Every finding on record at Forest Grove Post Acute

Based on interview and record review it was determined the facility failed to obtain orders related to unplanned removal of an indwelling catheter for 1 of 1 sampled resident (#1) reviewed for catheter care. This placed residents at risk for urinary retention. Findings include: Resident 1 admitted to the facility on [DATE] with diagnoses including dementia.A 4/2/26 physician order indicated the use of a foley (indwelling) catheter.The 4/2/26 Care Plan indicated Resident 1 had a foley catheter in place with interventions including changing the catheter per facility policy and physician order.Review of Resident 1's progress notes from 4/7/26 through 4/23/26 revealed the following:-On 4/7/26 Resident 1 pulled out the catheter during night shift. Nursing staff attempted to reinsert the catheter, but the resident refused. -On 4/20/26 during a care conference meeting Resident 1's family asked about the catheter and were informed by Staff 3 (LPN Resident Care Manager) the resident previously had a catheter and Staff 3 would follow up. -On 4/23/26 the provider reviewed the resident's bladder scan and indicated the foley did not need to be replaced.There was no indication in Resident 1's medical record the physician was notified of the resident pulling out the catheter, and there was no catheter in place, until 4/20/26 (13 days later).On 6/11/26 at 10:30 AM Staff 3 stated if a resident pulled out a catheter and refused to have it reinserted the provider was to be notified to get further direction on how to proceed. Staff 3 stated she notified the provider of Resident 1 not having a catheter in place when she asked for a post void scan (bladder scan) on 4/20/26. Staff 3 acknowledged the provider was not notified until 13 days after the resident pulled out the catheter and physician orders were not followed related to use of a catheter. On 6/11/26 at 2:31 PM Staff 2 (DNS) acknowledged Resident 1's physician orders were not followed related to having a catheter in place and the provider was not notified in a timely manner after the catheter was pulled out.

Based on interview and record review it was determined the facility failed to provide medication per the physician order for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of needed medication. Findings include:Resident 2 admitted to the facility in 4/2026 with diagnoses including hypothyroidism. The 4/17/26 physician orders indicated Resident 2 was to receive levothyroxine (thyroid medication) once daily. The 4/2026 MARs indicated Resident 2 did not receive levothyroxine on the following dates: 4/18/26; 4/19/26; 4/20/26 and 4/21/26.\ No information was found in the resident's clinical record related to the failure to administer the levothyroxine. On 6/11/26 at 2:53 PM Staff 2 (DNS) acknowledged Resident 2 did not receive levothyroxine on the identified dates.

Based on interview and record review it was determined the facility failed to ensure PRN psychotropic medication orders were discontinued after 14 days for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary psychotropic medication and adverse side effects of psychotropic medication. Findings include:Resident 20 was admitted to the facility in 6/2025 with diagnoses including dementia and depression. A 6/11/25 physician order indicated Resident 20 was prescribed the following PRN psychotropic medications:-Quetiapine Fumarate 25 MG Oral Tablet an antipsychotic indicated for agitation.-Prochlorperazine Maleate 5 MG Oral Tablet an antipsychotic indicated for nausea.-Hydroxyzine HCl 10 MG Oral Tablet an anxiolytic indicated for anxiety or insomnia. There was no evidence found in Resident 20's medical record to indicate her/his physician documented a rationale for extended use of the PRN psychotropic medications past 14 days, or evaluated her/his PRN psychotropics since admission to the facility. A 7/11/25 pharmacy review of Resident 20's medications recommended the facility discontinue her/his PRN psychotropic medications for non use. The PRN psychotropic medications were discontinued on 7/22/25. On 7/4/25 at 1:21 PM Staff 3 stated she was unaware that PRN psychotropics were limited to 14 days. Staff 3 acknowledged Resident 20's PRN psychotropic medication orders went beyond 14 days without a documented rationale for extended use, or evaluation by a physician.

Based on observation, interview, and record review it was determined the facility failed to assess residents for smoking safety and provide supervision for smoking residents for 2 of 3 sampled residents (#s 57 and 78) reviewed for accidents. This placed residents at risk for smoking related accidents. Findings include: 1. The facility’s 8/2024 Smoking Policy for Independent and Supervised states residents who wished to smoke were to have a smoking evaluation upon admission or at the time they decided to smoke, to evaluate their ability to smoke safely. Resident 57 was admitted to the facility in 10/2024 with diagnoses including Chronic Obstructive Pulmonary Disease (a lung and airway disease that restricts breathing). Resident 57’s 10/20/24 Baseline Care Plan stated she/he was an independent and safe smoker. The 5/7/25 Quarterly MDS indicated Resident 57 was cognitively intact. A review of Resident 57’s clinical record revealed no indication a smoking assessment was completed. On 7/21/25 the facility provided a list of residents who smoked independently, and Resident 57 was included on the list. On 7/21/25 at 12:36 PM Resident 57 was observed disposing of her/his cigarette on a bucket lid and not in the designated receptacle. On 7/22/25 at 1:33 PM Resident 57 stated she/he was an active smoker and smoked independently since admitting to the facility. Resident 57 expressed she/he was never assessed or observed for smoking safety, and she/he was provided the facility smoking policy for her/his review and signature about two weeks ago. On 7/22/25 at 12:52 PM Staff 3 (LPN Resident Care Manager) stated, per facility policy, residents were assessed for smoking safety upon admission. Staff 3 acknowledged resident 57 smoked independently and the resident’s care plan indicated she/he smoked independently, but there was no evidence in the clinical record to indicate an assessment was completed. 2. The facility's 3/2020 Smoking Policy and Procedure stated, “Residents who do not meet the established criteria to smoke independently are provided assistance/supervision during all smoking activities.” Resident 78 was admitted to the facility in 5/2022 with diagnoses including vascular dementia. Resident 78’s 5/21/22 Smoking Care Plan revealed the following: -The resident was allowed to smoke with supervision. -The resident's smoking supplies were to be stored in the medication room. On 7/21/25 at 11:30 AM Resident 78 was observed in her/his room with a pack of cigarettes stored inside her/his crossbody bag. On 7/21/25 at 12:29 PM Resident 78 was observed independently entering the smoking area with smoking supplies. Resident 78 proceeded to smoke a cigarette, which was lit by another resident in the smoking area. No staff were observed in the smoking area with Resident 78 while she/he smoked. On 7/21/25 at 3:37 PM Staff 13 (CNA) stated supervised smokers were required to keep their supplies “locked up at the nurses station.” On 7/21/25 at 4:03 PM Staff 14 (LPN) stated Resident 78 required supervision for smoking. Staff 14 further stated staff assigned to residents were care planned for supervised smoking were to conduct the following process: -Obtain the resident’s smoking supplies from the assigned nurse and accompany her/him to the smoking area. -Light the resident’s cigarette for her/him and provide one to one supervision from within the smoking area. On 7/21/25 at 4:34 PM Staff 3 (LPN Resident Care Manager) acknowledged Resident 19 was supposed to receive supervision with smoking and was not to have cigarettes stored in her/his room.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders related to oxygen administration for 5 of 7 sampled residents (#s 13, 15, 16, 17 and 19) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: 1. Resident 13 was admitted to the facility in 9/2024, with diagnoses including chronic respiratory failure with hypoxia (lack of oxygen) and heart failure. Resident 13's 9/20/24 Physician's Orders indicated staff was to administer oxygen continuously at 1 liter per minute via nasal cannula. Resident 13's 12/2024 TAR revealed staff documented the resident was on oxygen continuously at 1 liter per minute via nasal cannula. On 12/17/24 at 10:48 AM, observations of Resident 13's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 13's oxygen was set at 2 L/min. Staff 3 acknowledged the resident's physician orders were not followed. On 12/17/24 at 2:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 2. Resident 15 was admitted to the facility in 11/2024, with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema (chronic lung disease). Resident 15's 12/11/24 Physician's Orders indicated staff was to administer oxygen continuously at 2 liters per minute via nasal cannula. Resident 15's Weights and Vitals Summary from 12/1/24 through 12/19/24 revealed 12 entries which revealed the resident was on room air (no oxygen was administered). On 12/17/24 at 10:55 AM, observations of Resident 15's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 15's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 3. Resident 16 was readmitted to the facility in 12/2024, with diagnoses including acute respiratory failure with hypoxia (lack of oxygen) and transient cerebral ischemic attack (stroke). Resident 16's 12/6/24 Physician's Orders indicated staff were to administer continuous oxygen at 1 liter per minute per nasal cannula. Resident 16's 12/2024 TAR revealed staff were monitoring the resident's oxygen levels, but were not documenting the amount of liters per minute of oxygen the resident was receiving. On 12/17/24 at 10:58 AM, observations of Resident 16's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 16's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 4. Resident 17 was admitted to the facility in 12/2024, with diagnoses including congestive heart failure and acute respiratory failure with hypoxia (low oxygen). Resident 17's 12/13/24 Physician's Orders revealed no orders for oxygen. Resident 17's 12/16/24 Daily Skilled Charting Form revealed the resident continued with oxygen via nasal cannula. On 12/17/2024 at 10:51 AM, observations of Resident 17's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 17's oxygen was set at 2.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders. 5. Resident 19 was admitted to the facility in 9/2024, with diagnoses including chronic obstructive pulmonary disease and dysphagia (difficulty swallowing) following cerebrovascular disease (stroke). Resident 19's 12/17/24 physicians order revealed staff were to administer oxygen continuously at 2 liters per minute via nasal cannula. Resident 19's 12/2024 TAR revealed staff administered oxygen at 2 liters per minute nasal cannula. On 12/17/2024 at 10:50 AM, observations of Resident 19's oxygen concentrator with Staff 3 (LPN/RCM) revealed Resident 19's oxygen was set at 1.5 liters per minute. Staff 3 acknowledged the physician orders were not followed. On 12/17/24 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged physician orders were not followed and expected staff to follow physician orders.

