multiple times while I was attempting to replace the airway. This nurse had CNA contact 911 to have patient sent to hospital while myself and other nurse ensured airway was still open. SP 02 stayed at 93% with [MEDICAL CONDITION] place, blow by 02 was set at 8L per minute as patient refused to keep 02 mask on (her/his) face. Resident out of facility by EMTs at 0815. This nurse called the family to give them update and let them know (she/he) had been sent to the ER for immediate treatment. An edited Progress Note dated 7/8/17 at 12:37 pm by Staff 7 (Agency RN) indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I asked CNa's to hold (her/his) arm as I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. An Incident Investigation report dated 7/8/17 indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. The report recommended the resident be transported to the hospital to replace [MEDICAL CONDITION] stabilize behaviors. The Progress Notes and the incident report failed to provide rationale for the medical necessity to restrain the resident on 7/1/17 and 7/8/17. On 7/14/17 at 10:08 am Staff 6 acknowledged CNAs were told to hold the resident down on 7/1/17 and 7/8/17 while nurses attempted to reinsert the resident's [MEDICAL CONDITION]. She acknowledged the resident was able to breathe on her/his own without the [MEDICAL CONDITION] in place. On 7/27/17 at 10:22 am Staff 8 (CNA) acknowledged she was told to restrain the resident on 7/8/17 while Staff 6 and Staff 7 unsuccessfully attempted to forcefully reinsert the resident's [MEDICAL CONDITION] for several minutes. Staff 8 stated the resident clearly did not want it, was struggling and turning red. She stated it was gruesome to watch. Staff 8 stated the resident's oxygen saturation was steady 95% so there was plenty of time to call 911 and have them take care of the resident. Staff 8 stated the resident was able to communicate with hand gestures and a white board but no one attempted to communicate to the resident what they were doing or why. Staff 8 stated on another occasion Staff 6 instructed her to restrain the resident while Staff 6 placed a piece of equipment labeled Respironics on the resident. Staff 6 stated the resident did not have the right to refuse it and to hold her/him down. She was unable to recall the date of that incident. Refer to F-221 example 1 2. On 7/24/17 at 10:06 am Witness 2 stated Resident 39 received too much tube feeding on one occasion. The resident was burping and hitting her/his chest, the feeding pump had to be shut off and the resident was about to choke. Resident 39's physician's orders [REDACTED]. A Physician Communication Sheet dated 4/11/17 indicated the resident was administered 329 ml of tube feeding formula which was more than the prescribed amount and the excess 79 ml was removed from the resident. On 7/27/17 at 8:48 am Staff 2 (LPN/Resident Care Manager) acknowledged Resident 39's tube feeding pump was set for the full days amount of 1250 ml instead of the ordered interval amount of 250 ml. Staff 2 stated he removed the excess formula from the resident's stomach via the feeding tube and left in the ordered 250 ml. Staff 2 stated an incident report should have been completed.

Based on observation and interview it was determined the facility failed to implement interventions to reduce the risk of injury for 2 of 4 sampled residents (#s 31 and 74) randomly observed and reviewed for accidents. This failure, determined to be an immediate jeopardy situation, resulted in Staff 10 (CNA) pushing a resident in a wheelchair while the resident's foot was dragging on the floor and placed residents at risk for falls. Findings include: 1. Resident 31 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 6/19/17 Annual MDS Section C indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 4 (which indicated severe mental impairment). The 4/19/17 In Room Care Plan indicated the following for Resident 31: - Locomotion: extensive assistant of 1 person in wheelchair. - Cognition: some confusion and forgetfulness; communication. - Allow resident time to process and speak - may be slow. The 6/24/17 Behavioral Symptoms Care Plan indicated Resident 31 had a [DIAGNOSES REDACTED]. The resident required a simple explanation of needs and time to thought process and respond. Approach the resident with simple explanations of cares or treatments and medication needs prior to providing. Offer her/him time to thought process question/express any concerns or questions. Validate her/his decisions. Revisit at later time as safety and cares allow. Refer to charge nurse. Refer to RCM (Resident Care Manager) and or SSD as needed for further assessment of behaviors. Observe tone of voice when attempting to encourage her/his participation. Be aware that you are not causing resident to feel rushed into responding. The 6/24/17 Care Plan for Communication indicated Resident 31 had cognitive deficits with impaired comprehension and decision making abilities. Approaches included: - Support and validate resident decision making abilities. - Provide her/him with simple, clear, concise information and explanation of cares and directions. - Allow her/him time to thought process and respond/express self. The 6/24/17 Care Plan for Cognitive Loss/Dementia indicated: - Resident 31 had a [DIAGNOSES REDACTED]. - Required cues and reminders to maintain active involvement with daily cares and decision making. - Encourage resident with her/his participation in daily cares and acts with support and validation of decisions. - Provide her/him opportunity to express self and participate in decisions as needed. - Allow her/him time to thought process and express self. - Repeat and rephrase instructions and/or messages as needed. The 2/18/17 ADL Care Plan indicated Resident 31 had an alteration in ADL function secondary to [DIAGNOSES REDACTED]. Approaches included to see in room care plan for ADL needs and level of assistance. On 8/8/17 at 7:46 am Staff 10 (CNA) was observed to push Resident 31 down the 300 hallway in a wheelchair. The resident yelled no. Staff 10 stopped in the hallway attempted to place Resident 31's foot on the wheelchair foot rest, Resident 31 again yelled no. Staff 10 then stated I will just drag your feet then, God bless America. Staff 10 continued to push Resident 31 down the hall with the bottom of his/her foot dragging on the floor. Staff 10 was pushing the resident very fast down the hall toward the nurses station. Staff 10 told the resident 'here comes a bump' as he went through the double doors by the nurses station, Staff 10 continued down the hallway toward the dining room. When Resident 31 was observed in the hallway next to the elevator both feet were resting on the foot rest. On 8/8/17 at 8:02 am Staff 10 stated Resident 31 didn't want to put her/his foot up on the foot rest and told the resident if she/he didn't put her/his foot up we were going to have to drag it, then the resident had her/his foot down and I told her/him to put it up. She/he put her/his foot up when we went by the double doors by the nurses station since I told her/him there was a bump. On 8/8/17 at 8:17 am Staff 9 (CMA) stated she observed Staff 10 bring Resident 31 out into the hallway from the resident's room. Staff 9 told Staff 10 Resident 31's foot had fallen off the foot rest. Staff 10 attempted to put the residents foot back up on the footrest of the wheelchair, Resident 31 said no and Staff 10 stated then we will just push her/his foot on the ground and off he went down the hall. On 8/8/17 at 8:20 am Staff 10 stated Resident 31 could lift both feet onto the footrests of the wheelchair by herself/himself and the left side (foot) was slower. Refer to F-223 2. Resident 74 was admitted to the facility 2017 with [DIAGNOSES REDACTED]. A 7/22/17 progress note revealed Resident 74 suffered a fall when the shower chair she/he sat in broke after a shower was finished. A revised Incident Investigation dated 8/4/17 indicated Resident 74 sat in a shower chair not appropriate for her/his weight and the chair came apart at the connection joint. A comprehensive ADL care plan was not in place and the In Room Care Plan did not specify the resident needed a bariatric shower chair until after the fall. On 8/4/17 at 1:19 pm Staff 30 (RN) stated Resident 74 was in a normal, standard shower chair, the chair did not break but the PVC (like) tubing came apart at the sides. Staff 30 further stated she had not seen a bariatric chair in the facility and weight limits were not labeled on any shower chair. On 8/7/17 at 2:09 pm Staff 25 (CNA) stated she had previously not showered Resident 74 so she verbally questioned other staff to inquire how it was to be completed. No other staff had showered Resident 74 before so she proceeded without guidance. Staff 25 stated weight limits were not on any facility shower chair and none were labeled as bariatric. Staff 25 stated the facility standard of practice was for the CNAs to eyeball the chair for the correct fit. On 8/7/17 at 9:18 am Resident 74 stated she/he was horrified when the fall happened and the facility now utilized the right equipment. Resident 74 further stated if she heard a creak when in any of the chairs she/he would panic inside because in the other shower chair she/he had heard a crack and immediately fell down. On 8/7/17 at 9:28 am Staff 1 (Administrator) stated the shower chair came apart which resulted in Resident 74's fall. Staff 1 verified the weight limit was not listed on this or any other facility chair.

Based on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 7 of 7 sampled residents (#s 31, 52, 68, 69, 70, 71 and 72) reviewed for dignity and during random observations. This failure, determined to be an immediate jeopardy situation, resulted in staff speaking to Resident 31 in an undignified manner. Findings include: 1. Resident 31 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 6/19/17 Annual MDS Section C indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 4 (which indicated severe mental impairment). The 4/19/17 In Room Care Plan indicated the following for Resident 31: - Locomotion: extensive assistant of 1 person in wheelchair. - Cognition: some confusion and forgetfulness; communication. - Allow resident time to process and speak - may be slow. The 6/24/17 Behavioral Symptoms Care Plan indicated Resident 31 had a [DIAGNOSES REDACTED]. The resident required a simple explanation of needs and time to thought process and respond. Approach the resident with simple explanations of cares or treatments and medication needs prior to providing. Offer her/him time to thought process question/express any concerns or questions. Validate her/his decisions. Revisit at later time as safety and cares allow. Refer to charge nurse. Refer to RCM (Resident Care Manager) and or SSD as needed for further assessment of behaviors. Observe tone of voice when attempting to encourage her/his participation. Be aware that you are not causing resident to feel rushed into responding. The 6/24/17 Care Plan for Communication indicated Resident 31 had cognitive deficits with impaired comprehension and decision making abilities. Approaches included: - Support and validate resident decision making abilities. - Provide her/him with simple, clear, concise information and explanation of cares and directions. - Allow her/him time to thought process and respond/express self. The 6/24/17 Care Plan for Cognitive Loss/Dementia indicated: - Resident 31 had a [DIAGNOSES REDACTED]. - Required cues and reminders to maintain active involvement with daily cares and decision making. - Encourage resident with her/his participation in daily cares and acts with support and validation of decisions. - Provide her/him opportunity to express self and participate in decisions as needed. - Allow her/him time to thought process and express self. - Repeat and rephrase instructions and/or messages as needed. The 2/18/17 ADL Care Plan indicated Resident 31 had an alteration in ADL function secondary to [DIAGNOSES REDACTED]. Approaches included to see in room care plan for ADL needs and level of assistance. On 8/8/17 at 7:46 am Staff 10 (CNA) was observed to push Resident 31 down the 300 hallway in a wheelchair. The resident yelled no. Staff 10 stopped in the hallway attempted to place Resident 31's foot on the wheelchair foot rest, Resident 31 again yelled no. Staff 10 then stated I will just drag your feet then, God bless America. Staff 10 continued to push Resident 31 down the hall with the bottom of his/her foot dragging on the floor. Staff 10 was pushing the resident very fast down the hall toward the nurses station. Staff 10 told the resident 'here comes a bump' as he went through the double doors by the nurses station, Staff 10 continued down the hallway toward the dining room. When Resident 31 was observed in the hallway next to the elevator both feet were resting on the foot rest. On 8/8/17 at 8:02 am Staff 10 stated Resident 31 didn't want to put her/his foot up on the foot rest and told the resident if she/he didn't put her/his foot up we were going to have to drag it, then the resident had her/his foot down and I told her/him to put it up. She/he put her/his foot up when we went by the double doors by the nurses station since I told her/him there was a bump. On 8/8/17 at 8:17 am Staff 9 (CMA) stated she observed Staff 10 bring Resident 31 out into the hallway from the resident's room. Staff 9 told Staff 10 Resident 31's foot had fallen off the foot rest. Staff 10 attempted to put the residents foot back up on the footrest of the wheelchair, Resident 31 said no and Staff 10 stated then we will just push her/his foot on the ground and off he went down the hall. On 8/8/17 at 8:20 am Staff 10 stated Resident 31 could lift both feet onto the footrests of the wheelchair by herself/himself and the left side (foot) was slower. Refer to F-223 2. Resident 52 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 52's In Room Care Plan dated 2/5/17 indicated the resident ate in her/his room with plastic and paper equipment. A Progress Note dated 2/14/17 indicated there were guards at the resident's bedside. A Progress Note dated 2/16/17 indicated there were two guards at the resident's bedside. On 8/4/17 at 9:15 AM Staff 1 (Administrator) acknowledged the resident was not afforded privacy related to the presence of guards, the resident was required to eat in her/his room and was required to use paper and plastic eating utensils. 3. Resident 68 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 68's 2/3/17 Psychosocial Well-Being CAA indicated My analysis and supporting factors restriction of cuffs on the legs will keep (the resident) from activities. Does not have the opertunity (sp) to enteract (sp) with others. On 8/4/17 at 9:15 AM Staff 1 acknowledged the resident was not allowed to attend group activities. 4. Resident 69 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 68's 1/4/17 Discharge Summary/Recapitulation of Stay indicated the resident's activity participation was limited due to her/his incarceration status. On 8/4/17 at 9:15 AM Staff 1 acknowledged the resident was not allowed to attend group activities. 5. Resident 70 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. A Progress Note dated 9/2/16 indicated 2 guards remain in room at all times. Resident 70's In Room Care Plan dated 9/1 indicated the resident was to eat in her/his room. On 8/4/17 at 9:15 AM Staff 1 acknowledged the resident was not afforded privacy related to the presence of guards and the resident was required to eat in her/his room. 6. Resident 71 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Resident 71's In Room Care Plan updated 7/18/16 indicated the resident used paper and plastic eating utensils. Resident 71's 8/2/16 ADLs Functional Status/Rehabilitation Potential CAA indicated the resident was an inmate at a local corrections facility and was accompanied by an armed guard at all times. On 8/4/17 at 9:15 AM Staff 1 acknowledged the resident was not afforded privacy related to the presence of guards, the resident was required to eat in her/his room and was required to use paper and plastic eating utensils. 7. Resident 72 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Resident 72's In Room Care Plan dated 5/17/16 indicated the resident was not allowed visitors without checking with the charge nurse and was not allowed to have a phone in her/his room. A Progress Note dated 6/12/16 indicated Resident wanting more time to go over every medication. Informed (the resident) this is not going to continue. I have went over every one two days in a row. (The resident) seems to be manipulating. Resident 72's 5/24/16 Psychosocial Well-Being CAA indicated the resident was a prisoner in a federal facility and was in a structured environment. The resident was generally restricted and had limited access to recreational activities. The resident did watch TV in her/his room and was offered reading materials. On 8/4/17 at 9:15 AM Staff 1 acknowledged the resident's access to visitors and telephone was restricted by prison officials. Staff 1 acknowledged residents had the right to have their medications explained to them before administration. Staff 1 acknowledged the resident was not allowed to attend group activities.

Based on observation and interview it was determined the facility failed to ensure residents were free from physical abuse for 1 of 1 sampled residents (#31) during a random observation. This failure, determined to be an immediate jeopardy situation, resulted in Resident 31 being subjected to physical abuse. Findings include: Resident 31 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 6/19/17 Annual MDS Section C indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 4 (which indicated severe mental impairment). The 4/19/17 In Room Care Plan indicated the following for Resident 31: - Locomotion: extensive assistant of 1 person in wheelchair. - Cognition: some confusion and forgetfulness; communication. - Allow resident time to process and speak - may be slow. The 6/24/17 Behavioral Symptoms Care Plan indicated Resident 31 had a [DIAGNOSES REDACTED]. The resident required a simple explanation of needs and time to thought process and respond. Approach the resident with simple explanations of cares or treatments and medication needs prior to providing. Offer her/him time to thought process question/express any concerns or questions. Validate her/his decisions. Revisit at later time as safety and cares allow. Refer to charge nurse. Refer to RCM (Resident Care Manager) and or SSD as needed for further assessment of behaviors. Observe tone of voice when attempting to encourage her/his participation. Be aware that you are not causing resident to feel rushed into responding. The 6/24/17 Care Plan for Communication indicated Resident 31 had cognitive deficits with impaired comprehension and decision making abilities. Approaches included: - Support and validate resident decision making abilities. - Provide her/him with simple, clear, concise information and explanation of cares and directions. - Allow her/him time to thought process and respond/express self. The 6/24/17 Care Plan for Cognitive Loss/Dementia indicated: - Resident 31 had a [DIAGNOSES REDACTED]. - Required cues and reminders to maintain active involvement with daily cares and decision making. - Encourage resident with her/his participation in daily cares and acts with support and validation of decisions. - Provide her/him opportunity to express self and participate in decisions as needed. - Allow her/him time to thought process and express self. - Repeat and rephrase instructions and/or messages as needed. The 2/18/17 ADL Care Plan indicated Resident 31 had an alteration in ADL function secondary to [DIAGNOSES REDACTED]. Approaches included to see in room care plan for ADL needs and level of assistance. On 8/8/17 at 7:46 am Staff 10 (CNA) was observed to push Resident 31 down the 300 hallway in a wheelchair. The resident yelled no. Staff 10 stopped in the hallway attempted to place Resident 31's foot on the wheelchair foot rest, Resident 31 again yelled no. Staff 10 then stated I will just drag your feet then, God bless America. Staff 10 continued to push Resident 31 down the hall with the bottom of his/her foot dragging on the floor. Staff 10 was pushing the resident very fast down the hall toward the nurses station. Staff 10 told the resident 'here comes a bump' as he went through the double doors by the nurses station, Staff 10 continued down the hallway toward the dining room. When Resident 31 was observed in the hallway next to the elevator both feet were resting on the foot rest. On 8/8/17 at 8:02 am Staff 10 stated Resident 31 didn't want to put her/his foot up on the foot rest and told the resident if she/he didn't put her/his foot up we were going to have to drag it, then the resident had her/his foot down and I told her/him to put it up. She/he put her/his foot up when we went by the double doors by the nurses station since I told her/him there was a bump. On 8/8/17 at 8:17 am Staff 9 (CMA) stated she observed Staff 10 bring Resident 31 out into the hallway from the resident's room. Staff 9 told Staff 10 Resident 31's foot had fallen off the foot rest. Staff 10 attempted to put the residents foot back up on the footrest of the wheelchair, Resident 31 said no and Staff 10 stated then we will just push her/his foot on the ground and off he went down the hall. On 8/8/17 at 8:20 am Staff 10 stated Resident 31 could lift both feet onto the footrests of the wheelchair by herself/himself and the left side (foot) was slower.