Based on interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 1 of 1 sampled resident (#4) reviewed for pressure ulcers. This failure resulted in Resident 4's pressure ulcer worsening. Findings include: Resident 4 admitted to the facility in 2017 with diagnoses including hypertension and diabetes. The undated facility Event Summary Report indicated the following: -Resident 4 had a dressing in place dated 12/27/23 to her/his right ankle. -On 12/27/23 Staff 8 (LPN) measured Resident 4's wound on the right ankle and measurements were given to the Staff 12 (Former DNS) as requested. There was a dressing in place on the right ankle and Staff 8 measured the wounds and replaced the old bandage with a new one. -On 12/27/23 the wound measured 1.8 cm x 1.2 cm. -On 1/3/24 at approximately 1:30 PM Staff 11 (RNCM) and Staff 10 (LPN Resident Care Manager) completed wound rounds with the outside wound care provider. -On 1/3/24 the dressing was removed and revealed a Stage 3 pressure ulcer that measured 2 cm x 2.5 cm x 0.3 cm revealing a deterioration of the wound. On 6/12/24 at 10:53 AM Staff 11 stated on 1/3/24 she completed wound rounds with Staff 10 and the outside wound care provider. Staff 11 stated Staff 8 measured the wound on 12/27/23 and provided the measurements to Staff 12. Staff 11 stated she did not recall the observation of the dressing and wound from 1/3/24. On 6/12/24 at 11:14 AM Staff 10 stated on 1/3/24 she completed wound rounds with Staff 11 and the outside wound care provider and Resident 4 had a dressing on her/his right ankle initialed by Staff 8 and dated 12/27/23. Staff 11 stated the dressing was saturated when it was removed, and the information was reported to Staff 12. Staff 10 further stated Staff 8 measured the wound on 12/27/23 and reported the measurements to Staff 12. On 6/12/24 at 11:22 AM Staff 8 stated she worked on 12/27/23 and Resident 4 had a dressing on her/his ankle. Staff 8 stated she removed the dressing and took measurements of the wound and provided the measurements to Staff 12. Staff 8 stated she did not remember if she put a new dressing on the wound after measuring it. On 6/14/24 at 11:17 AM Staff 12 stated she was working as the DNS on 12/27/23 and Staff 8 provided Resident 4's right ankle wound measurement. Staff 12 stated she emailed the measurements to a resident care manager, there was no follow up notification to the physician and no orders were put in place for the pressure ulcer. Staff 12 acknowledged she did not follow up on the wound and wound care was not implemented. Staff 12 stated on 1/3/24 the facility staff and wound care provider identified there were no treatments in place for the wound from 12/27/23 through 1/3/24. Staff 12 stated in-services were provided regarding pressure ulcer assessments and wound care on 1/3/24. On 6/14/24 at 11:33 AM Staff 2 acknowledged Resident 4's pressure ulcer to the right ankle measured 1.8 cm x 1.2 cm on 12/27/23, treatments were not put in place and physician orders were not obtained until 1/3/24. Staff 2 acknowledged the wound worsened and on 1/3/24 the wound measured 2 cm x 2.5 cm x 0.3 cm. Staff 2 stated an in-service was provided on 1/3/24. On 6/14/24 at 10:54 AM the facility provided information to indicate education and an in-service was provided to nursing staff related to the identified incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.

Based on Interview and record review was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNAs (#14, 18, 19, 20 and 21) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff. Findings include: On 6/14/24 at 11:06 AM a review of facility personnel records with Staff 2 (Interim Administrator) indicated the following: - Staff 14 (CNA) was hired on 8/20/20; no annual performance review was completed. - Staff 18 (CNA) was hired on 8/20/04; no annual performance reviews were completed. - Staff 19 (CNA) was hired on 11/12/10; no annual performance reviews were completed. - Staff 20 (CNA) was hired on 6/14/18; no annual performance reviews were completed. -Staff 21 (CNA) was hired on 11/5/21; no annual performance reviews were completed. On 6/14/24 at 11:43 AM Staff 2 confirmed the annual performance reviews were not completed for Staff 14, Staff 18, Staff 19, Staff 20, or Staff 21. Staff 2 stated it was his expectation the annual performance reviews were completed annually.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 7 out of 30 days reviewed for staffing. This placed residents, the public and staff at risk for lack of accurate staffing information. Findings include: On 6/10/24 at 3:51 PM the Direct Care Staff Daily reports were provided from 5/7/24 through 6/10/24. The forms revealed seven instances where portions of the form were left blank or were incomplete. The incomplete information included census, number of staff working and number of hours worked. On 6/14/24 at 10:21 AM Staff 1 (Administrator) and Staff 22 (Corporate Consultant) acknowledged the Direct Care Staff Daily reports were incomplete for 7 out of 30 days. Staff 1 stated it was her expectation staff completed the daily staffing sheets at the beginning of each shift every day.

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 1 of 1 medication storage refrigerator reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: On 6/13/24 at the medication refrigerator temperature logs were observed to be blank on the following dates: -5/3/24 -5/10/24 -5/11/24 -5/12/24 -5/13/24 -5/18/24 -5/19/24 -5/20/24 -5/21/24 -5/26/24 -5/27/24 -5/28/24 -5/31/24 -6/1/24 -6/2/24 -6/3/24 -6/4/24 -6/9/24 On 6/13/24 at 11:37 AM Staff 2 (DNS) acknowledged the blank temperature logs for the identified dates for the medication refrigerator and stated the expectation was for the nurse to complete the temperature logs.

Based on interview and record review, it was determined the facility failed to treat residents with dignity and respect for 1 of 2 sampled residents (#32) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 32 was admitted to the facility in 2/2021 with diagnoses including ventricular tachycardia (irregular heartbeat) and chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). Resident 32's 2/13/24 Annual MDS indicated she/he was cognitively intact. A facility investigation created and signed by Staff 2 (Interim Administrator) on 4/11/24 indicated Staff 8 (LPN) lifted Resident 32's left arm to remove her/his jacket, obtain her/his blood pressure and apply a lidocaine patch. Per the investigation, Staff 8 did not stop when Resident 32 told her the action caused her/him increased pain in her/his left shoulder. This action resulted in Staff 8 being placed on administrative leave while the facility completed an internal investigation. On 6/10/24 at 12:52 PM Resident 32 stated she/he told staff about her/his shoulder pain prior to the incident because, I didn't want people to pull on it. She/he also stated, When she was lifting my arm I told her to stop because it hurt so bad. Resident 32 said she/he thought Staff 8 was in a hurry and needed to get it done. On 6/11/24 at 3:15 PM Staff 8 stated she forgot Resident 32 had pain in her/his left shoulder when she started to help her/him remove her/his jacket on 4/11/24. She said she apologized to Resident 32 and told her/him I forgot you had pain in your shoulder. A review of Resident 32's care plan initiated 3/1/24 revealed staff were advised to allow 'no' to be a response, follow through with what you say you will do, give choices whenever possible, avoid rushing cares, maintain calm demeanor and provide active listening. On 6/11/24 at 4:22 PM Staff 2 stated [Staff 8] no longer worked in the facility and was in a hurry and did not slow down when lifting Resident 32's arm. He added, She should have been more patient and listened to the resident. Staff 2 confirmed Resident 32 was already receiving a lidocaine patch for shoulder pain and acknowledged Staff 8, should have taken her time and not caused [Resident 32] more pain.

Based on interview and record review it was determined the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely fashion for 1 of 3 sampled residents (#29) reviewed for Beneficiary Protection Notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 29 was admitted to the facility in 2/2024 with diagnoses including metabolic encephalopathy (a problem in the brain caused by chemical imbalances in the blood) and chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). Resident 29's Admission Record indicated she/he was her/his own responsible party and her/his 2/27/24 Admission MDS revealed she/he was cognitively intact. A review or Resident 29's health record revealed her/his last covered day of Medicare Part A Service was 4/22/24. No evidence was found in Resident 29's medical record to indicate the facility provided her/him with a SNF ABN, Form CMS-10055. On 6/11/24 at 12:33 PM Staff 9 (Social Services Director) confirmed Resident 29's last covered day of Medicare Part A services was 4/22/24 and stated she issued it to the resident on 6/11/24. Staff 9 acknowledged she issued it late and stated it should have been issued to Resident 29 on or before her/his last covered day under Medicare Part A Service. On 5/3/24 at 10:37 AM Staff 1 (Administrator) stated, We should be giving residents 48 hour notice so they are aware of the change.

Based on interview and record review it was determined the facility failed to provide assistance with incontinence care in a timely manner for 2 of 3 residents (#s 30 and 56) reviewed for ADLs. This placed residents at risk of delayed assistance with personal hygiene and increased risk of skin impairment. Findings include: 1. Resident 30 was admitted to the facility in 7/2023 with diagnoses including acute systolic (congestive) heart failure (a type of heart failure that occurs in the heart's left ventricle) and type two diabetes mellitus (a disease that occurs when blood sugar is too high). Resident 30's 7/17/23 Admission MDS indicated she/he was cognitively intact, frequently incontinent of bowel and bladder and she/he required extensive physical assistance from two persons to use the toilet. Resident 30's 7/17/23 Care Plan revealed staff were directed to offer and assist [Resident 30] with using the toilet upon awakening; after meals; before rest/HS; NOC rounds and as [she/he] asks. On 6/10/24 at 10:17 AM Witness 1 (Case Manager) reported during an in-person visit with Resident 30 on 2/1/24, she observed her/him use her/his call light to request incontinence care. She stated three CNAs entered Resident 30's room at different times but did not provide her/him with incontinence care. She stated a fourth CNA arrived and provided Resident 30 with incontinence care. Witness 1 reported Resident 30 told her it was typical for her/him to wait approximately two hours for care to be provided after pressing her/his call button. On 6/12/24 at 12:56 PM Staff 27 (LPN) stated there are times where Resident 30 told her she/he had to wait a long time for caregivers to provide care. On 6/12/24 at 5:15 PM Staff 1 (Administrator) stated he was aware of complaints regarding long call light response times for incontinence care. He said he expected staff to respond to call lights in a timely fashion. He added, We will re-emphasize that again with them. 47005 2. Resident 56 was admitted to the facility on ,d+[DATE] with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease). Resident 56's Care Plan dated 3/27/24 indicated the resident required two-person extensive assistance with toileting, one-to-two-person assistance with bed mobility and mechanical lift assistance with transfers out of bed. On 6/10/24 at 11:15 AM Resident 56 stated on 6/7/24 approximately 8:00 AM she/he pressed the call light for toileting assistance. Resident 56 stated about 15 minutes later, Staff 13 (CNA) came into her/his room to deliver the breakfast tray. Resident 56 informed Staff 13 she/he had a bowel movement and needed to be changed. Staff 13 stated she would return after delivering the trays but did not return. Resident 56 stated she/he waited over 90 minutes before calling the front receptionist to ask for assistance. On 6/12/24 at 10:25 AM Staff 14 (CNA) stated she was the CNA hall partner with Staff 13 who was assigned to Resident 56 on 6/7/24. Staff 14 stated she noticed Resident 56 had her/his call light on for a long time and she answered the resident's call light after completing all her morning ADL cares for her residents. Staff 14 stated Resident 56 was crying and very upset that she/he was left in her/his soiled brief for almost two hours. On 6/12/24 at 11:37 AM Staff 17 (Receptionist) stated she answered a phone call from Resident 56 who stated she/he had been waiting for nursing assistance for two hours. Staff 17 stated she walked down to the nurses' station to get assistance for Resident 56. On 6/12/24 at 12:10 PM Staff 13 stated she was assigned to Resident 56 on 6/7/24 and did not provide incontinence care in a timely manner. Staff 13 stated there was confusion on the room assignments and she was not aware she was assigned to Resident 56 until Staff 14 provided the incontinence care for the resident. On 6/13/24 at 11:44 AM Staff 2 (Interim Administrator) stated he expected that resident care would be provided in a timely manner and staff answered all the call lights regardless of room assignments.