Based on interview and record review it was determined the facility failed to ensure residents were not restrained unless for a medical reason for 4 of 7 sampled residents (#s 39, 52, 68 and 69) reviewed for restraints and [MEDICAL CONDITION] care. This failure, determined to be an immediate jeopardy situation, resulted in Resident 7 being restrained on two occasions without medical rationale. Findings include: 1. Resident 39 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. A Progress Note dated 4/23/17 by Staff 6 (LPN) indicated Gums appear to have no sign of bleeding, resident minimally cooperative with oral care this shift. Resident started grinding teeth and shaking (her/his) head when I approached to do oral care x2 attempts. A Progress Note dated 7/1/17 at 9:30 pm indicated the resident's [MEDICAL CONDITION] popped out during cares. Staff 6 (LPN) was attempting to replace it and the resident was trying to hit her. An aide restrained the resident's hand and Staff 6 told the resident her/his combative behavior was inappropriate. The resident flipped the nurse off and allowed her complete the treatment. At 3:00 am aides went in to change residents(sp) brief and found (her/him) crying. A Progress Note by Staff 6 dated 7/8/17 at 12:30 pm indicated At approximately 0800 this shift this nurse was called down from other hall to assist LN with getting [MEDICAL CONDITION]. Patient had pulled (her/his) [MEDICAL CONDITION] completely. This nurse attempted x2 to replace [MEDICAL CONDITION] and met resistance, failed x2. Resident attempted to hit me multiple times while I was attempting to replace the airway. This nurse had CNA contact 911 to have patient sent to hospital while myself and other nurse ensured airway was still open. SP 02 stayed at 93% with [MEDICAL CONDITION] place, blow by 02 was set at 8L per minute as patient refused to keep 02 mask on (her/his) face. Resident out of facility by EMTs at 0815. This nurse called the family to give them update and let them know (she/he) had been sent to the ER for immediate treatment. An edited Progress Note dated 7/8/17 at 12:37 pm by Staff 7 (Agency RN) indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I asked CNa's to hold (her/his) arm as I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. An Incident Investigation report dated 7/8/17 indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. The report recommended the resident be transported to the hospital to replace [MEDICAL CONDITION] stabilize behaviors. The Progress Notes and the incident report failed to provide rationale for the medical necessity to restrain the resident on 7/1/17 and 7/8/17. On 7/14/17 at 10:08 am Staff 6 acknowledged CNAs were told to hold the resident down on 7/1/17 and 7/8/17 while nurses attempted to reinsert the resident's [MEDICAL CONDITION]. She acknowledged the resident was able to breathe on her/his own without the [MEDICAL CONDITION] in place. On 7/27/17 at 10:22 am Staff 8 (CNA) acknowledged she was told to restrain the resident on 7/8/17 while Staff 6 and Staff 7 unsuccessfully attempted to forcefully reinsert the resident's [MEDICAL CONDITION] for several minutes. Staff 8 stated the resident clearly did not want it, was struggling and turning red. She stated it was gruesome to watch. Staff 8 stated the resident's oxygen saturation was steady 95% so there was plenty of time to call 911 and have them take care of the resident. Staff 8 stated the resident was able to communicate with hand gestures and a white board but no one attempted to communicate to the resident what they were doing or why. Staff 8 stated on another occasion Staff 6 instructed her to restrain the resident while Staff 6 placed a piece of equipment labeled Respironics on the resident. Staff 6 stated the resident did not have the right to refuse it and to hold her/him down. She was unable to recall the date of that incident. 2. Resident 52 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. A Progress Note dated 2/4/17 indicated Resident 52 was admitted to the facility accompanied by two guards. Resident 52's Resident Face Sheet with an admission date of [DATE] indicated Please note we must follow STRICT guidelines for Federal inmate residents Refer to guideline list in front of chart and in MACC book under resident tab If you do not know how to handle a situation contact SSD DNS or Administrator Resident 52's 2/11/17 MDS assessment indicated the resident used a limb restraint daily when out of bed or in a chair. Resident 52's Preliminary Care Plan dated 2/5 did not address the resident's use of a limb restraint or activity preferences. Resident 52's In Room Care Plan dated 2/5/17 failed to address the resident's use of a limb restraint. A review of Resident 52's clinical record revealed no indication the resident was comprehensively assessed and care planned for the safe use of a limb restraint or monitored for potential injury including skin damage or breakdown related to the use of a restraint. No medical justification for the use of restraints was found in the clinical record. 3. Resident 68 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 68's 2/3/17 Psychosocial Well-Being CAA indicated My analysis and supporting factors restriction of cuffs on the legs will keep (the resident) from activities. Does not have the opertunity (sp) to enteract (sp) with others. Resident 68's 2/3/17 MDS assessment indicated the resident used a limb restraint when in bed or in a chair daily. Resident 68's 2/3/17 Pressure Ulcers CAA indicated Resident is restrained by law enforcement. Resident 68's 2/3/17 Physical Restraints CAA indicated the resident had physical restraints applied by two correctional officers who supervised the resident at all times. The officers reviewed the resident's skin condition for breakdown as well as the nurses. Resident 68's Preliminary Care Plan dated 1/27/17 did not address the resident's use of restraints. Resident 68's In Room Care Plan updated 2/14/17 did not address the resident's use of restraints. A Progress Note dated 2/7/17 indicated Resident resting in bed through the night, guards at bedside. Resident restrained to the bed. A Progress Note dated 2/9/17 indicated In bed with guards present. and Officers present as resident awoke and attempted to pull off cuffs which they state (the resident) does on waking. A review of Resident 68's clinical record revealed no indication the resident was comprehensively assessed and care planned for the safe use of a limb restraint or monitored for potential injury including skin damage or breakdown related to the use of a restraint. No medical justification for the use of restraints was found in the clinical record. 4. Resident 69 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 69's 12/26/16 MDS assessment indicated the resident used a bed rail and limb restraint daily. Resident 69's 12/26/16 Physical Restraints CAA indicated the resident was a federal prisoner and on admission to the facility a bed rail was requested and was used for a hand cuff and ankle cuff. Resident 69's In Room Care Plan updated 12/23/16 did not address the resident's use of restraints. Resident 69's Enabler/Physical Restraint Consent form dated 12/23/16 indicated a side rail was in place for the use of a handcuff for the duration of the resident's stay in the facility. The consent was signed by an individual identified as FBOP (Federal Bureau of Prisons) officer. A review of Resident 69's clinical record revealed no indication the resident was comprehensively assessed and care planned for the safe use of a limb restraint or monitored for potential injury including skin damage or breakdown related to the use of a restraint. No medical justification for the use of restraints was found in the clinical record. On 6/28/17 at 9:52 am and 7/14/17 at 12:31 pm Staff 1 (Administrator) acknowledged justice involved residents (including Residents 52, 68 and 69) were restrained at the direction of the guards and they made the decision when a resident would be restrained. Sometimes the residents were restrained when in a wheelchair and sometimes when in their room. When staff provided care the guards would remove the restraints. Typically handcuffs were the type of restraint used. Staff 1 acknowledged the restraints were used for security and not for medical reasons.

Based on interview and record review it was determined the facility failed to allow a resident the right to refuse treatment for 1 of 1 sampled resident (#39) reviewed for [MEDICAL CONDITION] care. This failure, determined to be an immediate jeopardy situation, resulted in staff inserting or attempting to insert a [MEDICAL CONDITION] cannula against the resident's wishes while restraining her/him. Findings include: Resident 39 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. A Progress Note dated 4/23/17 by Staff 6 (LPN) indicated Gums appear to have no sign of bleeding, resident minimally cooperative with oral care this shift. Resident started grinding teeth and shaking (her/his) head when I approached to do oral care x2 attempts. A Progress Note dated 7/1/17 at 9:30 pm indicated the resident's [MEDICAL CONDITION] popped out during cares. Staff 6 (LPN) was attempting to replace it and the resident was trying to hit her. An aide restrained the resident's hand and Staff 6 told the resident her/his combative behavior was inappropriate. The resident flipped the nurse off and allowed her complete the treatment. At 3:00 am aides went in to change residents(sp) brief and found (her/him) crying. A Progress Note by Staff 6 dated 7/8/17 at 12:30 pm indicated At approximately 0800 this shift this nurse was called down from other hall to assist LN with getting [MEDICAL CONDITION]. Patient had pulled (her/his) [MEDICAL CONDITION] completely. This nurse attempted x2 to replace [MEDICAL CONDITION] and met resistance, failed x2. Resident attempted to hit me multiple times while I was attempting to replace the airway. This nurse had CNA contact 911 to have patient sent to hospital while myself and other nurse ensured airway was still open. SP 02 stayed at 93% with [MEDICAL CONDITION] place, blow by 02 was set at 8L per minute as patient refused to keep 02 mask on (her/his) face. Resident out of facility by EMTs at 0815. This nurse called the family to give them update and let them know (she/he) had been sent to the ER for immediate treatment. An edited Progress Note dated 7/8/17 at 12:37 pm by Staff 7 (Agency RN) indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I asked CNa's to hold (her/his) arm as I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. An Incident Investigation report dated 7/8/17 indicated Around 0815 called to residents room regarding trach. It was pulled halfway out and it happened when they attempted to place humidity mask. (She/he) grabbed mask and then threw it to the side and then they [MEDICAL CONDITION] out.[MEDICAL CONDITION] out and and resident combative and hit me as I attempted to replace trach. I made a pass and felt resistance and called staff nurse as she is familiar with residents trach. She met resistance and did not continue. While [MEDICAL CONDITION] noted it was difficult to pass catheter due to swelling. 911 called and arrived about 815 to assess and transfer patient. Residents vital signs were 93% on RA and then we place a o2 mask over (her/him) at blow b with 8 liters. 118/76, 92, RR 22. (She/he) did not show any signs of distress through the event and was transferred to Willamette Valley Hospital for evaluation. Doctor faxed and Step mom notified by phone. The report recommended the resident be transported to the hospital to replace [MEDICAL CONDITION] stabilize behaviors. The Progress Notes and the incident report failed to provide rationale for the medical necessity to restrain the resident on 7/1/17 and 7/8/17. On 7/14/17 at 10:08 am Staff 6 acknowledged CNAs were told to hold the resident down on 7/1/17 and 7/8/17 while nurses attempted to reinsert the resident's [MEDICAL CONDITION]. She acknowledged the resident was able to breathe on her/his own without the [MEDICAL CONDITION] in place. On 7/27/17 at 10:22 am Staff 8 (CNA) acknowledged she was told to restrain the resident on 7/8/17 while Staff 6 and Staff 7 unsuccessfully attempted to forcefully reinsert the resident's [MEDICAL CONDITION] for several minutes. Staff 8 stated the resident clearly did not want it, was struggling and turning red. She stated it was gruesome to watch. Staff 8 stated the resident's oxygen saturation was steady 95% so there was plenty of time to call 911 and have them take care of the resident. Staff 8 stated the resident was able to communicate with hand gestures and a white board but no one attempted to communicate to the resident what they were doing or why. Staff 8 stated on another occasion Staff 6 instructed her to restrain the resident while Staff 6 placed a piece of equipment labeled Respironics on the resident then Staff 6 stated the resident did not have the right to refuse it and to hold her/him down. She was unable to recall the date of that incident. Refer to F-221 example 1

1. Based on observation, interview and record review it was determined the facility failed to promote a resident's autonomy and choice free of coercion for 1 of 1 sampled resident (#31) randomly observed. This failure, determined to be an immediate jeopardy situation resulted in a violation of Resident 31's right to be free of interference, coercion and reprisal. Findings include: Resident 31 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 6/19/17 Annual MDS Section C indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 4 (which indicated severe mental impairment). The 4/19/17 In Room Care Plan indicated the following for Resident 31: - Locomotion: extensive assistant of 1 person in wheelchair. - Cognition: some confusion and forgetfulness; communication. - Allow resident time to process and speak - may be slow. The 6/24/17 Behavioral Symptoms Care Plan indicated Resident 31 had a [DIAGNOSES REDACTED]. The resident required a simple explanation of needs and time to thought process and respond. Approach the resident with simple explanations of cares or treatments and medication needs prior to providing. Offer her/him time to thought process question/express any concerns or questions. Validate her/his decisions. Revisit at later time as safety and cares allow. Refer to charge nurse. Refer to RCM (Resident Care Manager) and or SSD as needed for further assessment of behaviors. Observe tone of voice when attempting to encourage her/his participation. Be aware that you are not causing resident to feel rushed into responding. The 6/24/17 Care Plan for Communication indicated Resident 31 had cognitive deficits with impaired comprehension and decision making abilities. Approaches included: - Support and validate resident decision making abilities. - Provide her/him with simple, clear, concise information and explanation of cares and directions. - Allow her/him time to thought process and respond/express self. The 6/24/17 Care Plan for Cognitive Loss/Dementia indicated: - Resident 31 had a [DIAGNOSES REDACTED]. - Required cues and reminders to maintain active involvement with daily cares and decision making. - Encourage resident with her/his participation in daily cares and acts with support and validation of decisions. - Provide her/him opportunity to express self and participate in decisions as needed. - Allow her/him time to thought process and express self. - Repeat and rephrase instructions and/or messages as needed. The 2/18/17 ADL Care Plan indicated Resident 31 had an alteration in ADL function secondary to [DIAGNOSES REDACTED]. Approaches included to see in room care plan for ADL needs and level of assistance. On 8/8/17 at 7:46 am Staff 10 (CNA) was observed to push Resident 31 down the 300 hallway in a wheelchair. The resident yelled no. Staff 10 stopped in the hallway attempted to place Resident 31's foot on the wheelchair foot rest, Resident 31 again yelled no. Staff 10 then stated I will just drag your feet then, God bless America. Staff 10 continued to push Resident 31 down the hall with the bottom of his/her foot dragging on the floor. Staff 10 was pushing the resident very fast down the hall toward the nurses station. Staff 10 told the resident 'here comes a bump' as he went through the double doors by the nurses station, Staff 10 continued down the hallway toward the dining room. When Resident 31 was observed in the hallway next to the elevator both feet were resting on the foot rest. On 8/8/17 at 8:02 am Staff 10 stated Resident 31 didn't want to put her/his foot up on the foot rest and told the resident if she/he didn't put her/his foot up we were going to have to drag it, then the resident had her/his foot down and I told her/him to put it up. She/he put her/his foot up when we went by the double doors by the nurses station since I told her/him there was a bump. On 8/8/17 at 8:17 am Staff 9 (CMA) stated she observed Staff 10 bring Resident 31 out into the hallway from the resident's room. Staff 9 told Staff 10 Resident 31's foot had fallen off the foot rest. Staff 10 attempted to put the residents foot back up on the footrest of the wheelchair, Resident 31 said no and Staff 10 stated then we will just push her/his foot on the ground and off he went down the hall. On 8/8/17 at 8:20 am Staff 10 stated Resident 31 could lift both feet onto the footrests of the wheelchair by herself/himself and the left side (foot) was slower. Refer to F-223 2. Based on observation and interview it was determined the facility failed to ensure residents were able to exercise their right to freely exit the building for 2 of 2 public entrances and an elevator with an electronic keypad. This placed residents and their visitors at risk of not being able to freely enter or exit the building. Findings include: a. On 8/8/17 at 7:45 am the front entrance to the facility was locked and the keypad code was no longer posted on the keypad. An unidentified individual who stated he was working as security in the parking lot stated there was a new code. No facility staff was immediately available to assist residents or visitors in or out of the building. On 8/8/17 at 7:50 am Staff 28 (Interim DNS) acknowledged the door code was changed and there was a sign on the front door which indicated persons wanting to enter or exit the building needed to see a staff person for assistance. On 8/8/17 at 1:58 pm Resident 53 was observed attempting to enter the elevator which required putting a code into a keypad. The resident asked Staff 38 (RN) and Staff 13 (CNA) for assistance. Both staff told the resident they did not know the code and walked away without assisting the resident. On 8/8/17 2:04 pm Staff 23 (HR/Payroll/Staffing) stated there was no reason Resident 53 was not allowed to go down the elevator and the resident went down there to get to the smoking area outside. On 8/9/17 at 8:20 am Staff 1 (Administrator) was observed assisting Resident 53 to enter the elevator. b. On 8/10/17 at 7:45 am the front entrance doors were locked and no code was posted on the electronic keypad. An unidentified visitor was at the door and stated she had pressed the door bell but no staff had responded to let her in the building. This surveyor called the facility's phone number posted on the door but no staff answered the phone. There was no staff immediately available to let residents and visitors in or out of the building. No staff was available to confirm this surveyor and the visitor were unable to enter the building.

Based on observation, interview and record review it was determined the facility failed to ensure nurse aides were able to demonstrate competency in adhering to and understanding their responsibilities related to infection control standard precautions and caring for a resident in isolation for an uncontained antibiotic resistant infection for 7 of 7 staff (#s 10, 11, 12, 13, 14, 16 and 17) observed or interviewed for infection control. This failure, determined to be an immediate jeopardy situation, resulted from staff not using PPE (personal protective equipment), not performing hand hygiene and subsequently making direct physical contact with another resident potentially contaminating her/him with an antibiotic resistant microorganism. Findings include: 1. Resident 32 was readmitted to the facility in 2017 with [DIAGNOSES REDACTED]. On 7/28/17 at 10:37 am Staff 10 (CNA) was observed to exit Resident 32's room with a meal tray in hand. A contact precautions cart was noted outside the room with signs posted on the door to see the nurse before entering. Staff 10 was not wearing any PPE and was not observed to perform hand hygiene. Staff 10 took the meal tray to the dining room and placed it in a meal tray cart. Staff 10 then walked over to Resident 25 and put both his hands on the resident's shoulders and gave them a gentle rub while talking to the resident. Staff 10 acknowledged he did not use PPE, or perform hand hygiene. On 7/28/17 at 10:39 am Staff 4 (Interim DNS) was informed of this surveyor's observations and interview with Staff 10 and was asked to identify the resident who was contacted in the dining room but was now self-propelling her/himself down the hall. Staff 4 identified the resident as Resident 25. She stated she would get the resident cleaned up. Staff 4 stated Resident 32 had an [MEDICAL CONDITION] infection. On 7/28/17 at 10:50 am Staff 15 (Kitchen Manager) stated he was not aware there was a tray in the tray cart which came from a room with contact precautions. He stated usually the tray from a room with precautions would be bagged up and placed in the bottom of the cart. On 7/28/17 at 10:50 am Staff 16 (LPN) stated Resident 32 had a [MEDICAL CONDITION] infection. On 7/28/17 at 10:56 am Staff 4 acknowledged the tray should have been bagged up before it went to the kitchen. On 7/28/17 at 11:45 am With Staff 4 and Staff 16 Resident 32 was observed in bed on her/his back. The resident's gown was observed to have an approximately 6 cm dark red stain which appeared to be blood on the lower left. The resident stated it was blood from her/his wound care this morning. The resident then rearranged her/his gown pulling it down while touching it near the blood. Staff 4 told the resident she would have someone come clean the resident up. Five CNA staff were interviewed on 7/28/17 regarding infection control practices for Resident 32. Four staff interviewed (#s 10, 11, 12 and 13) were not knowledgeable of the source of the resident's infection. Four staff interviewed (#s 10, 11, 12 and 13) reported the resident's wound drained on the bedding and/or gown. Five staff interviewed (#s 10, 11, 12, 13 and 14) were inconsistent in how they applied gloves and gowns when providing care including answering call lights and provision and removal of the resident's meal tray. A hospital History & Physical dated 5/28/17 indicated the resident was started on antibiotics for infections including pseudomonas [MEDICAL CONDITION]. 2. On 8/4/17 at 10:36 am Staff 17 (Agency CNA) was observed to exit room [ROOM NUMBER] while still wearing gloves and enter room [ROOM NUMBER] (Resident 32's room), an isolation room related to [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus), wearing the same gloves. Posted instructions outside of Resident 226's room indicated hand hygiene and the application of gloves and a gown before entering the room. The PPE was available just outside of room [ROOM NUMBER]. Staff 17 was not observed to perform hand hygiene, apply new gloves or a gown before entering room [ROOM NUMBER]. On 8/4/17 at 10:37 am Staff 17 acknowledged she did not perform hand hygiene or apply new gloves or a gown prior to entering room [ROOM NUMBER]. On 8/4/17 at 11:27 am Staff 17 stated she was not in-serviced about room [ROOM NUMBER]'s infection control and the use of PPE. On 8/4/17 at 11:30 am Staff 18 (CNA) stated she was not in-serviced about room [ROOM NUMBER]'s infection control and use of PPE. On 8/4/17 at 10:44 am Staff 4 (Interim DNS) stated Staff 17 should have removed her gloves and performed hand hygiene before she exited room [ROOM NUMBER] and should have performed hand hygiene, donned gloves and a gown before she entered room [ROOM NUMBER]. Staff 4 acknowledged Staff 17 was not in-serviced regarding infection control and the use of PPE as per the plan of correction provided by the facility for the abatement of Immediate Jeopardy on 7/28/17. Refer to F-441

Based on interview and record review the Quality Assessment and Assurance (QAA) program failed to systematically identify issues related to infection control standard precautions, pressure ulcers, medication administration and assessments. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: On the morning of 8/11/17 Staff 1(Administrator) stated QAA committee meetings were held monthly. On the morning of 8/11/17 Staff 1 acknowledged the QAA committee had not identified system issue concerns related to infection control standard precautions, pressure ulcers, physicians orders, medication administration and assessments. Refer to F-272, F-314, F-309, F-332 and F-441.

Based on interview and record review it was determined the facility failed to provide clinical justification for the deterioration of a facility acquired Stage 4 pressure ulcer and accurately assess and monitor pressure ulcers for 3 of 6 sampled residents (#s 32, 36 and 77) reviewed for pressure ulcers and skin conditions. This resulted in the deterioration of Resident 36's wound and placed residents at risk for pressure ulcers. Findings include: 1. Resident 36 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 9/19/16 Quarterly MDS indicated Resident 36 was at risk for developing a pressure ulcer and did not have a current pressure ulcer. The Pressure Ulcer Care Plans dated 12/29/14 and 8/2/15 indicated Resident 36 had impaired skin integrity/worsening with a history of shearing to the buttocks. Interventions included a cushion for her/his wheelchair, a pressure reduction mattress on the bed, offer toileting before and/or after meals, upon waking and at night, encourage frequent position changes, monitor nutritional status at NAR (Nutrition at Risk) per protocol, obtain and apply treatment as ordered and PT/OT evaluation for repositioning and pressure reduction as needed. An incident investigation dated 12/13/16 indicated Resident 36 was found to have an open area on her/his coccyx measuring 2 cm by 2 cm by 0.2 cm. The wound bed was pink with a dark spot noted at the top of the wound and the area around the wound was blanchable. Resident 36 denied any pain or discomfort and the area was cleansed with normal saline, the skin was prepped around the wound and the area was covered with a Tegafoam (adhesive foam dressing). The physician was notified for treatment. Current interventions included barrier cream to the area. Mobility, cognition and positioning were contributing factors. Resident 36 was dependent for positioning and shear factors. A physician order [REDACTED]. On 1/22/16 Resident 36's Pressure Ulcer care plan was updated to include the following intervention, Resident often refuses and cries that (she/he) wants to only be on (her/his) back. Educate resident often the risk of skin breakdown. A progress note dated 2/6/17 indicated Resident 36's wound was not improving and new treatment orders were requested. On 2/11/17 the new treatment orders were obtained to include cleanse with normal saline, pat dry, apply small amount of mupirocin (topical antibiotic) ointment to wound bed, cover with Allevyn (adhesive foam dressing). Change every other day and PRN until resolved. A NAR note dated 2/7/17 revealed large portions, protein and multivitamin with minerals to be started to better meet the resident's estimated nutritional needs of 1600-1800 calories, 50-70 grams of protein for healing. A NAR note dated 2/20/17 indicated Resident 36 continued with shearing wound at coccyx and the wound was not healed. The physician would be consulted for a possible consult to the wound clinic. Physician orders [REDACTED]. A wound care clinic noted dated 3/16/17 indicated a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes tunneling and undermining) sacral wound. The wound clinic directed the facility to: keep pressure off, order a wound vac and provided new wound care orders. Subsequent wound care clinic notes through 6/14/17 indicated a Stage 4 sacral wound. On 8/1/17 and 8/8/10 Resident 36's Skin Grid Sheets for pressure ulcers from 1/27/17 through 8/3/17 were provided. No skin sheets prior to 1/27/17 were provided. The Skin Sheets indicated they were to be completed weekly and revealed the following: * The first entry on the skin sheet dated 1/27/17 indicated a Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister). The date the pressure ulcer was first identified was not indicated. * On 2/6/17 the pressure ulcer was staged at a level 2. Subsequent weekly assessments through 7/21/17 did not indicate the stage of the pressure ulcer. * The 2/17/17 entry was four days late. * The 5/2/17 entry was 17 days late, the 5/13/17 entry was four days late and the 5/25/17 entry was five days late. * The 7/14/17 entry was two days late and indicated 100% granulation. On 7/21/17 the wound was noted with 30% slough and improved. * On 7/27/17 the pressure ulcer was staged at a level 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling). On 7/13/16 Resident 36's Pressure Ulcer care plan was updated to include, when (Resident 36) start (sic) to whine and or cry sometimes (she/he) wants to go to the (bathroom) but has difficulty expressing (her/himself), offer toileting at this time. No other care plan updates related to the pressure ulcer were included after 7/1/3/16. No RN assessment of the pressure ulcer was found in the medical record which included evaluation of the resident's clinical condition, implementation of the care planned interventions and/or the need to revise those interventions and, it was not determined if the pressure ulcer was avoidable. The resident was on hospice and passed away at the facility on 8/7/17 without an opportunity for a nurse surveyor to observe the resident's wound. On 8/4/17 at 2:43 pm Staff 41 (CNA) stated when she first worked with Resident 36 two and a half years ago the resident was a two person assist for care, talkative and outgoing. Six months ago Resident 36 was a complete hoyer and one month ago was fully dependent for all care. Resident 36 was currently on hospice. On 8/7/17 at 9:11 am Staff 11 (CNA) stated Resident 36 was fully dependent for care and was that way for awhile. Prior to Resident 36's decline staff got her/him up with a hoyer and provided all care. On 8/7/17 at 11:53 am Staff 16 (LPN) stated Resident 36's dressing was done that day and the wound looked about the same. Staff 16 stated she could feel bone inside the wound, the tissue was granulated and was a stage 4. Staff 16 stated a week earlier the wound was a Stage 4, the peri area was pink, there was a lot of red drainage with odor and no tunneling. On 8/8/17 at 11:43 am Staff 12 (CNA) stated Resident 36 was less alert and experienced changes in her/his ability to communicate about two months ago. Staff 12 stated she repositioned Resident 36 every two hours and the resident preferred one side over the other. Resident 36 was dependent for all care. As Resident 36 declined staff would get her/him out of bed if the resident wanted to but toward the end she/he did not want to get up. On 8/10/17 at 7:46 am Staff 20 (RN) stated Resident 36 had a wound vac at one point and it was discontinued when the resident was admitted to hospice. Staff 36 did not know when the wound first developed or if a pressure relieving mattress was in place. Staff 36 stated Resident 36 was compliant with repositioning. On 8/10/17 at 9:11 am Staff 44 (CNA) stated Resident 36 had a wound vac, he repositioned Resident 36 and used pillows to keep to try and keep pressure off her/his coccyx area. Staff 44 stated Resident 36 did not refuse repositioning. On 8/10/17 Staff 12 (CNA) stated she was unable to recall when Resident 36's pressure ulcer developed but it had been there for quite some time. At the time the pressure ulcer developed Resident 36 was more alert and got out of bed but for the past two months was bedbound. Staff 36 stated the resident had a wheelchair cushion but could not recall if there was an air mattress. Staff 12 stated she repositioned the resident and would prop the resident off her/his back with pillows under her/his hips and alternate the resident onto her/his sides. Staff 12 stated if the resident was left too long the side of her/his face would swell, if she/he was repositioned every two hours no swelling occurred. Staff 12 stated during the time Resident 36 was bedbound she found the resident's face swollen on one side three different times and reported to the charge nurse that the night shift needed to reposition the resident more frequently. On 08/10/2017 at 12:58 pm Staff 28 (Interim DNS) was unable to locate an assessment of the pressure ulcer to indicate the pressure ulcer was avoidable or unavoidable or whether developed interventions were re-assessed to determine efficacy. Staff 28 acknowledged the documentation on the skin sheets was not completed and agreed 100% slough one week to 30% granulation the next would not be considered an improvement. 2. Resident 77 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. Resident 77's care plan dated 7/21/17 indicated the resident had a pressure ulcer and weekly skin assessments were to be completed. Resident 77's Skin Grid Sheets for pressure ulcers from 7/3/17 through 7/24/17 indicated Resident 77 had a pressure ulcer on her/his left buttock. The weekly Skin Grid Sheets indicated the following: *On 7/3/17 Resident 77's pressure ulcer was identified as both a Stage 1 (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) and a Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister ) wound. *The subsequent entry was dated on 7/15/17, five days late. *On 7/18/17 and 7/24/17 the wound was identified as a Stage 1 and Stage 2 pressure ulcer. The Center for Medicare and Medicaid Services (CMS) directs staging of a pressure ulcer in the Resident Assessment Instrument (RAI) as follows: If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. On 8/7/17 at 11:51 am Staff 38 (RN) stated she documented on the skin sheets to indicate Resident 77's pressure ulcer was a Stage 1 and a Stage 2. Staff 38 stated the wound was open but was currently closed. On 8/8/17 at 12:04 pm Staff 27 (Visiting DNS) confirmed the inaccuracy of the wound staging. 3. Resident 32 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Weekly Skin Grid reports dated 6/13/17 through 6/28/17 noted measurements of right and left buttock wounds, color of wound beds, odor and appearance of the wound beds but failed to identify visualized thickness of the wounds. Resident 32's Quarterly MDS completed on 7/10/17 indicated Resident 32 required extensive assistance for all ADLs. The next weekly Skin Grid report was completed on 7/20/17, which was 15 days late and it failed to identify visualized thickness of the wound. Weekly Skin Grid reports dated 7/27/17 through 7/28/17 noted measurements of right and left buttock wounds, color of wound beds, odor and appearance of the wound beds but failed to identify visualized thickness of the wounds. On 8/3/17 at 1:26 pm Resident 32 declined to be interviewed and did not want any observations related to her/his wound care treatments. On 8/9/17 at 7:57 am Staff 12 (CNA) stated Resident 28 directs her/his own care and can reposition herself/himself while in bed and she stated the resident does not like to lay on her/his side. On 8/10/17 at 11:58 am Staff 20 (RN) stated she provided daily dressing changes to Resident 32's right and left buttock region. She stated weekly Skin Grid sheets were to be completed weekly and documented. She further stated Resident 32 went to a wound care clinic once a week and she/he had multiple co-morbidities and healing to the buttock region was very slow. On 8/10/17 at 1:34 pm Staff 28 (Interim DNS) acknowledged the weekly Skin Grids were not complete or timely. She stated she expected staff to do weekly wound assessments and complete all documentation on the Skin Grid form.