Based on interview and record review it was determined the facility failed to order home health and in home care giving service to ensure a safe discharge for 1 of 2 sampled residents (#4) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include. Resident 4 was admitted to the facility in 2022 with diagnoses including elevated white blood cell count and muscle weakness. Resident discharged to the community on 9/1/23. A 7/15/23 Admission MDS revealed Resident 4 with a BIMS of 15 out of 15 which indicated no cognitive impairment. A 9/28/23 Hospital Discharge Summary revealed Resident 4 presented to the emergency department on 9/7/23 due to generalized weakness caused by the resident's inability to get up from her/his recliner. Additional hospital notes revealed Resident 4 was a resident of the facility six days prior to hospital admission and was not set up with in home health and caregiving services prior to discharge. On 10/5/23 at 1:05 PM Staff 3 (SSD) indicated she could not verify and confirm the date of service for in home health care and caregiving services prior to residents discharge. On 10/5/23 at 1:18 PM Staff 4 (PT) stated Resident 4 was recommended to a higher level of care due to the resident level of function related to transfers prior to discharge on 9/1/23. Staff 4 indicated the Resident 4 had poor capacity to recognize safety concerns which presented as a challenge for at home discharge. On 10/5/23 at 10:01 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from verbal abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include: The facility 2/2019 Abuse Screening, Training, Identification, Investigation, Reporting and Protection Policy defined verbal abuse as the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms. Resident 2 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/11/22 Quarterly MDS indicated Resident 2 was cognitively intact. Resident 2's 3/31/22 Care Plan indicated Resident 2 agreed that when Resident 16 went out to the smoking area, she/he would call staff to come assist her/him back to her/his room and/or when Resident 16 was out in the smoking area/patio Resident 2 would wait until Resident 16 left to minimize interacting with her/him. Resident 16 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/23/21 Annual MDS Dementia CAA indicated Resident 16 was alert and at risk for further cognitive loss. Staff were to provide cognitive support, reorienting and redirecting as needed. The 3/12/22 Quarterly MDS indicated Resident 16 had moderately impaired cognition (BIMS 11). The 8/31/22 BIMS Assessment indicated Resident 16 was cognitively intact (BIMS 13). Resident 16's 8/1/19 Care Plan last updated 8/22/22 indicated the following: -Behavior monitoring due to sexually inappropriate actions when staff were in room attempting to provide care, specifically female caregivers; -Cursing and yelling at staff during care; -History of sexually touching himself/ejaculation; -Inappropriate name calling/calling other residents names; -Provide privacy to resident by pulling curtain closed or closing door; -Offer hand hygiene; -Remind [her/him] that calling other residents or staff inappropriate names is not appropriate and not acceptable. An incident report dated 3/22/22 indicated Resident 2 informed the Administrator that on 3/21/22 while she/he was in the resident smoking area, Resident 16 came out to the smoking area and preceded to sit and stare at her/him. Resident 2 asked Resident 16 to please not sit there and stare and that she/he did not appreciate it. Resident 16 preceded to call her/him f****** c***. Per Resident 2, the exchange was witnessed by another resident but the alleged witness was unable to recall the incident when interviewed. Resident 2 was encouraged to call staff when she/he felt the presence of Resident 16 while in smoking area. Both are independent smokers and continued to be independent smokers. An incident report dated 3/26/22 indicated Resident 2 requested to speak to the Administrator about an incident that happened sometime during the mid-morning in the smoking area between Resident 2 and Resident 16. Resident 2 stated she/he was sitting in the smoking area and Resident 16 was staring at her/him. Resident 2 stated she/he asked Resident 16 to please not stare at her/him. Resident 2 stated Resident 16 extinguished her/his cigarette and was rolling away in her/his wheelchair and Resident 16 said I am sorry I called you a b**** before, I really should have called you a c***. Resident 16 went inside the building. The Administrator asked Resident 2 if she/he felt safe and she/he said yes and did not want Resident 16 to say mean things or stare at her/him. Behavior Monitoring indicated Resident 16 had sexually inappropriate behavior on 4/16/22, 7/21/22 and 7/22/22. There was no indication of what the behavior was, how the behavior was addressed, or if the care plan was updated. Interviews with residents revealed the following: -8/30/22 at 3:03 PM Resident 20 stated Resident 16 continuously harassed Resident 2 for months. Resident 20 stated Resident 16 called Resident 2 vulgar names including cunt and also blows [her/him] kisses and Resident 2 was upset about the behaviors. Resident 20 stated staff told Resident 2 that Resident 16 had dementia and did not know what [she/he] was doing but Resident 16 knows exactly what [she/he] is doing. -8/31/22 at 8:56 AM Resident 21 stated Resident 16 harassed Resident 2 for the past eight months and Resident 2 asked Resident 16 to leave her/him alone. Resident 21 stated she/he observed Resident 16 call Resident 2 a sweetie, cunt, and I want to eat your pussy. Resident 21 stated Resident 16 sat at the window near the smoking areas and blows [Resident 2] kisses. Resident 21 stated the behavior was reported to staff on several occasions and staff stated Resident 16 had dementia and Resident 16 was not monitored. -9/2/22 at 9:50 AM Resident 22 stated she/he observed Resident 16 call Resident 2 a cunt, [OBSCENITY] and whore. Resident 22 further stated Resident 16 sat near the sliding glass door and stared at Resident 2 while she/he was in the smoking area. On 8/30/22 at 1:35 PM and 2:07 PM Staff 20 (CNA) stated Resident 16 fully exposed her/himself in her/his room with the door open and masturbated while looking out in the hall and this occurred daily. Staff 20 stated he closed the curtain if he saw this behavior to provide Resident 16 privacy. Staff 20 stated he observed Resident 16 tell Resident 2 I want you to suck my dick, I want to play with your tits, and I want to grab you. Staff 20 stated Resident 2 told Resident 16 to please just get away from me and Resident 2 was upset. Staff 20 stated this happened a couple of months ago in the dining room and outside in the courtyard. Staff 20 stated he told Resident 16 the behavior was inappropriate and reported the incident to a nurse but was unsure of the nurse's name and did not believe she still worked at the facility. Staff 20 stated he witnessed Resident 16 make inappropriate sexual comments to residents once or twice weekly. Staff 20 stated Resident 16 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/22 at 1:57 PM Staff 26 (LPN) stated Resident 16 masturbated all the time with the door open while looking around her/his room and into the hall. Staff 26 stated Resident 16 was 100 percent alert and oriented. On 8/30/22 at 3:11 PM Staff 4 (CNA) stated Resident 2 was dependent on staff to take her/him to and from the smoking area and could not self-propel in her/his wheelchair. Staff 4 stated she had not seen Resident 2 and Resident 16 interact. On 8/31/22 at 6:22 AM Resident 16 was observed masturbating with her/his room door wide open and no privacy curtain pulled. Staff were observed passing by. On 8/31/22 at 11:26 AM Staff 19 (Social Services) stated Resident 16 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] ? and also called her/him a [OBSCENITY] and a cunt. Staff 19 stated when Resident 2 reported the incidents to her the resident was upset and crying and Resident 2 felt like not enough was being done about Resident 16's behavior. Staff 19 stated Resident 2 did not want to be around Resident 16 which was difficult since both residents were smokers. Staff 19 further stated Resident 16 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 19 stated she talked to Resident 16 about her/his behaviors but an hour later Resident 16 would be right next to [Resident 2] again. On 9/1/22 at 2:49 PM Resident 2 stated Resident 16 called her/him a [OBSCENITY] ing [OBSCENITY] and a cunt, I want to lick your pussy, and called her/him names almost daily. Resident 2 stated Resident 16 blows kisses at me and does vulgar things with [her/his] tongue. Resident 2 stated she/he reported the incidents to multiple staff on multiple occasions. Resident 2 stated when she/he saw Resident 16 she/he started sweating profusely and did not want to be harassed every day. Resident 2 stated her/his previous room was down the hall from Resident 16 and she/he observed Resident 16 masturbating with the door open when passing by the room on several occasions. On 9/1/22 at 3:19 PM Resident 16 stated Resident 2 was smart, pretty and she/he liked Resident 2 but they were currently in a pissing match. Resident 16 stated she/he called Resident 2 a [OBSCENITY] and a cunt and [she/he] hasn't got over it and [she/he] deserves it. Resident 16 stated staff talked to her/him regarding the behaviors but she/he wanted to get Resident 2 alone to talk to her/him and apologize, but Resident 2 did not want to talk to her/him. Resident 16 stated she/he blew [Resident 2] kisses. Resident 16 denied making sexually inappropriate comments to Resident 2. On 9/1/22 at 3:45 PM and 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated Resident 2 told staff of the identified incidents that occurred on 3/21/22 and 3/26/22. Staff 1 stated a plan was made to have Resident 2 and Resident 16 go out to the smoking area at different times of the day and staff were informed of the plan. Staff 1 further stated Resident 2 enjoyed staying out in the smoking area all day. Staff 1 and Staff 2 stated they were unaware of other incidents between Resident 2 and Resident 16 and staff did not report further incidents to them. Staff 1 and Staff 2 acknowledged the incidents occurred on 3/21/22 and 3/26/22 and Resident 2's care plan was not updated until 3/31/22 and Resident 16's care plan was not updated as of 9/1/22 for interventions to prevent further the incidents.