Based on interview and record review it was determined the facility failed to recognize, monitor and assess for severe weight loss for 1 of 4 sampled residents (#16) reviewed for nutrition. This resulted in Resident 16 developing a severe weight loss. Finding include: Resident 16 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident 16 was discharged from the facility on [DATE] for volume depletion and readmitted back to the facility [DATE]. The [DATE] MDS Admission Nutritional status CAA indicated Resident 16 was at minimal risk for nutritional issues and no care plan would be developed. The MDS also indicated a BIMS (brief interview for mental status) score of 15 out of 15 (which indicated no cognitive impairment) for the resident. The [DATE] Registered Dietitian (RD) assessment indicated Resident 21's admission weight was 176.1 pounds on [DATE] with usual body weight of 200 pounds. Resident 16's meal intake averaged from 25% to 60%. The assessment indicated the resident had high protein needs with venous ulcers. It was indicated hospital records had a recorded weight of 139.1 pounds, with a 61 pound weight loss over the past year. The resident was spoken to about the importance of good nutrition and healing and had agreed to a strawberry supplement between meals. Recommendations included a start of house supplement, continued yogurt in place of eggs and change of diet to general/regular (from a high protein diet). A physician order [REDACTED]. The house supplement was discontinued [DATE] due to the resident's discharge back to the hospital. The [DATE] care plan indicated the following interventions related to nutrition: *Serve a diet high in bulk in roughage (bran, whole grains, nuts, seeds, fresh and died fruits and raw vegetables) related to the resident bowel incontinence. *Monitor nutritional status, RD referral and supplements related to skin impairment. *Monitor nutritional status if significant weight loss is noted then notify MD and RD related to skin impairment related to ADL abilities and other co-morbidities. No specific nutritional risk care plan could be located in the care plan. Resident 16's weight record indicated the resident lost weight since her/his admission, indicating a severe weight loss. Resident 16's weight records included the following weights: *[DATE]- 176.1 *[DATE]- 153.2, this is a 22.9 pound weight loss or 13% of her/his total body weight in 23 days. *[DATE]-146.8, this is a 29.3 pound weight loss or 16.6% in 41 days. *[DATE]- 141.0, this is a 35.1 pound weight loss or 19.9% in 54 days. *[DATE]- 156.6, this is a 19.5 pound weight loss or 11% in 59 days. *[DATE]- 139.6, this is a 36.5 pound weight loss or 20.7% in 76 days. *[DATE]- 145, this is a 31.1 pound weight loss or 17.5% in 86 days since admission. Review of [DATE] MAR indicated [REDACTED]. Review of the July and [DATE] MAR indicated [REDACTED]. Resident 16 refused the Ensure every time except once with a comment on [DATE] indicating the resident stated it tasted like chalk. There was no documentation in Resident 16's medical record the RD or physician was notified of the severe weight loss or indication the resident was reassessed due to her/his weight loss. On [DATE] at 8:51 am Resident 16 stated she/he did not get fresh fruits very often, was provided only wheat bread not whole grains, only served cooked vegetables and his family had to purchase nuts for her/him. The resident further stated he did not like the health shakes (chocolate or strawberry) as they were too sweet and therefore she/he refused to drink it. On [DATE] at 12:09 pm Staff 43 (CNA) stated Resident 16 had a poor appetite and stated breakfast was the resident's best meal. Staff 43 stated the resident only sometimes received fresh fruits and was not served whole grains or raw vegetables that she had seen. On [DATE] at 8:25 am Staff 10 (CNA) Stated Resident 16's appetite varied. He stated the resident was not a breakfast eater but did eat her/his lunch most of the time. Staff 10 stated resident was offered fresh fruits sometimes and was not sure if she/he was offered whole grains and the resident's family provided the nuts as the facility did not offer it. On [DATE] at 9:32 am Staff 27 (Visiting DNS) with Staff 28 (Interim DNS) present, confirmed there was not a care plan in place for Resident 16 addressing her/his risk for weight loss. Staff 27 acknowledged the resident did have a significant weight loss since admission with no new interventions or reassessment completed.

Based on interview and record review it was determined the facility failed to assess, reassess and respond to a resident's change in condition and request to go to the hospital for 1 of 3 sampled residents (#1) reviewed for change in condition. Resident 1 experienced complaints of breathing difficulties for approximately three hours before the resident called 911 her/himself, was transported to the hospital and died later the same day. Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident died at the hospital on [DATE]. On [DATE] at 12:01 pm Witness 1 (Complainant) stated on [DATE] at 8:30 am she and Witness 3 (Resident 1's son) received a phone call from Resident 1 but the resident was unable to make her/himself understood. A facility CNA (not named) picked up the phone and stated the resident could not breathe well and wanted to go to the hospital but the nurse was not going to send the resident. Witness 1 stated they called the facility back and spoke to Staff 3 (LPN) who told them she thought the resident may have an upper respiratory infection or pneumonia and did not want the resident to be exposed to other germs at the hospital. Staff 3 told them she would call the physician and ask for a chest x-ray. Staff 3 called back later to tell them the resident had called 911 her/himself and went to the hospital. Witness 1 stated they called the hospital and were told they needed to get to the hospital right away. Resident 1's [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In a Progress Note dated [DATE] at 6:10 pm Staff 3 (LPN) documented Resident 1 C/O (complained of) SOB (shortness of breath). LCTA (lungs clear to auscultation). Declined to get out of bed for wt (weight) or smoking today. In a Progress Note dated [DATE] at 1:25 pm Staff 3 (LPN) documented Resident 1 was A&O (alert and oriented). C/O SOB, O2 sat (oxygen saturation) 80% on 4L (of oxygen) via n/c (nasal cannula). Neb Tx (breathing treatment) given with improvement of O2 sat to 93%. Resident called 911 on cell phone and went to ER. Now admitted . On [DATE] at 6:51 pm the note was edited to change the time from 1:25 pm to 10:00 am. A review of Resident 1's hospital ED Physician Record dated [DATE] revealed the resident was admitted to the emergency roiagnom on [DATE] at 10:18 am for acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen) and hypercapnia (high carbon [MEDICATION NAME]). Resident 1 complained of shortness of breath since 1:00 am. The paramedics reported the resident needed oxygen at 8 liters per minute via a non-rebreather mask to get an oxygen saturation of 100%. The paramedics administered [MEDICATION NAME] (diuretic) intravenously in route to the hospital for significant fluid overload. The physician discussed the resident's very poor condition with the family and she/he was in acute [MEDICAL CONDITION]. The resident did not want to be intubated and became unresponsive likely due to hypercapnia. The physician discussed comfort care for the resident to which the family agreed. On [DATE] at 4:01 pm Staff 6 (CNA) stated Resident 1 was having trouble breathing for a couple of days and on the morning of [DATE] the resident was struggling more to breathe. At approximately 6:30 am the resident's oxygen saturation reading was 84% (low) and she notified Staff 3 who stated she needed to finish her medication administration pass and the physician had ordered a urinalysis which needed to be done first. Staff 6 stated Resident 1 called Witness 3 but couldn't talk and the resident handed her the phone. She told Witness 3 the resident wanted to go to the hospital. Staff 6 stated she was in and out of the resident's room all morning. Staff 6 stated when she told Staff 3 the resident called 911 Staff 3 responded I thought I talked the son out of that. Staff 6 stated she did not see Staff 3 assess the resident or provide a breathing treatment and Staff 3 kept saying she had to do her medication administration pass. Staff 6 stated the resident was using accessory muscles to breathe and she told Staff 3 the resident looked like a fish out of water. Staff 6 acknowledged the resident appeared to be in distress. On [DATE] at 2:28 pm Staff 7 (CNA) stated on the morning of [DATE] when she and Staff 6 entered Resident 1's room the resident expressed her/his inability to breathe. She stated they told Staff 3 about the resident's complaints and the resident's oxygen saturation was 83% while on four liters per minute of oxygen. The resident stated she/he wanted to go to the hospital and they encouraged her/him to call Witness 3. When Staff 3 was told the resident wanted to go to the hospital she responded there was nothing they can do I can't. Staff 7 stated she was in the resident's room for about two hours and never saw Staff 3 enter the room to assess the resident or provide treatment, even after the paramedics arrived. Staff 7 stated the resident looked like a fish out of water, was audibly wheezing and acknowledged the resident was using accessory muscles to breath. On [DATE] at 3:47 pm Staff 8 (CNA) stated he worked with Resident 1 on [DATE] and the resident was not feeling well, had difficulty breathing and felt like an elephant was on her/his chest. Staff 8 stated Staff 3 was aware of the resident's concerns. On [DATE] at 9:18 am Staff 12 (RN) stated on [DATE] Resident 1 was not her patient that day but Staff 6 (CNA) approached her that the resident was having difficulty breathing and had asked Staff 3 to assess her but did not think Staff 3 did so. Staff 12 stated she went into the resident's room a few minutes after the resident had already called 911 and the resident sounded like she/he was underwater from the congestion. Staff 12 stated she could audibly hear the resident's breathing before she even pulled the privacy curtain back. The resident's breathing was labored, she/he was using accessory muscles to breathe and had difficulty getting words out. On [DATE] at 11:01 am, [DATE] at 11:14 am and [DATE] at 9:25 am Staff 3 stated prior to [DATE] Resident 1 had complained more frequently of shortness of breath and on [DATE] at about 7:00 am Resident 1 woke up short of breath, the resident's oxygen saturation was 79%, had coarse lung sounds and was working to breathe. Staff 3 stated she gave the resident a breathing treatment, the resident's lungs cleared up and oxygen saturation came up to 93%. About 15 minutes later the CNAs informed her the resident wanted to go to the hospital. Staff 3 stated she spoke with the resident about calling the physician for a chest x-ray instead of going to the hospital and the resident agreed to that plan. Staff 3 stated the resident received her/his scheduled medications, had breakfast and did not complain of further shortness of breath. Staff 3 stated it was on her to-do list to call the physician and request a chest x-ray but did not feel it was urgent and did not think the resident was going to die. Staff 3 acknowledged she could not say if she assessed the resident after the CNAs notified her the resident wanted to go to the hospital. Staff 3 stated she did not chart on the Medication Administration Record [REDACTED]. When Staff 3 was asked why the Progress Note she wrote on [DATE] did not include an assessment of Resident 1's lung sounds and breathing effort, the resident's request to go to the hospital, Staff 3's conversation with Witness 3 and the plan to contact the physician for a chest x-ray. Staff 3 stated she made a lousy note. A review of Resident 1's clinical record revealed no documentation to indicate the resident's respiratory status was assessed, reassessed, monitored, ordered PRN breathing treatment administered or that the physician was promptly notified of the resident's significant change in condition from when the resident complained of shortness of breath at approximately 6:30 am until approximately 10:00 am when the resident activated emergency medical services her/himself. On [DATE] at 12:30 pm Staff 1 (DNS) acknowledged Resident 1 was in discomfort and Staff 3 (LPN) should have notified the physician right away. Staff 1 stated when the CNA notified Staff 3 the resident wanted to go to the hospital, Staff 3 should have done a complete respiratory assessment of the resident and should have documented that assessment. Staff 1 acknowledged the Progress Note written by Staff 3 on [DATE] was not a comprehensive assessment of Resident 1's respiratory status and did not meet her expectations.

Based on interview and record review it was determined the facility failed to promptly notify the physician of a change in resident condition for 1 of 3 sampled residents (#1) reviewed for change in condition. Resident 1 experienced complaints of breathing difficulties for approximately three hours before the resident called 911 her/himself, was transported to the hospital and died later the same day. Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident died at the hospital on [DATE]. In a Progress Note dated [DATE] at 1:25 pm Staff 3 (LPN) documented Resident 1 was A&O (alert and oriented). C/O (complained of) SOB (shortness of breath), O2 sat (oxygen saturation) 80% on 4L (of oxygen) via n/c (nasal cannula). Neb Tx (breathing treatment) given with improvement of O2 sat to 93%. Resident called 911 on cell phone and went to ER. Now admitted . On [DATE] at 6:51 pm the note was edited to change the time from 1:25 pm to 10:00 am. A review of Resident 1's clinical record revealed no indication the resident's physician was notified of the resident's significant change in condition, request to go to the hospital or to request a chest x-ray. On [DATE] at 11:01 am, [DATE] at 11:14 am and [DATE] at 9:25 am Staff 3 stated prior to [DATE] Resident 1 complained more frequently of shortness of breath and on [DATE] at about 7:00 am Resident 1 woke up short of breath, the resident's oxygen saturation was 79%, had coarse lung sounds and was working to breathe. Staff 3 stated she gave the resident a breathing treatment, the resident's lungs cleared up and oxygen saturation came up to 93%. About 15 minutes later the CNAs informed her the resident wanted to go to the hospital. Staff 3 stated she spoke with the resident about calling the physician for a chest x-ray instead of going to the hospital and the resident agreed to that plan. Staff 3 stated it was on her to-do list to call the physician and request a chest x-ray but did not feel it was urgent and did not think the resident was going to die. Refer to F-309

Based on interview and record review it was determined Staff 3 (LPN) failed to promptly intervene and act upon a resident's complaint of ongoing respiratory difficulty and the resident's desire to go to the hospital, to promptly notify the physician and to accurately and comprehensively document a resident assessment according to professional standards for 1 of 3 sampled residents (#1) reviewed for change in condition. Resident 1 experienced complaints of breathing difficulties for approximately three hours before the resident called 911 her/himself, was transported to the hospital and died later the same day. Findings include: Oregon Administrative Rule 851¿045¿0040 indicated the following: Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; Oregon Administrative Rule 851¿045¿0050 indicated the following: Scope of Practice Standards for Licensed Practical Nurses (2) Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. Under the clinical direction of the RN or other licensed provider who has the authority to make changes in the plan of care, and applying practical nursing knowledge drawn from the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Licensed Practical Nurse shall: (a) Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status; and (E) Validating data by utilizing available resources, including interactions with the client and health team members. (A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling; and (B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner; (e) Evaluating client responses to nursing interventions and progress toward desired outcomes. Oregon Administrative Rule 851¿045¿0070 indicated the following: Conduct Derogatory to the Standards of Nursing Defined Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. (b) Neglecting a client. The definition of neglect includes, but is not limited to, carelessly allowing a client to be in physical discomfort or be injured. (3) Conduct related to communication: (a) Inaccurate recordkeeping in client or agency records. (b) Incomplete recordkeeping regarding client care; including, but not limited, to failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given. (g) Failing to maintain client records in a timely manner which accurately reflects management of client care, including failure to make a late entry within a reasonable time period. (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co¿worker) in an ongoing and timely manner; and Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The resident died at the hospital on [DATE]. On [DATE] at 12:01 pm Witness 1 (Complainant) stated on [DATE] at 8:30 am she and Witness 3 (Resident 1's son) received a phone call from Resident 1 but the resident was unable to make her/himself understood. A facility CNA (not named) picked up the phone and stated the resident could not breathe well and wanted to go to the hospital but the nurse was not going to send the resident. Witness 1 stated they called the facility back and spoke to Staff 3 (LPN) who told them she thought the resident may have an upper respiratory infection or pneumonia and did not want the resident to be exposed to other germs at the hospital. Staff 3 told them she would call the physician and ask for a chest x-ray. Staff 3 called back later to tell them the resident had called 911 her/himself and went to the hospital. Witness 1 stated they called the hospital and were told they needed to get to the hospital right away. Resident 1's [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In a Progress Note dated [DATE] at 6:10 pm Staff 3 (LPN) documented Resident 1 C/O (complained of) SOB (shortness of breath). LCTA (lungs clear to auscultation). Declined to get out of bed for wt (weight) or smoking today. In a Progress Note dated [DATE] at 1:25 pm Staff 3 (LPN) documented Resident 1 was A&O (alert and oriented). C/O SOB, O2 sat (oxygen saturation) 80% on 4L (of oxygen) via n/c (nasal cannula). Neb Tx (breathing treatment) given with improvement of O2 sat to 93%. Resident called 911 on cell phone and went to ER. Now admitted . On [DATE] at 6:51 pm the note was edited to change the time from 1:25 pm to 10:00 am. A review of Resident 1's hospital ED Physician Record dated [DATE] revealed the resident was admitted to the emergency roiagnom on [DATE] at 10:18 am for acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen) and hypercapnia (high carbon [MEDICATION NAME]). Resident 1 complained of shortness of breath since 1:00 am. The paramedics reported the resident needed oxygen at 8 liters per minute via a non-rebreather mask to get an oxygen saturation of 100%. The paramedics administered [MEDICATION NAME] (diuretic) intravenously in route to the hospital for significant fluid overload. The physician discussed the resident's very poor condition with the family and she/he was in acute [MEDICAL CONDITION]. The resident did not want to be intubated and became unresponsive likely due to hypercapnia. The physician discussed comfort care for the resident to which the family agreed. On [DATE] at 4:01 pm Staff 6 (CNA) stated Resident 1 was having trouble breathing for a couple of days and on the morning of [DATE] the resident was struggling more to breathe. At approximately 6:30 am the resident's oxygen saturation reading was 84% (low) and she notified Staff 3 who stated she needed to finish her medication administration pass and the physician had ordered a urinalysis which needed to be done first. Staff 6 stated Resident 1 called Witness 3 but couldn't talk and the resident handed her the phone. She told Witness 3 the resident wanted to go to the hospital. Staff 6 stated she was in and out of the resident's room all morning. Staff 6 stated when she told Staff 3 the resident called 911 Staff 3 responded I thought I talked the son out of that. Staff 6 stated she did not see Staff 3 assess the resident or provide a breathing treatment and Staff 3 kept saying she had to do her medication administration pass. Staff 6 stated the resident was using accessory muscles to breathe and she told Staff 3 the resident looked like a fish out of water. Staff 6 acknowledged the resident appeared to be in distress. On [DATE] at 2:28 pm Staff 7 (CNA) stated on the morning of [DATE] when she and Staff 6 entered Resident 1's room the resident expressed her/his inability to breathe. She stated they told Staff 3 about the resident's complaints and the resident's oxygen saturation was 83% while on four liters per minute of oxygen. The resident stated she/he wanted to go to the hospital and they encouraged her/him to call Witness 3. When Staff 3 was told the resident wanted to go to the hospital she responded there was nothing they can do I can't. Staff 7 stated she was in the resident's room for about two hours and never saw Staff 3 enter the room to assess the resident or provide treatment, even after the paramedics arrived. Staff 7 stated the resident looked like a fish out of water, was audibly wheezing and acknowledged the resident was using accessory muscles to breath. On [DATE] at 3:47 pm Staff 8 (CNA) stated he worked with Resident 1 on [DATE] and the resident was not feeling well, had difficulty breathing and felt like an elephant was on her/his chest. Staff 8 stated Staff 3 was aware of the resident's concerns. On [DATE] at 9:18 am Staff 12 (RN) stated on [DATE] Resident 1 was not her patient that day but Staff 6 (CNA) approached her that the resident was having difficulty breathing and had asked Staff 3 to assess her but did not think Staff 3 did so. Staff 12 stated she went into the resident's room a few minutes after the resident had already called 911 and the resident sounded like she/he was underwater from the congestion. Staff 12 stated she could audibly hear the resident's breathing before she even pulled the privacy curtain back. The resident's breathing was labored, she/he was using accessory muscles to breathe and had difficulty getting words out. On [DATE] at 11:01 am, [DATE] at 11:14 am and [DATE] at 9:25 am Staff 3 stated prior to [DATE] Resident 1 had complained more frequently of shortness of breath and on [DATE] at about 7:00 am Resident 1 woke up short of breath, the resident's oxygen saturation was 79%, had coarse lung sounds and was working to breathe. Staff 3 stated she gave the resident a breathing treatment, the resident's lungs cleared up and oxygen saturation came up to 93%. About 15 minutes later the CNAs informed her the resident wanted to go to the hospital. Staff 3 stated she spoke with the resident about calling the physician for a chest x-ray instead of going to the hospital and the resident agreed to that plan. Staff 3 stated the resident received her/his scheduled medications, had breakfast and did not complain of further shortness of breath. Staff 3 stated it was on her to-do list to call the physician and request a chest x-ray but did not feel it was urgent and did not think the resident was going to die. Staff 3 acknowledged she could not say if she assessed the resident after the CNAs notified her the resident wanted to go to the hospital. Staff 3 stated she did not chart on the Medication Administration Record [REDACTED]. When Staff 3 was asked why the Progress Note she wrote on [DATE] did not include an assessment of Resident 1's lung sounds and breathing effort, the resident's request to go to the hospital, Staff 3's conversation with Witness 3 and the plan to contact the physician for a chest x-ray. Staff 3 stated she made a lousy note. A review of Resident 1's clinical record revealed no documentation to indicate the resident's respiratory status was assessed, reassessed, monitored, ordered PRN breathing treatment administered or that the physician was promptly notified of the resident's significant change in condition from when the resident complained of shortness of breath at approximately 6:30 am until approximately 10:00 am when the resident activated emergency medical services her/himself. On [DATE] at 12:30 pm Staff 1 (DNS) acknowledged Resident 1 was in discomfort and Staff 3 (LPN) should have notified the physician right away. Staff 1 stated when the CNA notified Staff 3 the resident wanted to go to the hospital, Staff 3 should have done a complete respiratory assessment of the resident and should have documented that assessment. Staff 1 acknowledged the Progress Note written by Staff 3 on [DATE] was not a comprehensive assessment of Resident 1's respiratory status and did not meet her expectations. Refer to F-309