Based on observation, interview, and record review it was determined the facility failed to ensure adequate nursing staff to meet resident needs for 4 of 4 halls reviewed for staffing. This placed residents at risk for delayed care and unmet care needs. Findings include: A list provided by the facility on 9/2/22 indicated the facility had 15 residents who required a mechanical lift for transfers and 20 other residents who required two staff assistance for transfers. Resident Council Notes reviewed from 6/2022 through 8/2022 indicated the following: *6/24/22: No staffing concerns. *7/22/22: CNAs do not come when asking for help and eggs are served cold. *8/26/22: Food is always served cold. Facility Staff indicated the following concerns: - On 8/31/22 at 6:08 AM Staff 4 (CNA) stated the night prior she had 12 residents to care for independently on evening shift. Staff 4 stated the only reason she was able to complete showers was because both residents wanted a bed bath. Staff 4 further stated evenings were the hardest for staffing and she had to work a lot of double shifts. - On 8/31/22 at 6:08 AM Staff 22 (CNA) stated there were not enough staff for night shift and he often worked double shifts. Staff 22 stated on night shift Resident 13 waited a while for incontinence care and the resident needed to be changed when he responded to her/his room. Staff 22 further stated often times nurses would not answer call lights and CNA staff had to answer all of the call lights. - On 8/31/22 at 9:20 AM Staff 7 (LPN) stated due to staffing concerns nurses had to do CNA work. Staff 7 stated weekends for staffing were just horrible. Staff 7 stated there were times it was just one CNA and her for one hall and the facility had a lot of needy residents that required two staff for changing, toileting, dressing, and transferring. Staff 7 stated she had to tell CNA staff that she did not have time to assist them as she was doing medications and blood sugars, and there were less nurses on the floor. - On 8/31/22 at 12:20 PM Staff 25 (CNA) stated during 5/2022 the facility was short staffed on evening shift and all call lights took longer to be answered. - On 8/31/22 at 1:48 PM Staff 24 (CNA) stated in 5/2022 the facility was short staffed and call lights took longer to be answered due to a lack of staff. Facility Residents indicated the following concerns: - On 8/30/22 at 1:25 PM Resident 6 stated call lights took a long time (over an hour) and was worse during day shift. Resident 6 stated staff forget to help and she/he will have to yell out for assistance. - On 9/2/22 at 10:24 AM Resident 18 stated the facility was always short CNA staff. Resident 18 stated day shift and the weekends were the worst. The resident stated sometimes there was only one CNA for the whole hall. Resident 18 stated call light times varied and could ranged from 10 minutes to almost an hour. The resident stated she/he usually called for assistance to use the bathroom. The resident stated even her/his daughter called the facility to get assistance for her/him when the call light was not being answered. Resident 18 stated one time both she/he and her/his roommate called for assistance and waited for 45 minutes. Resident 18 stated all meals were late. - On 9/2/22 at 10:25 AM Resident 19 stated call light times took a long time depending on the day, especially weekends. Resident 19 stated when she/he pressed her/his call light she/he had to wait over half an hour for toileting assistance. Resident 19 stated if she/he waited a long time her/his roommate would call the front desk. Resident 19 further stated all facility meals were late, especially lunch that was scheduled to be served at 12:30 PM but did not arrive until 1:00 PM through 2:00 PM. 1. Resident 13 admitted to the facility in 3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 6/15/22 Quarterly indicated Resident 13 was cognitively intact. On 8/31/22 at 6:08 AM Staff 22 (CNA) stated there were not enough staff for night shift and he often worked double shifts. Staff 22 stated on night shift Resident 13 waited a while for incontinence care and the resident needed to be changed when he responded to her/his room. Staff 22 further stated often times nurses did not answer call lights and CNA staff had to answer all of the call lights. On 8/31/22 at 6:53 AM and 7:20 AM Resident 13 stated during night shift she/he was incontinent earlier that morning, and pushed her/his call light. Resident 13 stated she/he waited almost two hours for incontinence care and her/his sheets and pajamas were soaked. Resident 13 stated she/he has waited up to two hours for her/his call light to be answered and the facility was short staffed, especially on weekends. Resident 13 stated she would like to get up in her/his wheelchair during the day, go back to bed and then get up again, but due to staffing issues she gets up in her/his chair and stays up all day. A review of the call light logs indicated on 8/31/22 the call light was activated at 3:49 AM and Resident 13 waited two hours and 8 minutes for the call light to be answered. On 9/2/22 at 11:49 AM Staff 1 (Administrator) acknowledged the call light time on 8/31/22 was over two hours and the expectation was for staff to answer call lights immediately. 2. Resident 3 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/30/21 Witness 2 (Complainant) stated Resident 3 reported she/he waited two hours for her/his call light to be answered. A review of Resident 3's call light logs from 12/1/21 through 12/31/21 revealed 107 instances when Resident 3 waited over 30 minutes for the call light to be answered. On 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) stated the expectation is that staff answer call lights immediately and acknowledged the identified long call light times. 3. Resident 8 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concern was reported in April 2021 which indicated the facility was short staffed resulting in long call light times. Review of Resident 8's Call Light Logs for April, 2021 indicated the following call light times over 20 minutes for needs including transfers and bathroom assistance: - 4/3/21: 26 minutes - 4/8/21: 25 minutes - 4/9/21: 30 minutes - 4/11/21: 20 minutes - 4/12/21: 30 minutes and 20 minutes - 4/17/21: 37 minutes On 9/2/22 at 9:15 AM Staff 1 (Administrator) and Staff 2 (RNCM) confirmed the long call light times for the identified dates for Resident 8. 4. Resident 1 admitted to the facility in 10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged [DATE]. The 4/21/22 Quarterly MDS indicated the resident was cognitively intact, was always incontinent of bowel and bladder, and required two person assistance with bed mobility and toileting. On 5/6/22 and 8/30/22 Witness 1 (Complainant) stated Resident 1 often waited a long time for incontinence care and call lights took forever to be answered by staff. A review of Call Light Logs for Resident 1 for 5/2022 indicated the following dates the resident waited more than 20 minutes for her/his call light to be answered for bathroom assistance: *5/1/22: 30 minutes. *5/2/22: 53 minutes and then one hour and 41 minutes. *5/3/22: 45 minutes and then 38 minutes. *5/4/22: 42 minutes. *5/5/22: 37 minutes. *5/7/22: 41 minutes and then 55 minutes. *5/9/22: 34 minutes. *5/10/22: One hour and 16 minutes and then one hour and 43 minutes. *5/12/22: 26 minutes and then 41 minutes. *5/14/22: 32 minutes. *5/15/22: Two hours and 37 minutes. *5/16/22: 42 minutes. *5/17/22: One hour and 15 minutes. *5/18/22: 48 minutes. *5/19/22: 50 minutes. *5/20/22: 49 minutes. *5/23/22: 58 minutes. On 8/31/22 at 12:20 PM Staff 25 (CNA) stated during 5/2022 the facility was short staffed on evening shift and all call lights took longer to be answered. Staff 25 further stated there were times Resident 1 had to wait longer to get up with the Hoyer (mechanical lift) as it took two staff to assist the resident. On 8/31/22 at 1:48 PM Staff 24 (CNA) stated in 5/2022 the facility was short staff and there was a good chance Resident 1's call light would have taken longer to be answered. On 9/1/22 at 9:54 AM Staff 1 (Administrator) acknowledged the identified dates Resident 1's call light took 20 minutes or longer to answer. Staff 1 stated the expectation was for call lights to be answered immediately.

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of verbal abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include: The facility 2/2019 Abuse Screening, Training, Identification, Investigation, Reporting and Protection Policy defined verbal abuse as the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms. The facility's 2/2019 Accident/Incident Policy indicated all resident to resident altercations require an incident investigation to be started for each resident, regardless of whether the altercation was physical, verbal or attempted .if in doubt about what constitutes an incident, fill out the report. An incident report dated 3/22/22 indicated Resident 2 informed the Administrator that on 3/21/22 while she/he was in the resident smoking area, Resident 16 came out to the smoking area and preceded to sit and stare at her/him. Resident 2 asked Resident 16 to please not sit there and stare and that she/he did not appreciate it. Resident 16 preceded to call her/him f****** c***. Per Resident 2, the exchange was witnessed by another resident but the alleged witness was unable to recall the incident when interviewed. Resident 2 was encouraged to call staff when she/he felt the presence of Resident 16 while in smoking area. Both are independent smokers and continued to be independent smokers. An incident report dated 3/26/22 indicated Resident 2 requested to speak to the Administrator about an incident that happened sometime during the mid-morning in the smoking area between Resident 2 and Resident 16. Resident 2 stated she/he was sitting in the smoking area and Resident 16 was staring at her/him. Resident 2 stated she/he asked Resident 16 to please not stare at her/him. Resident 2 stated Resident 16 extinguished her/his cigarette and was rolling away in her/his wheelchair and Resident 16 said I am sorry I called you a b**** before, I really should have called you a c***. Resident 16 went inside the building. The Administrator asked Resident 2 if she/he felt safe and she/he said yes and did not want Resident 16 to say mean things or stare at her/him. The identified investigations did not include witness statements, other resident interviews, including the alleged perpetrator, and resident care plans were not updated for interventions to prevent further incidents. On 9/1/22 at 3:45 PM and 9/2/22 at 11:49 AM Staff 1 (Administrator) and Staff 2 (Interim DNS) acknowledged there were no witness statements for both incidents and Resident 2's care plan was not updated until 3/31/22 and Resident 16's care plan was not updated as of 9/1/22 related to the incidents. Staff 1 and Staff 2 acknowledged a thorough investigation was not completed for the incidents that occurred on 3/21/22 and 3/26/22. Refer to F600.

Based on interviews and record review it was determined the facility failed to ensure Staff 11 (Activities Assistant) adhered to professional standards related to misappropriation of resident personal funds for 1 of 3 sampled resident (#6) reviewed for misappropriation of property. This placed residents at risk for misuse of financial resources. Findings include: The facility's Gift and Gratuities Policy dated 2015, indicated employees were not to accept gifts from residents. The policy indicated the acceptance of gifts of cash is never permissible and no gift or items of value of any kind should be solicited from residents. The policy was signed by Staff 11 (former Activities Assistant) on 7/24/19. Resident 6 admitted to the facility 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/21 an incident was reported indicating Staff 8 (Business Office Manager) received a phone call from Resident 6's bank. The bank alleged Resident 6 had written several checks to Staff 11 including a check for $900. The facility investigation indicated on 5/4/22 Staff 8 was notified by Resident 6's bank of checks ($300, $500 and $900) written to Staff 11. Staff 8 directed the bank not to authorize the $900 check. Staff 11 was contacted and indicated the money was used to purchase personal items for Resident 6 (cell phone, hearing aid and groceries). The resident was interviewed and indicated she/he wrote Staff 11 the checks willfully. Resident 6 was upset, angry and indicated she/he could do what she/he wanted with her/his money and trusted Staff 11. Staff 11 was out state on vacation and was suspended upon her return on 5/13/21. Staff 11 stated she received checks from Resident 6 in the amount of $300 and $900. Staff 11 stated the $300 was for reimbursement that Resident 6 insisted she take. Staff 11 indicated she did not accept the checks for financial gain and it gave [Resident 6] dignity in getting the things she/he wanted. Staff 11 stated the $900 was for items she saw while on vacation that Resident 6 may have wanted. Staff 11 indicated there were other checks written to her that had been deposited. Staff 11 was asked to provide any receipts she had and to provide documentation of all checks deposited. Upon review, it was identified that additional checks in the amount of $60, $100, and $300 were written to her which Staff 11 indicated she forgot about. Upon conclusion of the investigation, the allegation of misappropriation was substantiated as Staff 11 was unable to account for or provide all receipts and violated facility policy. Staff 11 was terminated. On 8/30/22 at 1:25 PM Resident 6 stated Staff 11 did nothing wrong. Resident 6 stated she/he wrote the checks to Staff 11 because Staff 11 bought many items for her/him including a pillow and was paying her back. Resident 6 stated she/he was aware Staff 11 was going on vacation to Florida and was afraid Staff 11 may get stuck there or may get in trouble so she wrote Staff 11 a check for $900 to pay her back plus an additional $50. Resident 6 stated Staff 11 told her/him she was not allowed to accept the check, but she/he insisted that she take the money to pay her back. On 8/31/22 at 9:15 AM Staff 8 (Business Office Manager) stated Resident 6's bank contacted her and informed her that one of Resident 6's checks was attempted to be cashed by Staff 11 in Florida. Staff 8 stated in talking with the bank it was discovered that other checks were written to Staff 11. Staff 8 stated Resident 6 was reimbursed for all the checks written to Staff 11. Staff 8 stated a resident trust account was in place at the time of the incident and all resident money was to be signed out by the resident for staff to do any resident shopping. Staff 8 stated Staff 11 was aware of the process and knew better than to accept money from Resident 6. On 8/31/22 at 9:44 AM Staff 9 (Activities Director) stated he received a call from Staff 1 (Administrator) who informed him that Resident 6's bank called indicating Staff 11 attempted to cash a check from Florida. Staff 9 stated Staff 11 would often buy items for residents using her own money. Staff 9 stated he told Staff 11 that she did not have to use her own money and could be reimbursed. Staff 9 stated Staff 11 indicated she purchased items for Resident 6 and one of the checks for $500 was for the last six months of items that were purchased. Staff 9 stated no receipts were ever provided. Staff 9 stated Staff 11 knew better and was told they were not allowed to directly handle resident's personal funds. On 8/31/22 at 10:24 AM Staff 1 (Administrator) stated Staff 8 informed him that Resident 6's bank contacted her about a $900 check that was attempted to be cashed in Florida by Staff 11. Staff 1 stated he spoke with Resident 6 who became upset and stated she/he gave the money to Staff 11 to buy her/him things in Florida. Staff 1 stated he informed Resident 6 that staff were not allowed to accept personal money from residents. Staff 1 stated when he spoke with Staff 11 regarding the $900, Staff 11 stated Resident 6 wanted her to purchase items for her/him while she was on vacation in Florida. Staff 1 stated Staff 11 indicated she used her own money to purchase items for Resident 6 and could no longer do so. Staff 1 stated Staff 11 confirmed she cashed the checks and would purchase items for Resident 6 and return any change to the resident. Staff 1 stated in reviewing Staff 11's bank statements, additional checks for smaller amounts were identified written by Resident 6 to Staff 11. Staff 1 stated Staff 11 was able to provide only some of the receipts for items she purchased for Resident 6. Staff 1 confirmed the allegation of misappropriation of resident funds was substantiated for Resident 6. On 8/31/22 at 12:32 PM Staff 11 indicated she became really attached to Resident 6 and [NAME] versa. Staff 11 state she assisted residents with needs the facility did not provide such as clothes. Staff 11 stated Resident 6 requested specific items be purchased, and the resident would occasionally write her a check with any change given back to the resident. Staff 11 stated she was going to Florida and was busy preparing for the trip and accepted the check for $900 from Resident 6. Staff 11 stated the $900 was never used and never went into her account. Staff 11 stated she accepted the check because Resident 6 was upset and felt neglected. Staff 11 stated the situation went too far. Staff 11 acknowledged there was a process in place regarding shopping for residents and indicated she followed the process until she accepted the $900. Staff 11 stated she knew better but felt pressured by Resident 6 to accept the money. Staff 11 stated she never accepted money from other residents. Refer to F602.

Based on interview and record review it was determined the facility failed to ensure a resident received specialized rehabilitative services (physical and occupational therapy) for 1 of 3 sampled residents (#8) reviewed for therapy. This placed residents at risk for a physical decline. Findings include: Resident 8 admitted to the facility in 3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8 discharged from the facility 5/12/21. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8's 3/18/21 Care Plan indicated the resident was at risk for falls with PT and OT to evaluate and treat as ordered. The 3/25/21 Admission MDS indicated Resident 8 was working with therapy on strengthening, balance and transfers. Review of PT and OT records for March, April and May 2021 revealed the following missed sessions related to staffing: - 4 missed sessions in March. - 14 missed sessions in April. - 3 missed sessions in May. On 8/31/22 at 8:47 AM Staff 10 (PT Assistant) stated Resident 8 was scheduled to have PT and OT five times a week. Staff 10 confirmed Resident 8 missed both PT and OT sessions due to therapy staffing for the dates identified.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of financial resources for 1 of 3 sampled residents (#6) reviewed for misappropriation of property. This placed residents at risk for misuse of personal funds. Findings include: The facility's Gift and Gratuities Policy dated 2015, indicated employees were not to accept gifts from residents. The policy indicated the acceptance of gifts of cash is never permissible and no gift or items of value of any kind should be solicited from residents. The policy was signed by Staff 11 (former Activities Assistant) on 7/24/19. Resident 6 admitted to the facility 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/21 an incident was reported indicating Staff 8 (Business Office Manager) received a phone call from Resident 6's bank. The bank alleged Resident 6 had written several checks to Staff 11 including a check for $900. The facility investigation indicated on 5/4/22 Staff 8 was notified by Resident 6's bank of checks ($300, $500 and $900) written to Staff 11. Staff 8 directed the bank not to authorize the $900 check. Staff 11 was contacted and indicated the money was used to purchase personal items for Resident 6 (cell phone, hearing aid and groceries). The resident was interviewed and indicated she/he wrote Staff 11 the checks willfully. Resident 6 was upset, angry and indicated she/he could do what she/he wanted with her/his money and trusted Staff 11. Staff 11 was out state on vacation and was suspended upon her return on 5/13/21. Staff 11 stated she received checks from Resident 6 in the amount of $300 and $900. Staff 11 stated the $300 was for reimbursement that Resident 6 insisted she take. Staff 11 indicated she did not accept the checks for financial gain and it gave [Resident 6] dignity in getting the things she/he wanted. Staff 11 stated the $900 was for items she saw while on vacation that Resident 6 may have wanted. Staff 11 indicated there were other checks written to her that had been deposited. Staff 11 was asked to provide any receipts she had and to provide documentation of all checks deposited. Upon review, it was identified that additional checks in the amount of $60, $100, and $300 were written to her which Staff 11 indicated she forgot about. Upon conclusion of the investigation, the allegation of misappropriation was substantiated as Staff 11 was unable to account for or provide all receipts and violated facility policy. Staff 11 was terminated. On 8/30/22 at 1:25 PM Resident 6 stated Staff 11 did nothing wrong. Resident 6 stated she/he wrote the checks to Staff 11 because Staff 11 bought many items for her/him including a pillow and was paying her back. Resident 6 stated she/he was aware Staff 11 was going on vacation to Florida and was afraid Staff 11 may get stuck there or may get in trouble so she wrote Staff 11 a check for $900 to pay her back plus an additional $50. Resident 6 stated Staff 11 told her/him she was not allowed to accept the check, but she/he insisted that she take the money to pay her back. On 8/31/22 at 9:15 AM Staff 8 (Business Office Manager) stated Resident 6's bank contacted her and informed her that one of Resident 6's checks was attempted to be cashed by Staff 11 in Florida. Staff 8 stated in talking with the bank it was discovered that other checks were written to Staff 11. Staff 8 stated Resident 6 was reimbursed for all the checks written to Staff 11. Staff 8 stated a resident trust account was in place at the time of the incident and all resident money was to be signed out by the resident for staff to do any resident shopping. Staff 8 stated Staff 11 was aware of the process and knew better than to accept money from Resident 6. On 8/31/22 at 9:44 AM Staff 9 (Activities Director) stated he received a call from Staff 1 (Administrator) who informed him that Resident 6's bank called indicating Staff 11 attempted to cash a check from Florida. Staff 9 stated Staff 11 would often buy items for residents using her own money. Staff 9 stated he told Staff 11 that she did not have to use her own money and could be reimbursed. Staff 9 stated Staff 11 indicated she purchased items for Resident 6 and one of the checks for $500 was for the last six months of items that were purchased. Staff 9 stated no receipts were ever provided. Staff 9 stated Staff 11 knew better and was told they were not allowed to directly handle resident's personal funds. On 8/31/22 at 10:24 AM Staff 1 (Administrator) stated Staff 8 informed him that Resident 6's bank contacted her about a $900 check that was attempted to be cashed in Florida by Staff 11. Staff 1 stated he spoke with Resident 6 who became upset and stated she/he gave the money to Staff 11 to buy her/him things in Florida. Staff 1 stated he informed Resident 6 that staff were not allowed to accept personal money from residents. Staff 1 stated when he spoke with Staff 11 regarding the $900, Staff 11 stated Resident 6 wanted her to purchase items for her/him while she was on vacation in Florida. Staff 1 stated Staff 11 indicated she used her own money to purchase items for Resident 6 and could no longer do so. Staff 1 stated Staff 11 confirmed she cashed the checks and would purchase items for Resident 6 and return any change to the resident. Staff 1 stated in reviewing Staff 11's bank statements, additional checks for smaller amounts were identified written by Resident 6 to Staff 11. Staff 1 stated Staff 11 was able to provide only some of the receipts for items she purchased for Resident 6. Staff 1 confirmed the allegation of misappropriation of resident funds was substantiated for Resident 6. On 8/31/22 at 12:32 PM Staff 11 indicated she became really attached to Resident 6 and [NAME] versa. Staff 11 state she assisted residents with needs the facility did not provide such as clothes. Staff 11 stated Resident 6 requested specific items be purchased, and the resident would occasionally write her a check with any change given back to the resident. Staff 11 stated she was going to Florida and was busy preparing for the trip and accepted the check for $900 from Resident 6. Staff 11 stated the $900 was never used and never went into her account. Staff 11 stated she accepted the check because Resident 6 was upset and felt neglected. Staff 11 stated the situation went too far. Staff 11 acknowledged there was a process in place regarding shopping for residents and indicated she followed the process until she accepted the $900. Staff 11 stated she knew better but felt pressured by Resident 6 to accept the money. Staff 11 stated she never accepted money from other residents.