Based on observation, interviews and record review it was determined the facility failed to assess the resident's ability to use a call light to obtain assistance with transfers, provide supervision and update care plans for three of four sampled residents (#s 1, 3 and 4) reviewed for falls. Resident 4 fell and sustained a broken left clavicle (collarbone). Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident as a low risk for falls. The 2/19/15 In Room Care Plan indicated the resident was to have non-skid footwear, keep clutter to a minimum, personal belongings within reach and bed in low position with wheels locked. The resident was a two person maximum assistance with transfers and toileting. The 2/19/15 NN indicated the resident had an unwitnessed fall at 10:30 am in her/his room. The NN indicated the resident was found on her/his left side facing the bed. The CNA and family member stated the resident had been on the bedside commode and she/he got up to obtain some personal wipes which were not within reach. The neuro checks were with normal limits. The resident complained of a headache, bruising and swelling developed on her/his posterior left side of her/his head. The 2/20/15 NN written at 3:43 am indicated the resident had no latent injuries related to fall. No complaint of head pain. Resident was a two person assist to bed side commode with supervision. The 2/20/15 NN written at 1:17 pm indicated the resident was transported to another facility in the local area. An x-ray performed on 2/21/15 revealed the resident had a broken left clavicle. The facility's investigation of the incident indicated Resident 4's family member went into the resident's room and the resident was on the bedside commode with no facility staff in the room. The family member went to obtain tissues and when she turned back around the resident was on the floor. The facility's investigation revealed Staff 9 was the CNA who put the resident on the bedside commode. Staff 9 stated I answered the light, she was not my patient. I got (her/him) up on the BSC (bedside commode) then I went to get up one of my patients who had to be up for an appointment. Staff 9 stated the resident transferred well and she felt the resident was safe. When Staff 9 was asked how she transferred the resident she said extensive assist of one. When asked what the in room care plan directive indicated, Staff 9 stated there wasn't one in the closet. When asked how she knew how to transfer the resident Staff 9 stated I saw Staff 13 (CNA) transfer the resident that way earlier in the morning. When asked if she notified anyone that the resident was on the BSC she said she told Staff 13 (CNA).I heard in the hallway and it was intention that she (Staff 13) take over. You can ask Staff 7 (CNA) she was standing there too. Staff 7 (CNA) was interviewed and was asked did you hear (Staff 9) (CNA) tell (Staff 13) (CNA) that the resident was on the BSC? Staff 7 stated yes, I heard her say-'I put (Resident 4) on the BSC.' I wasn't sure if she meant that she had put (her/him) on and off or if (she/he) was still on (the BSC). I really couldn't' tell. (Staff 13) (CNA) was also talking at the same time. There was no documentation Staff 13 (CNA) was interviewed as a part of the incident investigation. The investigation contained an interview conducted with Witness 3 (family member) to indicate the resident was found sitting on the commode. Witness 3 stated Resident 4 stated she/he put the call light on. Witness 3 checked to see if the resident's call light was on and Witness 3 determined the resident pushed the bed control instead of the the call light. Witness 3 stated she (Witness 3) put the call light on. Witness 3 stated Resident 4 requested to be cleaned up after using the bedside commode. Witness 3 went into the bathroom to get some tissue and when she returned the resident had fallen off of the bedside commode onto the floor. Witness 3 went to the resident's door way to summon help. The investigation form contained a statement in the category of neglect to indicate facility staff demonstrates a serious disregard for circumstances with clear and present danger to resident. The answer to the question was Yes. The findings documented Staff 9 (CNA) was trying to be helpful in responding to the call bell in another section from hers. She did place the resident on the BSC. Staff 9 felt the resident transferred well and had sufficient strength to sit for a few minutes unattended while she went to report to the CNA who was assigned to the resident. The resident did not fall immediately. The resident's family member was present in the room at the time of the fall. The investigation determined no abuse was substantiated.Although there was a lack of good judgement in regards to leaving a stroke patient alone on the BSC. The CNA in question (Staff 9) did go and report to the assigned CNA (Staff 13) with the intent that CNA would follow up. No intended abuse or neglect. There was an immediate inservice via walking rounds given to the CNAs related to leaving residents unattended on toilet or BSC. LN (licensed nurses) reeducated via written memo to completed IRCP (in room care plan) and place in resident's closet within 2 hours of admit to facility. On 5/4/15 at 6:19 pm Staff 8 (CNA) stated sometimes it was difficult to contact and locate other CNAs and charge nurses when there were problems or when CNAs needed additional assistance. On 5/515 at 9:58 am Staff 4 (RN) stated she was the charge nurse who assessed the resident after the fall and initiated the incident investigation. Staff 4 stated the room was not set up well for a resident with a stroke as the commode was not near the resident's bed. Staff 4 stated there were no supplies of toilet paper or personal wipes within reach of the commode. On 5/5/15 at 11:55 am Staff 7 (CNA) stated she was present when Staff 9 (CNA) informed Staff 13 (CNA) Resident 4 had been assisted to the bedside commode. Staff 7 stated it was unclear if the resident was on the commode and needed assistance or if Staff 9 informed Staff 13 the resident had been toileted. On 5/5/15 at 1:38 pm Staff 5 (LPN-Care Manager) and Staff 2 (RN/future DNS) were interviewed. Staff 5 stated the facility staff assisted the resident onto the bedside commode and left her/him unattended. The facility provided inservices to staff not to leave residents unattended on bedside commodes and to ensure the care plans were updated. On 5/11/15 at 11:26 am Staff 9 (CNA) stated she was not assigned to care for Resident 4 on 2/19/15. Staff 9 stated she answered the call light and assisted the resident onto the commode. Staff 9 stated there was no in room care plan regarding the resident's care. Staff 9 stated another call light was on and she left Resident 4 alone on the commode to assist the other resident. Staff 9 stated she immediately informed Resident 4's assigned CNA, Staff 13, the resident was on the commode. Staff 9 stated it was not her normal practice to leave a resident alone on the commode when she was not sure of the amount of care the resident required. Staff 9 stated she was not thinking and should have put the call light on to indicate the resident required assistance. Staff 9 stated she should have asked the charge nurse the amount of care the resident required. Staff 9 stated the resident was able to transfer easily to the commode and thought she informed Staff 13 (assigned CNA) Resident 4 was on the commode. On 5/11/15 at 1:48 pm Staff 13 (CNA) stated she was the CNA assigned to care for Resident 4. Staff 13 stated her CNA partner was Staff 9 (CNA) answered call lights and she answered call lights for her. Staff 13 stated she did not hear Staff 9 state Resident 4 was on the commode. Staff 13 stated if she had been aware of the situation, she would have immediately went into the room. Staff 13 stated she personally would never have left the resident unattended on the commode. Staff 13 was not able to recall if there was an in room care plan in the resident's room and could not remember the number of CNAs the resident required for transfers. Staff 13 stated she could not recall being interviewed about the incident. Staff 13 stated the facility staff were inserviced never leave a resident unattended on a commode. On 5/12/15 at 4:19 pm Witness 3 (Resident 4's family member) stated Resident 4 was admitted to the facility on [DATE] at 7:00 pm. Witness 3 stated she had an appointment with the facility on 2/19/15 at 11:00 am though she arrived at 10:30 am. Witness 3 stated she found the resident sitting on the commode without staff assistance. Witness 3 stated she asked Resident 4 if she/he was finished, went to get wipes and the resident fell from the commode. Witness 3 stated the resident complained of pain and received an ice pack. Witness 3 stated Resident 4 was transferred to another local facility and x-rays revealed a broken left clavicle. On 5/20/15 Staff 1 (Administrator) provided additional information to indicate Resident 4 was assessed to be a low risk for falls, was able to use the call light for assistance and a family member was in the room at the time of the fall. On 6/2/15 at 11:20 am Staff 14 (Interim DNS) stated Resident 4 was identified to be able to use the call light. Staff 14 stated Staff 9 (CNA) responded to the resident's call light and assisted the resident onto the bedside commode. Staff 14 stated Staff 9 CNA informed the assigned CNA (Staff 13) the resident had been assisted to the bedside commode. Staff 14 stated Witness 3 (family member) was in the room when the resident fell . Staff 14 stated Witness 3 reported the resident thought she/he pushed the call light when she/he pushed the bed controls. Staff 14 stated she assessed the resident after the fall and the resident only complained of a head injury with no limitations of Range of Motion. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history and physical indicated the resident had been hospitalized a few weeks before the recent hospital admission for a fall also with delirium. The local hospital physical therapy assessment indicated the resident loses balance without recovery.impulsive.does not demonstrate safety skills.not safe with mobility.able to ambulate with CGA (contact guard assist) at times but then will lean backward pulling off FWW (front wheeled walker) off ground and rely on PT (Physical Therapist) to maintain balance. The resident was assessed by the facility to be a high fall risk and the interventions in place were non-skid footwear, keep belongings within reach, orient resident to surroundings, call light, keep clutter to a minimum, cue/remind resident to ask for help prior to self transfer and frequent safety checks. There was no evidence the facility thoroughly assessed the resident's dementia in regard to her/his ability to use the call light and to ask for assistance with transfers. The 3/9/15 NNs indicated the resident was admitted to the facility on 6:44 pm. The 3/9/15 NNs written at 11:15 pm indicated the resident was ambulating in her/his room, carrying her/his dentures to the sink when she/he lost balance and fell to the floor. The NNs indicated the fall was unwitnessed although a CNA stated she heard the resident hit the floor and was quick to find the resident. Resident 1 was found lying on her/his left side. Resident 1 reported she/he hit her/his head on the wall as she/he was falling. The notes indicated the resident complained of pain to her/his left hip. The resident was able to bear weight and required the assistance of two to be placed in bed. Resident 1's assessment indicated she/he sustained a hematoma to her/his left forehead; slightly raised and 2.5 cm diameter light purple in color. The NNs indicated CNA sitting at bedside for time being. The 3/9/15 NNs written at 11:50 pm indicated CNA has stayed at resident bedside in between other work, due to resident restlessness and frequent vital sign checks from previous fall. The 3/10/15 NNs written at 1:08 am indicated CNA was sitting right outside (Resident 1's) due to frequent checks related to restlessness and vital signs from previous fall, another resident light (call light) came on and CNA went to answer it. CNA reports that she heard a loud thump and went back to this resident room to find resident on the floor between foot of the bed and the wall. Resident lying on (her/his) back moaning in pain. Initial observation from LN (licensed nurse) Lt (left) leg distorted, approx (approximately) six inches longer in length than Rt (right) leg and turned out at awkward angle. Resident hold hip crying 'is it broken?' Resident encouraged not to move while waiting for the paramedics to transport her/him to the hospital but she/he rolled to her/his Rt (right) side to attempt to find more comfortable position. Lt. (left) hip protruding from side, skin pulled taut.Taken by ambulance. The 3/10/15 local emergency department documentation revealed the resident sustained [REDACTED]. On 5/4/15 at 11:00 am Witness 2 (Family member) stated Resident 1 had difficulties walking. Witness 2 stated the resident was at the facility for five hours before she/he fell and broke her/his hip. On 5/5/15 at 1:38 pm Staff 5 (LPN-Care Manager) and Staff 2 (RN/future DNS) were interviewed. Staff 5 stated the facility staff attempted to ensure Resident 1 was safe and provided additional supervision. Staff 5 stated sometimes falls were not able to be prevented. On 5/6/15 at 7:35 am Staff 6 (CNA) stated Resident 1 constantly attempted to get out of bed. Staff 6 stated the resident was not able to use the call light. Staff 6 stated the resident needed one on one supervision because of her/his attempts to get out of bed. Staff 6 stated she/he informed the charge nurse of the situation. Staff 6 stated she parked outside of Resident 1's room though she had to answer another resident's call light and when she returned, Resident 1 was on the floor. On 5/15/15 at 10:18 am Staff 10 (LPN) stated the resident's room was at the end of the hallway. Staff 10 stated after the resident fell on ce during the night shift she had a CNA provide more frequent checks on Resident 1. Staff 10 stated there were no staff available to provide one on one observations of the resident. Staff 10 stated Staff 6 had to answer another resident's call light and Resident 1 fell . Staff 10 stated it was difficult to know how significant a fall risk the resident was immediately after admission. Staff 10 stated it was difficult to provide supervision for the resident when her/his room was at the end of the hallway and there were no staff available to provide one on one supervision. On 5/20/15 Staff 1 (Administrator) provided additional information to indicate Staff responded to (Resident 1's) first fall with an immediate new intervention, increased observation by (her/his) CNA, which is documented. In a very short window of time, on NOC (night) shift, staff had numerous interactions with (Resident 1) and acted to attempt to keep (her/him) safe. 3. Resident 3 was admitted to the facility in February 2012 with [DIAGNOSES REDACTED]. The NNs indicated the resident was found on the floor in the dining room on 4/17/15. The investigation of the incident revealed the resident was found on the floor in the dining room by the dietary aide. The fall was unwitnessed and no injuries were sustained. CNAs were reminded of the importance of bringing the resident to the nurse's station after meals to be supervised. Interventions initiated were for the resident to be by nurse's station and remind CNAs to removed resident from dining room in timely manner and not leave alone in dining room after meals. The 4/29/15 NNs indicated the resident was found on the floor in the dining room. The resident was found lying on her/his left side on the floor next to the table. There were no injuries sustained. The resident's in room care plan dated 12/18/14 did not include the interventions for the resident not to be left alone in the dining room after meals and to be brought to the nurse's station for supervision. Observations on 5/4/15 from 12:55 pm to 1:00 pm revealed Resident 3 finished eating her/his lunch meal and was seated at the dining room table. The CNAs assisted other resident out of the dining room and left the resident in the dining room. At 1:00 pm Staff 12 (CNA) asked Resident 3 if she/he wanted to lie down or to sit near the nurse's station. The resident requested to sit near the nurse's station. At 1:05 pm Staff 12 confirmed she was Resident 3's CNA and she reviewed the resident's care plan approaches. Staff 12 stated the care plan did not include the intervention for the resident not to be left alone in the dining room after meals and to be brought to the nurse's station for supervision. At 1:35 pm Staff 3 (RN Corporate Consultant) and Staff 2 (RN/future DNS) were informed of the observations and interview. Staff 3 verified the care plan was not reflective of the approaches to prevent falls in the dining room.

Based on interview and record review it was determined the facility failed to act timely for 1 of 3 sampled residents(#2)reviewed for a change in condition. Resident 2 required hospitalization and a blood transfusion. Findings include: Resident 2 was admitted to the facility in 5/2014 with [DIAGNOSES REDACTED]. The 11/2014 quarterly MDS identified Resident 2 had no short or long term memory problems. The 6/11/14 care plan indicated Resident 2 had pressure ulcers and to notify the physician "of worsening in wound or deterioration." A progress note dated 9/24/14 indicated at 4:00 am the "resident's brief and drawsheet was soaked with a large amount of blood." A progress note dated 9/24/14 at 2:13 pm indicated a "large amount of bright red blood on bed linens." Orders were received from the physician at 2:10 pm to transfer Resident 2 to the E/R for the treatment "to stop the bleeding." A hospital note dated 9/25/14 indicated Resident 2 "will need [MEDICAL CONDITION] due to acute blood loss [MEDICAL CONDITION] secondary to bleeding from (her/his) pressure ulcers." A review of Resident 2's chart revealed there was no communication with the physician about Resident 2's change of condition until approximately 2:00 pm on 9/24/14. In interview on 1/9/15 at 12:30 pm Resident 2 stated she/he was bleeding all day and was not taken to the hospital until the afternoon. In interview on 1/12/15 at 1:00 pm Staff 6, RNCM stated she had not been told about Resident 2's increased bleeding from Staff 4, RN or any other staff until Staff 5, LPN informed her at approximately 2:00 pm on 9/24/14. In interview on 1/15/15 at 1:25 pm Staff 5, LPN stated when he observed Resident 2 on 9/24/14 at about 2:00 pm she/he had a "perfuse" amount of bleeding. He was not told by any staff about Resident 2's heavy bleeding at anytime on 9/24/14. Staff 5 stated he does not remember if he observed Resident 2 prior to the 2:00 pm observation recorded in the progress notes. In interview on 1/16/15 at 7:35 pm Staff 4, RN stated she observed Resident 2 at 4:00 am on 9/24/14 and had never seen that much blood before on Resident 2. The blood was on Resident 2's sheet, draw sheet and her/his brief. She stated she did not notify the physician's office because it was early in the morning and the physician would not receive the information until later in the day. Staff 2 stated she informed Staff 5, LPN the day nurse about the bleeding and had hoped Staff 5 would have notified the physician's office. She stated she would have notified the physician but was working off the clock.

Based on interview and record review it was determined the facility failed to follow the care planned interventions for a mechanical transfer for 1 of 1 (#3) sampled resident reviewed for accidents. Failure to follow the care plan resulted in Resident 3 sustaining a fractured humerus of the right leg. Findings include: Resident 3 was readmitted to the facility in 3/2014 with [DIAGNOSES REDACTED]. The annual assessment indicated the resident was dependent for transfers on a mechanical lift with a two person assist. The 10/2014 care plan identified Resident 3 required extensive two person assist with transfers using a mechanical lift. An incident report dated 12/18/14 indicated Staff 3, CNA attempted to transfer Resident 3 alone using a mechanical lift. Staff 3 stated the mechanical lift sling shifted and she lowered Resident 3 to the floor and "I did not follow the Plan of Care and I know I should have." Resident 3 complained of knee pain and was transferred to the E/R. The incident report concluded Staff 3 failed to follow Resident 3's care plan intervention for transfers. The 12/18/14 hospital notes identified Resident 3 suffered a right femur fracture. In interview on 1/12/14 at 12:20 pm Staff 7, CNA stated he knocked on Resident 3's door and found Staff 3, CNA on the floor next to the resident. Staff 7 stated Staff 3 stated she had attempted to transfer the resident independently using a mechanical lift. In interview on 1/13/14 at 10:02 pm Staff 3, CNA stated she was waiting for another CNA to assist with the mechanical transfer but decided to transfer Resident 3 by herself. Staff 3 stated Resident 3 was not properly positioned in the mechanical lift's sling and the mechanical lift fell over. Staff 3 stated she knew Resident 3's care plan for transfers was to use a mechanical lift with two people. In interview on 1/12/15 at 2:30 pm Staff 2, DNS stated the care plan was not followed by Staff 3, CNA at the time of the fall.

1. Based on interview and record review, it was determined the facility failed to provide an environment free of illegal substances and drug paraphernalia for 1 of 3 sampled residents (#1) reviewed for substance abuse. Resident 1 was treated in the hospital for septic thrombophlebitis and was at risk for injury, infection and overdose. Other residents were at risk of exposure and injury from illegal drug use. Findings include: Resident 1 was admitted in May 2014 with [DIAGNOSES REDACTED]. Although the Admission MDS dated [DATE] included a history of drug abuse, there was no assessment and no care plan developed related to signs/symptoms and precautions to take related to drug abuse. Progress Notes dated 6/22/14 indicated the resident was very "alert, facial twitching, hand wringing. Very talkative...Was seen to have a lighter, needle nose pliers and Q-tips. Making comments about smoking crack and 'Riding the white dragon'." The physician ordered a urine drug screen, and the drug screen came back with "opiates only." Progress Notes on 7/22/14 indicated the resident spit out her/his pain medication and told the CMA not to tell. The CMA told the charge nurse who found nine pills in a drawer in the resident's room. The resident agreed to have pain medications crushed. The physician visited on 7/23/14 and nurses reported concerns the resident might have smoked illicit drugs in her/his room. A urine drug screen showed "opiates". Progress Notes on 7/28/14 indicated the resident complained of pain to her/his arm/PICC (peripherally inserted central catheter) placed for Rocephin (antibiotic) administration. Resident 1 was acting peculiar when she/he received the morning medications. The resident wanted her/his pain medications given last and asked the CMA to shut the door. A search of the room found medication powder in several areas, whole pills, cups and small wads of dressings, sterile water, syringes, needles and a butterfly IV kit. The physician was notified that Resident 1 was suspected of putting drugs into the PICC line, and the physician ordered the resident's PICC line removed and the resident sent to the emergency room . A hospital Discharge Summary dated 8/5/14 indicated the resident recently had a PICC line placed for a urinary tract infection. It was reported the resident was crushing Oxycodone and injecting into the PICC line. Subsequently the resident developed septic thrombophlebitis of the PICC line. On 8/6/14 the comprehensive Care Plan was updated in the category of psychosocial well-being: " Recent history of inappropriate behaviors toward narcotic medications and drug paraphernalia. " The approach was to refer to the behavioral care plan related to sharp objects dated 7/28/14. The comprehensive Care Plan also included a problem dated 7/28/14: "Was found to have IV equipment and sharp objects in room and bedside tables" with approaches "If sharp objects or IV supplies are brought in room, ensure that they are not left unattended or left in room at any time. Materials need to be taken with staff out of the room anytime they leave the room." The July 2014 behavior flow sheet did not include any information about sharp objects; it did list hoarding medication and drug paraphernalia at bedside (undated); there was no description of what drug paraphernalia would include. Interventions included referring to LN, Administrator, DNS and SSD. Progress Notes dated 8/10/14 indicated the resident was acting suspicious and was "high" exhibiting abnormal behavior and conversation. The administrator was contacted and resident was found with a needle in her/his hand. Syringes, needles and a substance which appeared to be heroin were found in the resident's room. The police were notified and confiscated the drugs and met with the resident. On 8/13/14 Resident 1 was observed in her/his room. The resident stated she/he did not feel good and felt warm and sweaty. The resident's eyes appeared "glassy". The resident admitted she/he went to a local store and bought heroin from someone, and she/he "saved" narcotic pain medications given to her/him by facility staff, because she/he did not need them. Resident 1 stated facility nurses left syringes, normal saline and other supplies in her/his room. Interviews were conducted 8/12/14 from 1:00 pm to 8/14/14 at 2:53 PM with Staff 4 (SSD), Staff 5 (LPN), Staff 7 (LPN), Staff 8 (CNA), Staff 9 (CNA), Staff 10 (CNA), Staff 12 (CMA). All of the staff indicated they were aware of some or all of the following related to Resident 1: suspicious behavior, hoarding or secreting pain medications, attempts to distract staff giving medications, spitting out medications and asking staff not to tell, and finding drug paraphernalia such as a lighter, needle nose pliers, syringes, needles and powdered medications. None of the staff were aware of inservice/education provided related to signs/symptoms of drug use, what objects could be suggestive of drug paraphernalia, and how to protect the resident from overdose, protect visitors and other residents from exposure to illegal drug use. On 8/14/14 at 4:11 pm a discussion with Staff 1 (Administrator), Staff 2 (DNS), and Staff 14 (Regional Corporate Director) included the incidents of apparent drug abuse. The urine drug screen showing opiates was discussed and staff acknowledged it was not possible to differentiate between heroin/illegal opiates used and opiates routinely given for pain control. No further information was provided of a thorough investigation, updated Care Plans after each incident and staff education regarding drug abuse. 2. Based on interview and record review it was determined the facility failed to provide adequate supervision to prevent accidents for 3 of 3 sampled residents (#s 1, 2 and 3). Residents 1, 2 and 3 left the facility without informing the facility. Resident 1 sustained an abrasion to her/his toes. Residents 2 and 3 returned to the facility intoxicated. Findings include: The undated facility policy indicated "Any resident leaving the facility on her/his own or with family, POA or other responsible parties ...Must sign out when leaving and sign back in when returning. Be sure to tell the Nurse(s) before you leave, so medications may be packaged up for you to take with you." Each resident had a "Sign out-Sign in sheet Release of Responsibility for leaving the facility ...I, the undersigned, hereby accept complete responsibility for the above named Resident while away from (facility). I absolve the management of this facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident was away. I understand that the resident's bed will be held until he/she returns on or before the appointed date/time. Authorization must be signed by the resident, family member, POA (power of attorney) or responsible party .... " a. Resident 2 was admitted to the facility in April 2014 with [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. According to Drugs.com the use of alcohol could alter the effects of the medication and resident was to avoid the use of alcohol. The resident was assessed to be independent in using an electric wheelchair. The 7/5/14 Interdisciplinary Progress Notes (IPN) written at 3:06 am indicated the resident had been out of the facility and returned at 11:30 pm. There was no documentation when the resident left the facility. The 7/6/14 IPN written at 1:27 am indicated the resident left the facility at 12:00 am and there was no documentation when the resident returned. The 7/10/14 IPN written at 1:03 pm indicated the resident had been out of facility since 10:00 am and there was no documentation when the resident returned to the facility. The 7/11/14 IPN written at 12:00 am indicated the resident was out of the facility until 11:00 pm. There was no documentation when the resident left the facility. The 7/11/14 IPN written at 4:27 pm indicated the resident out of facility for the afternoon and evening. At 11:53 pm indicated the resident was out of the facility. The 7/12/14 IPN written at 2:55 am indicated the resident returned to the facility at 2:00 am. The 7/25/14 IPN written at 1:22 am indicated the resident was out of facility most of the evening and returned just before midnight. The 7/25/14 IPN written at 4:11 pm indicated the resident had been out of facility most of shift. The 7/25/14 In room care plan directed the CNAs to "notify nurse if res (resident) exhibits s/sx (signs/symptoms) of intoxication such as drowsiness, slurred speech, loud voice, smell of alcohol ...." The 7/30/14 IPN written at 1:02 am indicated the resident had been out of the facility for most of the shift. The 8/1/14 IPN written at 4:30 pm indicated the resident had been out of the facility from 11:00 am through the rest of the day shift. The 8/2/14 IPN written at 12:00 am indicated the resident had been out of the facility for most of the shift. The 8/2/14 IPN written at 8:28 am indicated the resident had been out of the facility with another resident until 3:00 am. The 8/3/14 IPN written at 12:14 pm indicated Resident 2 was out of the facility until 3:00 am. The CNA reported the resident appeared intoxicated upon return to facility. Resident 2 refused breakfast and requested not to be wakened by the staff. The IPN indicated the resident's blood pressure was slightly elevated. The 8/3/14 IPN written at 10:55 pm indicated the resident was out of the building. The 11:22 pm IPN indicated the resident returned at 11:13 pm. The 8/4/14 IPN written at 5:10 am indicated the resident was in tears and yelling out at 4:30 am. Resident was gripping her/his head. Resident stated "it feels like my head is going to explode." Resident 2 was very tearful, given narcotic pain medication and stated she/he wanted to go to the hospital. The 8/4/14 IPN written at 10:05 am indicated the resident was sent to the local emergency department and diagnosed with [REDACTED]. Resident 2's sign out-sign in sheet was reviewed and there was indication the resident was signed out of the facility from 7/5/14 through 8/4/14. The resident's care plan had not been updated to provide additional interventions. There was no documentation the resident's physician was informed of the resident's behaviors. On 8/13/14 at 11:30 am Staff 9 (CNA) stated she worked as a CNA float throughout the building. Staff 9 stated Resident 2 left the faciity on numerous occasions to go to the bar with Resident 3. Staff 9 stated the charge nurse talked with Resident 2 about the impact the resident's drinking had on her/his rehabilitation. Staff 9 stated the staff were encouraging Resident 2 to make the right choices. On 8/14/14 at 2:53 pm Staff 7 (LPN) stated there was a book at the nurse's station where the residents were to sign out. Staff 7 said if residents didn't sign out and were not located the facility was to search the building and grounds. If the residents were still not found the facility staff were to call the resident's cell phone and if there was no answer the staff were to call the Administrator and the police. Staff 7 stated she encouraged the residents to return to the facility for the medications and treatments. Staff 7 stated she would not send narcotics with the residents when they left the facility. On 8/18/14 at 8:15 am Resident 2 stated she/he left the faciity on occasion. Resident 2 stated she/he "sometimes forgot to sign out." Resident 2 acknowledged she/he consumed alcohol though denied getting drunk. Resident 2 could not remember the facility talking with her/him about the need to avoid alcohol because of the medication use. On 8/18/14 at 11:30 am Staff 2 (DNS) was asked to provide documentation the resident was informed of the risks of consuming alcoholic beverages when she/he was received an antidepressant medication. Staff 2 was asked to provide documentation the resident was informed of the risks of using the electric wheelchair when she/he was under the influence of alcohol. Staff 2 was asked for documentation the resident signed out to inform the facility staff when she/he left the facility. No additional information was provided. b. Resident 3 was admitted to the facility in June 2011 with [DIAGNOSES REDACTED]. According to Drugs.com the use of alcohol was to be avoided the use of alcohol as the combination may increase CNS (Central Nervous System) effects and increase Propranolol level. The resident was assessed to be independent in an electric wheelchair. The 7/18/14 In room care plan included an approach to "Monitor for s/sx (signs and symptoms) of intoxication such as slurred speech, drowsy, alcohol smell, increased agitation and loudness ...." The 7/23/14 Interdisciplinary Progress Notes (IPN) written at 6:25 am indicated the resident was "last seen up in wheelchair around 12:15 am." The resident "left building around that time and has not been back since ...called res. (resident) cell phone x2 (twice) but res. did not answer. Res. did not sign out, nor did she/he let anyone know she/he was leaving ...." The 7/23/14 IPN written at 7:17 am indicated the resident called to say she/he was at a friend's house, "had gotten drunk and could not make it back to facility. She/he stated that she would return around noon ...." The 7/23/14 IPN note written at 4:12 pm indicated the resident was out of the facility all day. The 7/23/14 IPN note written at 4:30 pm by Staff 4 (Social Services Director/SSD) to indicate Staff 1 (Administrator) was informed of the resident's overnight absence. The 7/23/14 IPN written at 4:45 pm by Staff 4 (SSD) indicated the resident returned from her/his overnight absence. The 7/24/14 IPN indicated Resident 3's quarterly care conference was held and the resident was counseled by Staff 2 (DNS), Staff 18 (RNCM) and Staff 4 (SSD) of risks associated with the behavior of leaving the facility overnight. The 8/2/14 IPN written at 1:04 pm indicated the resident had been gone from the facility since 9:00 pm. The 8/2/14 IPN written at 2:49 am indicated the resident returned at 2:45 am and the resident stated she/he was drunk. The resident was described as being "loud, disruptive and was reminded to keep her/his voice down ...." The 8/5/14 IPN written at 2:24 pm by Staff 4 (SSD) as a late entry for 8/4/14 to indicate Staff 4 was informed and updated of the resident's behaviors. Staff 4 attempted to visit with Resident 3 and the resident was out of the facility and not available. The 8/8/14 IPN written at 11:22 am indicated Staff 18 (RNCM) spoke with Resident 3 regarding mixing alcohol and her/his medications. The resident stated she/he understood but also stated "I do need to visit my friends." The 8/9/14 IPN written at 3:04 pm indicated Resident 3 left the facility with her/his daughter and son at 1:15 pm. The 8/10/14 IPN written at 2:15 am indicated the resident returned to the facility at 2:15 am intoxicated with alcohol. The resident's care plan had not been updated to provide additional interventions. The resident's behavior flow sheet included the need to monitor the resident's behavioral changes related to potential intoxication. The documentation indicated the resident appeared intoxicated on 8/10/14. Resident 3's sign out-sign sheet was reviewed and there was no documentation the resident signed out of the facility from 7/23/14 through 8/10/14. The 8/12/14 IPN indicated there was a care conference held with the resident to discuss her/his behaviors. The documentation indicated the resident stated she/he went to the local bars "3-4 times a month and I stay until the bars close down." The interdisciplinary team discussed the risks of her/his behaviors. The 8/14/14 IPN written by Staff 2 (DNS) indicated the resident was asked if she/he had been signing in and out of the facility. Staff 2 wrote Resident 3 stated she hadn't been signing out for awhile. Staff 2 told the resident if she/he didn't sign out of the facility and was gone from the facility she/he would be treated as a missing resident and the facility would call the police to let them know someone was missing. On 8/13/14 at 11:30 am Staff 9 (CNA) stated she worked as a CNA float throughout the building. Staff 9 stated she observed Resident 3 when she/he seemed drunk and giggly. Staff 9 couldn't remember the date of the observation. Staff 9 stated Resident 3 would go to the bars on occasion. Staff 9 stated if a resident didn't sign out they were treated as a missing person. When someone was reported missing the CNAs searched the facility and told the charge nurse. Staff 9 stated Resident 3 had a cell phone and the charge nurses called the resident on her/his cell phone. On 8/14/14 at 10:27 am Staff 6 (CNA) stated Resident 3 left the facility a couple of times a week and he could smell alcohol on her/his breath. Staff 6 stated the past weekend the CNAs stated Resident 3 didn't go to bed until 4:00 am. Staff 6 stated Resident 3 had been drinking in a local bar. Staff 6 stated all of the residents needed to sign out when they left the building so the staff knew they were gone. Staff 6 stated some residents "just go." Staff 6 stated the procedure was to look throughout the facility for the resident and call the resident on the intercom for them to return to their room. If the resident was not in the building the facility staff would look outside in a three block radius and if the resident was still not found the facility would call the police. Staff 6 stated some residents had cell phones so their cell phones were called. Staff 6 stated there was a book at the nurse's station where the residents were able to sign out. On 8/14/14 at 2:53 pm Staff 7 (LPN) stated there was a book at the nurse's station where the residents were to sign out. Staff 7 said if residents didn't sign out and were not located the facility was to search the building and grounds. If the residents were still not found the facility staff were to call the resident's cell phone and if there was no answer the staff were to call the Administrator and the police. Staff 7 stated she encouraged the residents to return to the facility for the medications and treatments. Staff 7 stated she would not send narcotics with the residents when they left the facility. On 8/18/14 at 8:30 am Resident 3 stated she/he left the faciity on occasion. Resident 3 stated she/he "sometimes forgot to sign out." Resident 3 stated the facility talked with her/him about the need to avoid alcohol because of the medication use. On 8/18/14 at 11:35 am Staff 2 (DNS) stated there was no consistent documentation the resident informed the facility staff when she/he left the facility. On 8/25/14 at 1:00 pm Staff 18 (RNCM) stated she talked with the resident on numerous occasions regarding the risks of drinking alcohol and her/his medication use. Staff 18 stated Resident 3 left the facility without informing the facility staff. Staff 18 confirmed the resident's in room care plan had not been updated since 7/18/14. c. Resident 1 was admitted in May 2014 with [DIAGNOSES REDACTED]. The resident's In Room Care Plan indicated she/he required extensive one person assistance with transfers. Progress Notes dated 8/9/14 indicated the resident was out of the facility from 11:00 am to 11:00 pm. Resident 1's sign out sheet did not include a sign out for 8/9/14. On 8/10/14 the resident was acting suspicious and was "high" exhibiting abnormal behavior and conversation. The administrator was contacted and resident was found with a needle in her/his hand. The resident admitted to using heroin one time since admission to the facility when she/he was at the movies with someone. Syringes, needles and a substance which appeared to be heroin were found in the resident's room. The police were notified and confiscated the drugs and met with the resident. An Incident Report dated 8/10/14 indicated the resident was out of the facility returning at 9:30 pm. While the resident was out, her/his left foot fell off the wheelchair foot pedal and dragged on the sidewalk, causing abrasions on the foot. The resident was wearing socks only, without protective foot wear. There was no documentation protective footwear was provided or encouraged prior to the incident or after the abrasion occurred. There was no assessment of placement of the feet/legs on the wheelchair foot rests to prevent the incident from recurring. Resident 1's sign out sheet did not include a sign out for 8/10/14. On 8/14/14 at 2:53 pm Staff 7 (LPN) stated there was a book at the nurse's station where the residents were to sign out. Staff 7 said if residents didn't sign out and were not located the facility was to search the building and grounds. If the residents were still not found the facility staff were to call the resident's cell phone and if there was no answer the staff were to call the Administrator and the police. Staff 7 stated she encouraged the residents to return to the facility for the medications and treatments. Staff 7 stated she would not send narcotics with the residents when they left the facility. No further information was provided regarding the lack of signing out and in, or other evidence the facility was following the policy for Release of Responsibility for Leaving the Facility.