Based on observation, interview and record review it was determined the facility failed to ensure residents' safety with dining for 3 of 6 sampled residents (#s 2, 3, and 6) reviewed for safety with dining. This placed residents at risk for a lack of safety with dining. Findings include: 1. Resident 3 admitted to the facility 12/2022 with diagnoses including [CONDITION(S)] and [CONDITION(S)]. Resident 3 was cognitively intact. Resident 3's current Face Sheet and meal card indicated she/he had an allergy to pineapple. Review of the menu from 3/7/22 through 4/8/22 revealed three documented opportunities when the resident was at risk of being served a meal with pineapple. On 4/8/22 at 10:20 AM Resident 3 stated she/he was served pineapple but did not eat it. The resident stated when she/he ate pineapple, her/his tongue would swell. On 4/8/22 at 11:02 PM Staff 8 (Activities Director) stated he was aware Resident 3 was allergic to pineapple and had been served pineapple. Staff 8 stated when fruit cups were served at meals they often contained pineapple. On 4/8/22 at 3:36 PM Witness 1 (Complainant) stated Resident 3 was blind and allergic to pineapple. Witness 1 stated the resident had recently been served pineapple but did not consume it. On 4/8/22 at 8:45 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Dining Service Specialist) and Staff 11 (Regional Director of Operations) were notified of the concerns. 2. Resident 2 admitted [DATE] with diagnoses including [CONDITION(S)] and diabetes and had a BIMS of 11 (moderately impaired cognition). Resident 2's current meal card indicated she/he was allergic to fish. Review of the facility's menu from 3/7/22 through 4/8/22 indicated the following: -On 3/8/22 the dinner meal included a fish sandwich. -On 3/11/22 the lunch meal included stuffed baked fish. -On 3/18/22 the dinner meal included grilled fish. -On 3/25/22 the lunch meal included her and lemon fish. -On 3/28/22 the lunch meal included fried fish. -On 4/4/22 the dinner meal included baked fish in butter. -On 4/8/22 the dinner meal included tuna noodle casserole. On 3/28/22 Witness 1 (Complainant) stated she/he had first hand knowledge staff attempted to serve Resident 2 fish. The witness did not indicate what staff member attempted to serve the resident fish. On 4/8/22 at 9:40 AM Resident 2 indicated staff had attempted to serve her/him meals with fish more than once over the last month. Resident 2 was unable to recall what staff attempted to serve her/him the meals with fish. The resident then stated she/he could have any fish other than salmon or tilapia, and was notserved anything other than that in the last few weeks. On 4/8/22 at 3:36 PM Witness 1 (Complainant) stated she/he had knowledge Resident 2 was allergic to and recently was almost served fish. She/he stated the incident was caught during a routine tray cart audit, and Staff 6 (Former Dietary Manager) intervened before the tray was served. On 4/8/22 at 8:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 2 had a documented fish allergy and was served a meal tray with fish. 3. Resident 6 admitted to the facility 3/2021 with diagnoses including a [CONDITION(S)] and was cognitively intact. The resident's current meal card and face sheet indicated she/he was allergic to bell peppers and onions. Review of the facility menu from 3/7/22 through 4/8/22 indicated green peppers or onions were documented to be served as follows: - 3/9/22 - chopped pepper with steak. - 3/12/22 - green peas with pearl onions. - 3/14/22 - sauteed onions. - 3/19/22 - sauteed onions and peppers. -3/20/22 - onion roasted potatoes. -3/23/22 - stuffed peppers. -3/25/22 - cucumber onion salad. -3/26/22 - potatoes and onions. -3/31/22 - peas and pearl onions. A 3/22/22 facility grievance form filed by Resident 6 was signed by Staff 1 (Administrator). The resident indicated she/he continued to receive peppers and onions on her/his meal tray despite having allergies listed on her/his meal card. Resident 6 specified she/he received allergens on her/his meal tray on 3/18/22 and 3/19/22. The Administrative Review portion completed by Staff 1 indicated he met with the Staff 6 and asked her to meet with the dietary department to educate them on the importance of tray card accuracy. The follow up section of the document indicated staff training was completed on 3/29/22. On 4/8/22 at 10:15 AM Resident 6 stated she/he had recently received a stuffed bell pepper, and that she/he often had onion in her/his meals. Resident 6 stated Staff 6 (Former Dietary Manager) would often be helpful to try and ensure she/he didn't get peppers or onions, but she/he would still received meals with them. The resident further stated she/he had stomach upset when she/he was served bell peppers or onions. The resident stated/he would usually just leave the tray alone and wouldn't eat a meal. On 4/8/22 at 10:56 AM Staff 7 (CNA) stated he was aware Resident 6 received meal trays with green peppers. Staff 7 further stated the resident complained on multiple occasions about this. Staff 7 stated he knew the resident couldn't have peppers and he would try and get her/him a replacement if he saw them on her/his tray. On 4/8/22 at 8:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified Resident 6 had a documented green pepper and onion allergy and served her/him a meal tray with green peppers and/or onions.

Based on observation, interview and record review it was determined the facility failed to have sufficient staff for residents who required one to one supervision for 1 of 1 sampled resident (#11) reviewed for behavioral health. This failure resulted in an immediate jeopardy situation in which Resident 11 was able to self-harm and was hospitalized . Findings include: Resident 11 admitted to a locked behavioral health unit (Unit) located within the facility in 6/2018 with [DIAGNOSES REDACTED]. Resident 11's 8/11/18 Care Plan for behavioral symptoms indicated the resident had a history of [REDACTED]. Interventions included to follow facility protocol if she/he displayed suicidal ideation. Review of Resident 11's behavior monitoring from 9/2018 through 11/15/18 revealed the following: * In 9/2018 the resident had documented behaviors two days out of the month, with one documented episode of suicidal ideation. * In 10/2018 the resident had documented behaviors four days out of the month, with no documented episodes of suicidal ideation. * From 11/1/18 through 11/15/18 the resident had documented behaviors on five days and the resident reported she/he heard voices and had [MEDICAL CONDITION] on five days. The 11/12/18 In Room Care Plan directed staff to keep glass and sharp objects away from the resident and to dispose of these items when found. It further stated the resident also used her/his own fingernails to cut her/himself. Review of progress notes from 11/1/18 through 11/15/18 revealed the following: * On 11/12/18 Resident 11 indicated she/he was currently experiencing suicidal ideation and stated (she/he) wanted to jump out of a window or overdose on (her/his) medication. The note further indicated the resident was placed on one to one supervision (1:1). * On 11/14/18 Resident 11 stated she/he was still sad and she/he did not want to feel like this anymore. The resident remained on one to one supervision. * On 11/15/18 at 6:25 PM the resident was documented to cut her/his wrists bilaterally using broken glass. The note indicated the resident had a current one on one staff person with her/him, who got the current resident care manager and a charge nurse who were immediately outside locked doors. The resident was noted to be transferred out to the emergency department after she/he was de-escalated and her/his wounds were cleaned and dressed. The 11/15/18 Incident Investigation indicated the following: * On 11/15/18 at 6:30 PM Resident 11 sustained bilateral superficial self-inflicted cuts bilaterally on her/his arms. The investigation indicated the resident was able to self-harm while she/he was on one on one supervision. The root cause analysis of the investigation indicated the resident had actively experienced auditory hallucinations and at the time of the incident had active visual hallucinations. The resident had hidden a picture frame with glass in it and at that time had evaded (her/his) (one to one supervision) by 'slamming' the door on her and gaining enough time to cut self with broken glass that (she/he) had hidden from staff. De-escalation techniques were used, the glass was removed from the resident, and she/he was sent out for a psychiatric evaluation. Mental health program director and facility staff were noted to have completed a sweep of the resident's room before she/he returned to the facility. Glass and potentially unsafe items were noted to be removed from the resident's room. Witness interviews indicated Staff 6 (CNA) was assigned as the one to one supervision for the resident at the time of the incident. The interview with Staff 6 indicated one CNA staff had left for a lunch break at 6:15 PM and the other CNA on duty left to use the restroom about five minutes later. Staff 6 stated when the second and only other CNA on the floor left to use the restroom, Staff 9 (RN) was in and out of the Unit and was unable to indicate if the charge nurse was in fact on the Unit at the time of the incident because she was too busy watching Resident 11. A review of staffing schedules in the Unit revealed at the time of the 11/15/18 incident, Staff 7 was assigned as Resident 11's one to one, along with Staff 6 and Witness 5 (former CNA) on the Unit. On 7/8/19 at 2:45 PM and 2:47 PM Staff 7 (CNA) and Staff 28 (CNA) stated when a Unit resident was placed on one to one supervision, they were to have a separate staff person assigned to supervise them while the CNAs working the floor provided care. On 7/10/19 at 1:55 PM Staff 7 acknowledged she was the one to one supervision for Resident 11 on the evening shift of 11/15/18. She stated she went to her lunch break and asked Witness 5 (Former CNA) on the floor to cover the one on one supervision for Resident 11. She further stated Witness 5 stepped out of the Unit to use the bathroom a few minutes after she went to lunch, which left Staff 6 (CNA) alone in the Unit. On 7/10/19 at 3:09 PM Staff 6 acknowledged she was working alone in the Unit on the evening shift of 11/15/18 while Resident 11 was on one to one supervision and was able to perform an act of self harm. Staff 6 stated as the resident continued to self-harm and sifted through broken glass to find sharper pieces of glass, Staff 6 left the resident's room and went to the entrance to the Unit to call for additional staff to come. On 7/10/19 at 6:06 PM Staff 1 (Administrator) was informed the incident on 11/15/18 constituted an immediate jeopardy situation. Due to the facility's identification of the deficient practice as well as implemented and sustained corrections the immediate jeopardy was determined to be past non-compliance and the immediate jeopardy was determined to be removed as of 11/29/18. As a result of the incident on 11/15/18 the facility instituted the following: - A policy on 1:1 precautions was developed which included prohibition of staff on the Unit from being utilized to cover for 1:1 staff during breaks. - In-service training for Unit staff on the 1:1 precautions policy. - Additional in-service trainings for Unit staff on 12/27/18, 2/7/19, 2/22/19, 2/26/19 and 3/2/19 regarding resident safety and 1:1 precautions. - Audits to ensure staff providing 1:1 supervision were trained on the facility's 1:1 precautions policy. A review of Resident 11's clinical record revealed the resident was placed on 1:1 in 3/2019. No evidence was found to indicate deficient practice occurred related to the resident's 1:1 precaution status in 3/2019. Observations of the Unit during survey from 7/8/19 through 7/12/19 revealed no concerns related to staffing and no residents were currently on 1:1 precautions. During interviews with staff on the Unit from 7/8/19 through 7/12/19 the staff indicated awareness of the 1:1 precautions policy and appropriate coverage for staff during breaks.

Based on observation, interview and record review the facility failed to ensure Staff 9 (RN), Staff 10 (LPN), Staff 17 (LPN), Staff 19 (RN) Staff 29 (LPN) and Staff 30 (RN) adhered to professional standards related to provision and documentation of treatments for 2 of 7 sampled residents (#s 23 and 225) reviewed for pressure ulcers and skin conditions. This failure resulted in Resident 23 experiencing a worsening pressure ulcer and placed other residents at risk for worsening skin conditions. Findings include: Oregon Administrative Rule [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined includes: 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: (1) Conduct related to general fitness to practice nursing: (b) Demonstrated incidents of dishonesty, misrepresentation, or fraud. (3) Conduct related to the client's safety and integrity: (c) Failing to develop, implement or modify the plan of care; (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (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; 1. Resident 23 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A current order initiated 6/14/19, indicated Resident 23 had a Stage 3 (full thickness skin damage) pressure ulcer to the right lateral calf and staff were to complete the following treatment: -Cleanse the area, pat dry, apply [MEDICATION NAME] treatment, skin prep the surrounding tissue, cover with border or foam gauze and secure with tape daily and PRN until resolved. On 7/2/19 the Skin Grid indicated Resident 23's Stage 2 right lateral calf pressure ulcer measured 3.4 cm x 1.0 cm x 0.1 cm. Review of the 7/2019 TAR from 7/1/19 through 7/11/19, indicated treatments were completed as ordered on all dates including: -7/9/19, signed off by Staff 10 (LPN) -7/10/19, signed off by Staff 17 (LPN) On 7/11/19 at 1:47 PM Resident 23 was observed during wound care. Resident 23's dressing contained serosanguineous (blood and fluid) drainage and the dressing was dated as last changed on 7/8/19. Staff 2 (DNS) was present during wound care and confirmed the date of the dressing. The right lateral calf wound was observed to be a Stage 3 pressure ulcer and the wound bed measured 2.5 cm x 0.5 cm x 0.3 cm (an increase of 0.2 cm in depth since the previous assessment). On 7/12/19 at 8:30 AM Staff 17 wrote a statement acknowledging she signed the treatment as completed on the TAR on 7/10/19 but was unable to perform the ordered dressing change for Resident 23 because the resident was asleep and she did not want to wake her/him up. On 7/12/19 at 10:09 AM Staff 10 stated wound care was to be done daily for Resident 23. She acknowledged she signed the treatment as complete on the TAR for 7/9/19 before the treatment was done. She stated she did not complete the treatment due to becoming occupied with other resident care and forgot to go back and do the treatment. On 7/11/19 at 2:11 PM and 7/12/19 at 11:50 AM Staff 2 confirmed the dressing was dated 7/8/19 during the dressing change on 7/11/19 and confirmed two wound treatments were signed on the TAR by nursing staff but were not completed. She acknowledged the wound bed was assessed 7/2/19 and measured 0.1 cm in depth and then the wound was assessed on 7/11/19 and measured 0.3 in depth, indicating the wound worsened. Refer to F686. 2. Resident 225 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/19 at 2:19 PM Resident 225 was observed to have an ACE bandage wrapped around her/his lower left leg, with only the resident's toes exposed. The resident was observed to have several surgically implanted pins, which extended out from the resident's skin and attached to an external stabilizing cage on her/his lower left leg. The tops of the pins were visible, but the bottom of the pins, where the pins entered the skin, were not visible due to the bandage. None of the Resident 225's skin on the left lower leg was visible between her/his knee and toes due to the bandage. On 7/9/19 at 11:33 AM the same bandage was observed covering the resident's left lower leg. Resident 225 stated the bandage was present since her/his surgery prior to admission to the facility. Resident 225 stated staff did not monitor her/his skin and the incisions under the bandage. A review of the resident's 11/2019 TAR indicated the pin sites were to be monitored for signs of infection on each shift and the TAR noted the treatment was completed on each shift from 7/6/19 through 7/10/19. Staff 9 (RN), Staff 17 (LPN), Staff 19 (RN), Staff 29 (LPN) and Staff 30 (RN) all documented the treatment was completed. On 7/10/19 at 2:05 PM Staff 19 (RN) stated he monitored Resident 225's leg for infection the past few days but had not yet assessed the resident's skin that day. Staff 19 stated Resident 225's left lower leg was to be assessed on each shift. Staff 19 stated he was on his way to look at Resident 225's leg. The surveyor accompanied Staff 19 to Resident 225's room to observe the resident's leg. On 7/10/19 at 2:15 PM Staff 19 was observed to provide treatment to the resident's leg incision and pin sites. Asked again how often the resident's leg was to be monitored and treated Staff 19 stated wound care to the incision and pin sites was to be completed once per day. As the bandages were removed the resident expressed that the current time was the first time she/he saw the wounds since surgery. No signs of infection or skin deterioration were observed. It was noted that the same bandage previously observed on 7/8/19 and 7/9/19 was surrounding the resident's leg. On 7/10/19 at 2:28 PM Staff 2 (DNS) stated it was not possible for staff to assess the resident's pin sites for signs of infection without removing the bandage. On 7/10/19 at 2:31 PM Staff 17 acknowledged she documented monitoring of Resident 225's pin sites for infection. Staff 17 acknowledged she did not remove the bandage in order to assess the pin sites for infection. Staff 17 stated she looked at the skin adjacent to the bandage and determined there was no infection present. On 7/10/19 at 2:59 PM Staff 19 acknowledged he documented monitoring of Resident 225's pin sites for infection. Staff 19 acknowledged he did not remove the bandage in order to assess the pin sites for infection. Staff 19 stated he looked at the skin adjacent to the bandage and determined there was no infection present. Staff 19 acknowledged the bandage he removed from Resident 225 on that day was in place since the resident's admission to the facility. During an interview on 7/10/19 at 3:08 PM with Staff 2 and Staff 4 (Corporate RN) both staff acknowledged Staff 9, Staff 17, Staff 19, Staff 29 and Staff 30 all documented the resident's leg was monitored for infection, however the resident's leg was not monitored as the same dressing was in place since the resident's admission to the facility. Refer to F684.