Based on observation, interview and record review it was determined the facility failed to ensure new pressure ulcers did not develop for 1 of 2 sampled residents (#1) reviewed for wound management. Resident 1 developed a right ischial (bony prominence on lower buttocks) ulcer and a right ankle ulcer which were not discovered until they had 100% necrotic (dead) tissue and were unstageable. The resident also sustained penile erosion related to pressure from urinary (Foley) catheter tubing, and abrasions on the left outer foot and toes. Findings include: Resident 1 was admitted in May 2014 with [DIAGNOSES REDACTED]. The sacral ulcer was a stage 4 ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The resident had a [MEDICAL CONDITION] bladder with a Foley catheter and was incontinent. An Observation Record dated 6/3/14 and Admission MDS dated [DATE] indicated the resident had pressure ulcers on her/his coccyx, left heel, left malleolus, and left hip, with the highest stage at stage 4. Large portions of food were to be provided and a nutritional supplement, med pass 2.0 cal offered four times/day to increase protein intake. Pressure reducing devices were provided for the chair and bed. The In-Room Care Plan dated 6/11/14 with an update on 7/5/14 did not include the pressure ulcers, their locations and pressure reducing devices. The comprehensive Care Plan with a start date of 6/11/14 and long term goal target date of 9/11/14 indicated the resident had pressure ulcers present. The location, severity and number of pressure ulcers was not identified and approaches/interventions did not include pressure reducing devices. Food and fluid intake was to be encouraged to ensure the resident was getting adequate calories and fluids. There was no information about the calories needed, the nutritional supplement offered and the quantity of fluids needed. The July 2014 MARs indicated the resident refused all of the med pass 2.0 cal supplements. There was no documentation of an alternative supplement offered and no risk/benefit completed with the resident which explained the risks of refusing the supplement versus the benefits of accepting it. Skin Grid Sheets and an Observation Report dated 7/8/14 indicated two new pressure ulcers were discovered, one on the right ischium and one on the right ankle. Both ulcers were unstageable due to 100% necrotic tissue when found. An Incident Report completed on 7/23/14, did not include how the pressure ulcers progressed to unstageable status before they were discovered. Although it was noted the care plan was followed, it did not include whether all devices were in place and functioning properly, and whether the resident was receiving adequate nutrition and fluids. There was no assessment of seating in the wheelchair, to determine whether the resident bumped her/his ankle on the wheelchair, if the legs/ankles needed to be secured, if protective footwear was used/needed and whether a pressure reducing cushion was in place and effective. An Incident Report dated 8/10/14 indicated the resident's left foot fell off the wheelchair foot pedal and dragged on the sidewalk, causing abrasions on the foot. The resident was wearing socks only, without protective foot wear. There was no documentation protective footwear was provided or encouraged prior to the incident or after the abrasion occurred. There was no assessment of placement of the feet/legs on the wheelchair foot rests to prevent the incident from recurring. On 8/18/14 at 4:10 pm Staff 3 (RNCM) stated the resident sustained [REDACTED]. On 8/18/14 at 4:15 pm Resident 1 was interviewed and observed with Staff 16 (LPN) present. Resident 1 stated she/he felt pulling from the Foley catheter and saw the penis was split through the head and was bleeding. Observation of the penis with the Foley catheter in place revealed a split underneath the head of the penis; it was not bleeding and was healed. Staff 16 (LPN) stated no instructions were provided regarding rotating the catheter tubing placement/attachment and he knew of no preventative measures taken or care planned to prevent further erosion. On 8/19/14 at 1:10 pm the resident's pressure ulcers were observed with Staff 3 (RNCM) doing a wound assessment. The right ankle, right hip and left outside ankle were assessed at stage 2, and the right ischium was staged at stage 3. Staff 3 stated the coccyx ulcer was a stage 4, but changed it to stage 3 per the hospital documentation. On 8/19/14 at 1:45 pm Staff 17 (RD) stated Resident 1 needed to have extra protein to heal the pressure ulcers; the resident refused the med pass 2.0 cal supplement. Staff 17 encouraged double portions of food for dinner, but had not considered an alternative to the med pass supplement. On 8/19/14 at 2:30 pm the lack of care planning, monitoring, use of protective devices and preventive treatment for [REDACTED]. No further information was provided.

Based on observation, interview and record review, the facility failed to provide timely treatment and services for symptoms of depression for 1 of 1 sampled residents (#77) reviewed with a [DIAGNOSES REDACTED]. Findings include: Resident 77 was admitted to the facility in 9/2012 with [DIAGNOSES REDACTED]. The resident had also experience complications from [MEDICAL CONDITION] bypass surgery in previous years. A 10/1/12 Mood Care Plan identified target behaviors of staying in bed, crying and refusal of care or rehabilitation as symptoms of her depression and anxiety. Non-pharmalogical approaches to address her mood issues included family presence and to let her " vent " to staff. A 12/30/12 Nurses note identified that on 12/29/13 the resident had made remarks to the speech therapist about suicide and that she knew how to do it. The resident was placed on 15 minute checks and social service was notified. On 1/2/13, a referral for a PASRR level II Evaluation (a mental health evaluation) was made based on the resident ' s signs and symptoms of depression including suicidal ideation, self-reported depressed mood, sad affect and break through pain. Per the 1/8/13 PASRR report, the resident had told staff that she was in constant pain and could " no longer stand to live this way." Contributing factors to her mood issues were identified as the sale of her home and business, and the discontinuation of her narcotic pain medication. At the time of the evaluation, the resident identified feeling depressed with suicidal ideation and admitted that she had thought about " throwing up and choking " on her vomit. Pain on her left side was identified as a 7-10 on a 0 to 10 pain scale with heat therapy and hot baths of assistance in easing pain. PASRR level II treatment recommendations included: - Referral to a pain management specialist as chronic pain could contribute to her depressed mood and " significantly impact quality of life " - Psychiatric hospitalization (resident agreed that she would benefit from this) - Ongoing counseling services to deal with the loss and cope with the new disability - Medication management by a mental health professional - To avoid additional stress, staff needed to be especially vigilant and responsive to her care needs - Solicit feedback from the resident regarding her voiced need for a specialized diet due to [MEDICAL CONDITION] bypass surgery - Try to identify " soothing " activities to offer during periods of agitation/anxiety - Attempt to spend a few minutes socializing to promote positive mood, increased rapport and allow for expressions of concerns/fears - Give choices whenever possible - Promote a relaxed, calm environment to help reduce stress and anxiety. Consider utilizing relaxing scents, reducing noise levels, playing favorite music, utilizing stress reduction audio tapes/CDs and/or pet therapy. A 1/7/13 Physician After Visit Summary identified anxiety and chronic pain had been addressed during the visit. [MEDICATION NAME] (an anti-anxiety medication) 3 times daily and [MEDICATION NAME] (a narcotic pain medication) every 12 hours was ordered. [MEDICATION NAME] (an antidepressant medication) was to be taken every other day for 3 weeks before it was stopped. Additional medications listed included [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (used to treat nausea and vomiting), [MEDICATION NAME] (an anti-anxiety) and [MEDICATION NAME] to address pain. The 1/18/13 Social Service Review identified the resident as very tearful with outburst of anger and frustration. Pain was also identified as an issue. A PASRR level II evaluation had been completed and the physician was working on medications. A referral for " mental health possibly " was noted. Although the 1/18/13 Updated Care Plan reflected the resident ' s negative emotional status and threats to commit suicide, it did not provide approaches to deal with the resident ' s mood issues and did not address the PASRR II recommendations. From 2/17 to 3/27/13, Nurse's Notes reflected four instances of self-reported " chest pain " with [MEDICATION NAME] found to be effective in relieving symptoms and seven episodes of induced vomiting witnessed or reported to staff. A 2/27/13 Nurses Note identified that the resident seemed to be increasingly agitated in the evenings. On 2/28/13, the resident was observed by staff putting her fingers down the back of her throat in order to vomit. Changes to the [MEDICATION NAME] and [MEDICATION NAME] (changed to PRN) with the addition of [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication used for pain) were ordered on [DATE]. On 3/10/13, it was identified that the resident told staff that her self-induced vomiting was in an effort to "make the pain go away." A 3/17/13 note described the resident writing " Help " on her window blinds in feces. She apologized for vomiting that day and using her feces to write on her blinds, stating "people (with) mental illness play with their poop. " By 3/19/13, notes described a purple abdominal bruise which the resident could not explain. Screaming, anxiety and crying with requests for the [MEDICATION NAME] were noted throughout the notes. There was no evidence in the medical record that the resident's emerging/increasing behaviors and mood issues were assessed. In addition, the care plan was not updated to direct staff how to interact with the resident and/or an acknowledgement of the severity of the symptoms in relation to the resident 's quality of life. In interviews conducted on 4/1/13 at 2:13 pm and 4/2/13 at 10:29 am, Resident 77 shared that she was bulimic and frequently self-induced vomiting. The resident stated that she had not been seen by a doctor or a mental health specialist and had asked Staff 9, SSD, several times to see a mental health specialist...."(mental health) was supposed to come out here and work with me, I want to see them." During the 4/2/13 interview, the resident was observed to be in bed, again stated her need to see a mental health specialist, sharing that she had already thrown up that day. When interviewed on 4/1/13 at 2:18 pm and 4/2/13 at 10:34 am, Staff 9 stated that the resident was hurting herself by hitting her stomach in order to vomit and had threatened suicide in the past. The resident ' s processing was very limited and she needed medication management. Staff 9 had been in touch with local programs regarding in-patient treatment, but had not documented her efforts. In- facility treatment was not available and the resident was unable to tolerate appointments outside of the facility. Staff 9 stated that the resident continued to need an evaluation to stabilize the bulimic behaviors and her depression. Staff 2, DNS, confirmed on 4/1/13 at 12:22 pm that the resident had bulimic behaviors. On 4/1/13 at 12:04 pm, Staff 16, CMA, stated Resident 77 had bulimia. Staff stated that the resident had been vomiting on a regular basis for approximately 1 month. In a 4/1/13 interview at 12:28 pm, Staff 8, RNCM, stated that the resident was bulimic, although she was not sure when the behavior had started. The care plan had not been updated with that information. During a follow-up interview on 4/4/13 at 11:45 am, Staff 8 stated that the bruising on the resident ' s abdomen was purple because the resident continued to have "the behavior." When asked the source of the bruising, Staff 8 stated the resident pushed hard on her abdomen to make herself throw up. During a 4/4/13 interview at 12:25 pm, Staff 1, Administrator, Staff 2, DNS, Staff 9 and Staff 8 confirmed the resident continued to require evaluation for her symptoms of self-induced vomiting, anxiety and clear verbal expressions of a depressed mood.

Based on interview and record review it was determined the facility failed to ensure care planned transfer devices were used to prevent a fall for 1 of 3 sampled residents (#1). Resident 1 was transferred without the use of a mechanical lift which resulted in a fall and a fractured leg. Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's Kardex (care plan) updated 11/6/12 indicated the resident required extensive assistance for transfers with a sit to stand lift. The resident's care plan noted she/he was alert, confused and had short term memory impairment. The resident was also noted to be at risk for falls but did not try to get up independently any longer. The resident was at risk for bruising and bleeding related to anticoagulant use. A facility incident report dated 1/3/13 indicated the resident was lowered to the floor during a transfer. The resident was initially assessed as uninjured but, later the same day experienced a decline. The conclusion to the investigation indicated Staff 7 (CNA) was in a hurry to get the resident up for dinner and did not read the Kardex. Staff 7 attempted a one person stand pivot transfer and the resident was lowered to the floor. The resident's foot was caught on the wheelchair and the resident was sent to the hospital for a leg fracture in the evening. In an interview on 1/23/13 at 12:58 pm Staff 7 (CNA) indicated she was new to the facility and had not previously worked with the resident. Staff 7 received report on 1/3/13 the resident was in bed and would want to get up soon. Staff 7 stated she went to check the resident and talked with her/him. The resident stated she/he was ready to get up. Staff 7 told the resident she would be right back after she got help. The resident told Staff 7 all she needed to do was move the wheelchair over near the bed and help the resident scoot over. Staff 7 assumed the resident was accurate and she/he seemed alert and oriented. Staff 7 further indicated she should have checked the Kardex/care plan but she did not check it to see what transfer assistance the resident needed. She attempted a stand pivot transfer and the resident's legs gave out. Staff 7 lowered the resident to the floor but the resident's left leg was bent and caught on the wheelchair. Staff 7 got the nurse and the resident was assessed. The resident had minimal complaints of pain before and after the nurse assessed and did not seem to be injured. Later in the evening the appearance of the resident's leg changed and the resident had more complaints of pain. The resident was sent to the hospital for evaluation. Interviews on 1/24/13 at 10:45 pm and 3:40 pm with Staff 2 and Staff 6 (LPNs) showed Staff 2 assessed the resident after the fall on 1/3/13. Staff 2 indicated the resident did not complain of pain, range of motion was within the resident's normal limits and there were no visual indications of injury. The resident attended dinner without incident and was one of the first residents laid down for the evening. Staff 6 indicated later in the evening the resident had further complaints of pain and a decline in condition. The resident showed increased pain with range of motion, the left leg was bruised/discolored and swollen. Staff 6 contacted the resident's physician and the resident was sent to the hospital. Staff 2 and 6 both indicated the resident was confused at baseline with memory impairments but could express her/his needs. The staff further indicated the resident was not safe for a stand pivot transfer and was care planned for a sit to stand lift. A Hospital Consultation report dated 1/4/13 indicated the resident sustained [REDACTED]. The resident was provided medications to reverse her/his anticoagulation therapy in preparation for surgery to repair/stabilize the fracture. The resident returned to the facility on [DATE] after surgical repair of the leg.

Based on observation, interview and record review it was determined the facility failed to provide a [MEDICATION NAME] for 1 of 2 sampled residents (#1) who were reviewed for use of [MEDICATION NAME]es for pain control. Resident 1 did not receive a [MEDICATION NAME] for a 72 hour time period, had intractable pain and went to the emergency room . Findings include: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Doctor's Progress Note dated 10/12/11 indicated the resident reported chronic thigh pain probably due to [MEDICAL CONDITION]. Medication Records dated 1/1/2012 included a [MEDICATION NAME] 100 mcg to be changed every 72 hours. Initials indicated the patch was changed on 1/3/12, 1/6/12 and 1/9/12. Although the location of the patch was not recorded on 1/3/12 and 1/6/12, the placement of the [MEDICATION NAME] was initialed as checked at the start of each shift (twice daily) from 1/1/12 through 1/9/12. Nurse's Notes dated 1/7/12 indicated the resident was having increased pain on the night and day shifts. The resident complained of knee and thigh pain. The on-call physician was notified, who made some changes in dosage of PRN pain medications. Nurse's Notes for night shift on 1/8/12 indicated the resident continued to have a lot of pain in the left lower extremity. [MEDICATION NAME], a narcotic pain medication was given PRN (as needed) at 8:00 pm, "which helped a bit." Tylenol 650 mg PRN was given at 10:00 pm at Resident 1's request, and [MEDICATION NAME] was given again at 3:00 am,"which finally yielded (positive) results." Nurses Medication Notes from 1/1/12 to 1/6/12 showed the resident took PRN [MEDICATION NAME] and/or Tylenol from 1 to 3 times/day. On 1/7/12 and 1/8/12 the PRN use of [MEDICATION NAME]/Tylenol increased to 6 and 7 times/day with results of "helped a little" and "wasn't a lot of help." There were no Nurse's Notes for day shift on 1/8/12 or for night shift on 1/9/12. On 1/9/12 at 9:00 am the resident was up in a wheelchair and complained of "a lot of pain" in the left lower extremity. [MEDICATION NAME] ([MEDICATION NAME]) PRN was given with "good relief so (the resident) could eat." The Control Log for [MEDICATION NAME] ([MEDICATION NAME] Patch) 100 mcg/hr, applied topically every 72 hours, was signed out on 1/3/12 at 5:00 pm and not again until 1/9/12 at 11:30 am. Nurses Medication Notes on 1/9/12 indicated [MEDICATION NAME] two tablets were given at 7:30 am with some relief, and at 3:00 pm it "didn't help at all." There was no evidence staff assessed the increased use of PRN pain medications, or checked the date on the [MEDICATION NAME]. Nurse's Notes dated 1/9/12 at 4:00 pm indicated "MD & POA (power of attorney) informed of missed [MEDICATION NAME]." At 6:00 pm the resident complained of pain in knees at a level of 9/10 and PRN pain medication was given. Staff offered to send the resident to the ER (emergency room ), but the resident refused. Nurse's Notes dated 1/9/12 at 8:30 pm indicated the resident was crying and "upset" with pain at a level 12/10. The resident was sent to the ER for pain control. At 3:00 am on 1/10/12 the resident returned from ER still complaining of pain. Nurse's Notes dated 1/12/12 indicated the resident was in too much pain to allow bowel care. On 1/13/12 a physician's orders [REDACTED]. [MEDICATION NAME] PRN was continued and given once during the night shift with positive results. The resident slept "somewhat well throughout the night." The resident's POA (Power of Attorney) stated on 1/18/12 at 2:00 pm, Resident 1 was in uncontrolled pain due to the pain patch not being changed per physician's orders [REDACTED]. The resident received 3-4 injections of pain medication in the ER. On 1/18/12 at 2:30 pm, Staff 1, RNCM stated Resident 1 had uncontrolled pain due to not receiving the [MEDICATION NAME] on 1/6/12. Staff 1 stated Staff 2, CMA signed the patch was changed on 1/6/12, and then initialed it was in place at the time of shift change on 1/6/12. On 1/9/12 in the morning, Staff 5, CMA discovered the patch had not been changed on 1/6/12, and physician's orders [REDACTED]. However, the resident's pain increased, the resident was crying in pain and asked to go to the hospital. On 1/18/12 at 3:00 pm Resident 1 stated sometimes when (she/he) reported pain, staff would say it was not time for another pain pill. Whenever the resident lay down in bed, the resident had increased pain. Sometimes the pain patch did not work and the resident cried out in pain. During the investigation, two CMAs, Staff 2 and 3; and Staff 4, LN stated when they checked for the [MEDICATION NAME] between shifts, they just would feel to make sure the patch was in place, but would not check the date on the patch. On 1/19/12 at 1:40 pm, Staff 2, CMA stated she signed the Medication Record on 1/6/12 as having applied the [MEDICATION NAME] before she actually applied it. Staff 2 did not realize she had not given the [MEDICATION NAME]. Staff 2 stated the patch placement should be rotated from one arm/shoulder to the other, but she had not charted the location of the patch on 1/6/12. Staff 2 could not explain why the patch was not discovered at change of shift, when the patch was on the same arm/shoulder, and not rotated. No further information was provided related to missing the 1/6/12 [MEDICATION NAME], the lack of documentation of the placement site, or how all staff who checked for placement of the patch missed that the location should have been different.

Based on interview and record review it was determined the facility failed to administer and accurately record in the MAR indicated [REDACTED]. Resident 1 did not receive a [MEDICATION NAME] for a 72 hour time period, had intractable pain and went to the emergency room . Findings include: The Oregon State board of Nursing (OSBN) Nurse Practice Act Authorized Duties and Standards for Certified Medication Aides [PHONE NUMBER](9)(e)Accurately record on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Doctor's Progress Note dated 10/12/11 indicated the resident reported chronic thigh pain probably due to [MEDICAL CONDITION]. The facility's [MEDICATION NAME] Patch Application Sites procedure indicated the [MEDICATION NAME] application was to be charted by site on the resident's MAR. "Be sure to rotate application sites to prevent skin irritation and reduce skin tears. Use at least 4 different sites." Medication Records dated 1/1/2012 included a [MEDICATION NAME] 100 mcg to be changed every 72 hours. Initials indicated the patch was changed on 1/3/12, 1/6/12 and 1/9/12. Although the location of the patch was not recorded on 1/3/12 and 1/6/12, the placement of the [MEDICATION NAME] was initialed as checked at the start of each shift (twice daily) from 1/1/12 through 1/9/12. The Control Log for [MEDICATION NAME] ([MEDICATION NAME] Patch) 100 mcg/hr, applied topically every 72 hours, was signed out on 1/3/12 at 5:00 pm and not again until 1/9/12 at 11:30 am. Nurse's Notes dated 1/9/12 at 6:00 pm indicated the resident complained of pain in knees at a level of 9/10 and PRN pain medication was given. Staff offered to send the resident to the ER (emergency room ), but the resident refused. Nurse's Notes dated 1/9/12 at 8:30 pm indicated the resident was crying and "upset" with pain at a level 12/10. The resident was sent to the ER for pain control. The resident's POA (Power of Attorney) stated on 1/18/12 at 2:00 pm, Resident 1 was in uncontrolled pain due to the pain patch not being changed per physician's orders [REDACTED]. The resident received 3-4 injections of pain medication in the ER. On 1/18/12 at 2:30 pm, Staff 1, RNCM stated Resident 1 had uncontrolled pain due to not receiving the [MEDICATION NAME] on 1/6/12. Staff 1 stated Staff 2, CMA signed the patch was changed on 1/6/12, and then initialed it was in place at the time of shift change on 1/6/12. On 1/9/12 in the morning, Staff 5, CMA discovered the patch had not been changed on 1/6/12, and physician's orders [REDACTED]. However, the resident's pain increased, the resident was crying in pain and asked to go to the hospital. On 1/18/12 at 3:00 pm Resident 1 stated sometimes when (she/he) reported pain, staff would say it was not time for another pain pill. Whenever the resident lay down in bed, the resident had increased pain. Sometimes the pain patch did not work and the resident cried out in pain. During the investigation, two CMAs, Staff 2 and 3; and Staff 4, LN stated when they checked for the [MEDICATION NAME] between shifts, they just would feel to make sure the patch was in place, but would not check the date on the patch. On 1/19/12 at 1:40 pm, Staff 2, CMA stated she signed the Medication Record on 1/6/12 as having applied the [MEDICATION NAME] before she actually applied it. Staff 2 did not realize she had not given the [MEDICATION NAME]. Staff 2 stated the patch placement should be rotated from one arm/shoulder to the other, but she had not charted the location of the patch on 1/6/12. Staff 2 could not explain why the patch was not discovered at change of shift, when the patch was on the same arm/shoulder, and not rotated. No further information was provided related to missing the 1/6/12 [MEDICATION NAME], the lack of documentation of the placement site, or how all staff who checked for placement of the patch missed that the location should have been different.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services to prevent a pressure ulcer and promote healing, for one of one sampled resident (#1), who was reviewed for facility acquired pressure ulcers. Resident 1 developed a Stage III pressure ulcer, required wound clinic treatment and suffered pain. Findings include: Resident 1 was admitted on [DATE] with a fractured knee. An Admission Status form dated 2/11/11 indicated the resident had 2+ [MEDICAL CONDITION] to all extremities and had a knee immobilizer on the left knee/leg. A Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at high risk for developing pressure ulcers. However the assessment did not include the use of the knee immobilizer as a risk factor. "Presence of [MEDICAL CONDITION]" was coded as 1+ present. A Kardex (care plan) indicated that a knee immobilizer was to be worn by the resident at all times. A second care plan included that the knee immobilizer on the left lower extremity be checked for placement and fit. Treatment Records dated 2/2011 indicated the brace be removed and skin checked twice a day; there was no information about the type of brace or how it was to be positioned. On 2/18/11 a therapy notation included "Pt's (spouse) brought her/his old knee immobilizer and PT (physical therapy) replaced pt's brace with this one and left it on after r/x (treatment)." There was no assessment for fit and positioning of the brace, or a physician's orders [REDACTED]. Nurse's Notes dated 3/6/11, included that there was a "scraped area on posterior ankle. Appears to be from immobilizer. (Spouse) present & aware.." An Incident Report dated 3/6/11 indicated an abrasion, 2 cm long, was found on the back of the resident's left ankle. It was found "during cares and removal of brace for skin inspection. Appears brace rubbed on back of ankle." No further description of the abrasion was found. The "Preventive plan after incident" included to 1) increase brace inspection to before and after transfers or therapy, and 2) Follow-up with therapy to ensure brace is still the correct fit. Skin Condition Flow Sheets showed an onset date of an abrasion on 3/6/11. However there was no assessment of the wound until 3/15/11, when the length was 4 cm and width 5 cm with a scabbed base, (twice as long as noted in the 3/6/11 Incident Report). The next skin assessment was on 3/24/11, with the type of wound changed to "Pressure knee immobilizer" and with measurements unchanged from 3/15/11. On 3/31/11 an RCM Weekly Assessment described the ulcer as "currently" a Stage III with the "deepest stage" as un-stageable. There was no documentation found that staff were checking under the brace before and after therapy/transfers, or of therapy's assessment of the fit of the brace. Care Conference Information dated 3/9/11 indicated the resident/family had concerns that the "Brace not properly placed!!" Nursing comments included that the sore was secondary to the brace rubbing, and therapy suggested a pillow be used for padding. The action plan included to follow-up with staff regarding appropriate placing of brace, "and therapy reviewed placement." A Therapy Weekly Progress Report dated 3/1/11 to 3/15/11 indicated that "brace placement reviewed." There was no assessment of the brace, type of brace, or whether the brace was continuing to cause pressure on the resident's ankle. Nurse's Notes dated 3/11/11 indicated that a physician's orders [REDACTED]. On 3/24/11, the resident returned from the wound clinic with physician's orders [REDACTED]. physician's orders [REDACTED]." There was no documented evidence that a new immobilizer was obtained, or that the "shorter" one was used. Doctor's Progress Notes dated 3/30/11 indicated the resident complained of pain, "has ulcer from brace... exam - full thickness ulcer." It was noted the knee fracture had healed and the immobilizer was discontinued. On 4/8/11 Nurse's Notes indicated the resident returned from the wound clinic with a wound vac on the left leg wound. The RCM Weekly assessment dated [DATE] indicated the resident was complaining of pain during the dressing change. On 5/6/11 at 3:25 pm, Witness 2, Family stated the brace in the hospital did not fit the resident, so when the resident got to the nursing home, Witness 2 brought a brace that had been used for another person. Staff told Witness 2 that the brace did not fit right, but Witness 2 felt staff did not lace the brace up correctly. Witness 2 told staff daily that the brace was not applied properly. Staff 3, the head physical therapist, would adjust the brace and tighten it, but he couldn't get all the staff to do it right. On the day the pressure ulcer was discovered, the therapist came to get the resident up, and Witness 2 stated there was blood and pus on the sheets, and the sore was right where the brace would hit. Staff put a dressing over it, but it got worse, and they had to send the resident to the wound clinic. On 5/6/11 at 2:10 pm, Staff 2, RNCM stated staff had increased checking the skin under the brace before and after therapy and/or transfers, and that therapy was checking for the fit of the brace. Staff 2 was unable to provide documentation that the checks were done. On 5/6/11 at 3:00 pm, Staff 3, PT stated he was unable to find any documentation that the brace had been assessed for proper fit, and there was nothing documented as to the type of brace it was. On 5/6/11 at 4:10 pm, Staff 1, DNS stated the brace would slide down during therapy and rubbed on the resident's leg. It was not always adjusted correctly. Staff were unable to provide a documented assessment of the brace related to risk of pressure ulcers before the pressure ulcer developed, or after it developed when the brace was continued. The pressure ulcer worsened, required treatment at a wound clinic, and caused the resident pain.