Based on observation, interview, and record review it was determined the facility failed to implement interventions to prevent and treat pressure ulcers for 2 of 4 sampled residents (#s 23 and 268) reviewed for pressure ulcers. This resulted in Resident 23 experiencing a worsened pressure ulcer and placed residents at risk for the development of pressure ulcers. Findings include: 1. Resident 23 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. A 1/4/19 admission nursing assessment indicated Resident 23 readmitted to the facility from the hospital and had a fluid filled blister on the back of her/his right heel. The 1/2019 TAR indicated weekly skin checks were to be completed on Tuesdays. On 1/8/19 there was no indication of new skin changes for Resident 23. A 1/10/19 Skin Incident Investigation indicated a CNA reported a new skin issue on Resident 23's right posterior lower leg. The wound was noted to have non-blanchable redness discoloration and measured 6 cm x 2 cm. Resident 23 preferred to lay in bed with legs elevated on pillows and was unable to move her/his legs independently. The investigation indicated Resident 23 was rehosptalized on [DATE] so the investigation was unable to be completed. A 1/10/19 physician order [REDACTED]. A 1/14/19 Hospital Wound, Ostomy and Skin Department Progress Note indicated Resident 23 had a 3 cm x 1 cm non-blanchable red area to the right posterior leg, source unknown. A 1/14/19 admission nursing assessment indicated Resident 23 readmitted to the facility with an abrasion to the right lower leg. No measurements were indicated. No indication of non-blanchable redness was noted. The 1/2019 TAR indicated no treatment was completed for Resident 23's right leg wound until 1/20/19, seven days after the resident readmitted . A 1/20/19 Skin Incident Investigation indicated new skin impairment on Resident 23's right lower calf. The wound measured 5 cm x 1 cm. The investigation noted the wound was present on admission per the 1/14/19 nursing assessment. A 1/20/19 physician order [REDACTED]. A 1/21/19 Skin Grid indicated Resident 23 had a Stage 2 pressure ulcer (partial-thickness skin loss) on the right lateral lower leg which measured 5.5 cm x 1.2 cm. The resident's current care plan, last updated 5/6/19, indicated on 1/14/19 Resident 23 had a pressure ulcer on the right lateral calf and was at risk for slow healing secondary to impaired mobility, disease process and a preference to support/elevate leg with pillows, which could increase the risk of pressure. On 7/11/19 at 2:11 PM and at 4:02 PM Staff 2 (DNS) confirmed the Stage 2 pressure ulcer was identified on 1/14/19 but treatment was not initiated until 1/20/19. She further acknowledged the 1/14/19 hospital record assessed the wound as 3 cm x 1 cm and the Skin Incident Investigation dated 1/20/19 assessed the wound as 5 cm x 1 cm, indicating the wound had increased in size. Staff 2 stated the heel blister, the non-blanchable redness and the skin abrasion were all the same wound; a pressure ulcer on the resident's right calf. b. Resident 23's current care plan, last revised 5/6/19, indicated Resident 23 was at risk for developing further skin breakdown and had a pressure ulcer on the right lateral calf and was at risk for slow healing secondary to impaired mobility, disease process and preference to support/elevate leg with pillows, which could increase the risk of pressure A 5/5/19 physician order [REDACTED]. The 5/7/19 Skin Grid indicated Resident 23 had a Stage 2 (partial thickness skin loss) Pressure Ulcer to the right lower lateral calf and the wound bed measured 2.0 cm x 1.0 cm x 0.2 cm. A 5/28/19 admission nursing assessment indicated Resident 23 readmitted from the hospital with a right lower extremity sore measuring 3.8 cm x 1.9 cm x 0.2 cm. Treatment was initiated. The 6/4/19 Skin Grid indicated Resident 23 had a Stage 2 right lateral lower leg pressure ulcer measuring 3.2 cm x 1.0 cm x 0.2 cm. A current order initiated 6/14/19, indicated Resident 23 had a Stage 3 pressure ulcer to the right lateral calf and staff were to complete the following treatment: -Cleanse the area, pat dry, apply [MEDICATION NAME] treatment, skin prep the surrounding tissue, cover with border or foam gauze and secure with tape daily and PRN until resolved. A 6/14/19 late entry wound note, completed 7/11/19 by Staff 2 (DNS), indicated Resident 23 readmitted to the facility from the hospital on [DATE] with a Stage 3 right lateral calf pressure ulcer. The note further indicated on 6/14/19 Staff 2 reassessed the resident's right lateral calf wound and the wound bed measured 3.4 x 1 cm x 0.1 cm with 50% yellow adherent slough (dead tissue). On 7/2/19 the Skin Grid indicated Resident 23's Stage 2 right lateral calf pressure ulcer measured 3.4 cm x 1.0 cm x 0.1 cm. Review of the 7/2019 TAR from 7/1/19 through 7/11/19, indicated treatments were completed as ordered on all dates including: -7/9/19, signed off by Staff 10 (LPN) -7/10/19, signed off by Staff 17 (LPN) On 7/11/19 at 1:47 PM Resident 23 was observed during wound care. Resident 23's dressing contained serosanguineous (blood and fluid) drainage and the dressing was dated as last changed on 7/8/19. Staff 2 was present during wound care and confirmed the date of the dressing. The right lateral calf wound was observed to be a Stage 3 pressure ulcer and the wound bed measured 2.5 cm x 0.5 cm x 0.3 cm (an increase of 0.2 cm in depth since the previous assessment). On 7/12/19 at 8:30 AM Staff 17 wrote a statement acknowledging she signed the treatment as completed on the TAR on 7/10/19 but was unable to perform the ordered dressing change for Resident 23 because the resident was asleep and she did not want to wake her/him up. On 7/12/19 at 10:09 AM Staff 10 stated wound care was to be done daily for Resident 23. She acknowledged she signed the treatment as complete on the TAR for 7/9/19 before the treatment was done. She stated she did not complete the treatment due to becoming occupied with other resident care and forgot to go back and do the treatment. On 7/11/19 at 2:11 PM and 7/12/19 at 11:50 AM Staff 2 acknowledged the discrepancies with the wound staging and condition. She confirmed the dressing was dated 7/8/19 during the dressing change on 7/11/19 and confirmed two wound treatments were signed on the TAR by nursing staff but were not completed. She acknowledged the wound bed was assessed 7/2/19 and measured 0.1 cm in depth and then the wound was assessed on 7/11/19 and measured 0.3 in depth, indicating the wound worsened. 2. Resident 268 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/6/19 admission nursing assessment indicated Resident 268 was dependent on staff for bed mobility and she/he had unblanchable redness to the coccyx. The 7/6/19 In Room Care Plan indicated Resident 268 required extensive 1-2 person assistance for bed mobility and skin care interventions including keep linen clean, dry and turn and reposition every two hours. Multiple observations of Resident 268 on 7/10/19 and 7/12/19 found the resident in bed on her/his back. On 7/10/19 at 11:20 AM Staff 14 (LPN Resident Care Manager) stated Resident 268 was difficult to turn and turning caused the resident pain. She also stated she assisted the resident with incontinent care on 7/8/19 and did not observe any pressure wounds. The coccyx area was red but blanchable. Staff 14 stated Resident 268 was high risk for skin integrity issues due to immobility. On 7/12/19 at 12:28 PM Staff 23 (CNA) stated Resident 268 had a lot of pain when turning and it was difficult to turn the resident when performing incontinent care. Staff 23 stated she was unable to turn Resident 268 for repositioning and acknowledged the resident remained on her/his back most of the time. She also stated if Resident 268 could not turn there was not much that could be done about it. On 7/12/19 at 10:30 AM Staff 14 stated the physician was not notified of Resident 268's inability to turn due to pain prior to 7/10/19 and no alternate interventions were care planned or implemented to reduce risk for pressure ulcer formation. On 7/12/19 at 1:00 PM Staff 2 (DNS) stated she was unable to meet with Resident 268 since admission to assess her/his needs and plan interventions because it was a busy week.

Based on observation, interview, and record review it was determined the facility failed to address a change of condition in a timely manner, complete alert charting after a fall, and follow physician orders [REDACTED].#s 1 & 2) reviewed for changes in condition, physician orders, and incidents. Resident 2's health status worsened resulting in a hospitalization and was at risk for complications from a fall. Resident 1 was at risk of potential injuries from falls. Findings include: 1. a. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/19/17 Cognitive Loss/Dementia, ADL Functional Status/Rehabilitation, and Urinary Incontinence and Indwelling Catheter CAAs noted the resident was alert and oriented, able to have conversation, was continent of bowel and bladder and took herself/himself to the bathroom. The resident did not appear to have dementia and behaviors were related to her/his mental health diagnoses. She/he required supervision with most ADLs and at times limited assist. The resident was able to use a walker to walk independently but used a wheelchair due to preference and staff encouraged the resident to use the walker. The 7/12/17 discharging hospital physician orders [REDACTED]. The 7/31/17 CBC noted Resident 2's WBC (white blood cell count, a test used to measure health status such as infections) was within range at 6.9 (reference range 4.5 to 10.5). [DIAGNOSES REDACTED]s Auto % and [DIAGNOSES REDACTED]s Absolute levels (type of WBC that fights infections in the body) were within the normal range at 66.0 (reference range 38.3 to 70.3) and 4.5 (reference range 1.1 to 5.5) respectively. The 8/2/17 CBC noted Resident 2's WBC was high at 14.6, the [DIAGNOSES REDACTED]s Auto % was high at 81.3, and the [DIAGNOSES REDACTED]s Absolute was high at 11.8. The clinical record lacked documentation why the resident's CBC was checked again on 8/2/17. There was no documentation the physician or nurse practitioner was notified of the 8/2/17 elevated lab values. The 7/2017 and 8/2017 Meal Monitors indicated the resident had a decline in oral intake from 8/5/17 to 8/16/17. There was no documentation of the resident's health status related to the elevated labs, the resident's behavior changes or feeling ill until 8/11/17 at 12:00 PM when Witness 3 (NP, Nurse Practitioner) documented Chief complaint: behavior changes, malaise (general feeling of being unwell). Witness 3 (NP) documented she was notified by nursing that morning the resident had increased confusion and behaviors. The resident was incontinent of urine and had a history of [REDACTED]. [DIAGNOSES REDACTED].Will have nursing send UA (urinalysis) today .await CBC . Staff were to push oral fluids. The 8/11/17 at 1:35 PM Progress Note disclosed staff were to obtain the UA. Staff reported the resident was not acting like herself/himself and was confused. The 8/12/17 at 12:30 AM Progress Note disclosed staff were unable to obtain a urine sample. Resident observed with bladder incontinence. The 8/12/17 at 3:10 PM Progress Note revealed a urine sample was collected. The 8/12/17 UA preliminary report noted the WBC in the urine was greater than 182, with a reference range of 0-5 and a RBC (red blood cell count) of 16, with a reference range of 0-5. The UA was positive for protein and [MEDICATION NAME], was large for Leukocyte esterase (a WBC), and a colony count of greater than 100,000 of Escherichia coli was identified. The 8/13/17 at 1:50 PM Progress Note indicated the resident had a poor appetite, tolerated 240cc of house health shake, and vitals were stable. The UA results were received, noted with elevated UA WBC. The oncall physician was notified who ordered a STAT (urgent) CBC noting a WBC greater than 10.5. The 8/13/17 CBC results revealed the WBC was at 10.1, however, the [DIAGNOSES REDACTED]s Auto% and [DIAGNOSES REDACTED]s Absolute levels were elevated at 87.1 and 8.8 respectively. The 8/14/17 at 7:57 AM Progress Note indicated the resident's vitals were stable and she/he was drinking lots of fluids. The CBC lab results were reported to the oncall physician. Will notify House MD/NP about resident condition. The 8/14/17 at 4:49 PM NP Progress Note revealed the NP followed up on the resident, who continued to be confused and incontinent of urine. The UA was positive for [MEDICATION NAME], Still waiting for sensitivity report to come back. Eating okay, sleeping a bit more than (Resident 2's) norm these past several days. [DIAGNOSES REDACTED]. UTI positive. Likely d/t (due/to) this. Will start abx (antibiotics) . Will go ahead and [MEDICATION NAME](an antibiotic) x 7 days. The NP [MEDICATION NAME] mg every 12 hours and for staff to push fluids. The 8/14/17 Final UA with C&S (Culture and Susceptibility) verified the urine colony count and noted the organism was resistant to Cipro. The 8/2017 MAR indicated [REDACTED]. There was no documented evidence the facility reviewed the C&S findings regarding [MEDICATION NAME] the physician or the NP. The 8/14/17 at 11:01 PM AM/PM Charting noted the resident was very confused and lethargic during the morning and she/he refused breakfast. At 8:50 AM the resident had a blood pressure of 152/100, followed by a 10:00 AM blood pressure of 122/90. The NP was notified and orders were given for [MEDICATION NAME] the first dose given that evening. The 8/15/17 at 1:06 PM NP Progress Note disclosed the resident continued to feel poorly with ongoing restlessness and confusion. The vital signs were stable but the resident appeared pale and was not eating well. The resident was drinking lots of fluids but appeared to be quite dehydrated. The review of symptoms with the resident was limited due to her/his cognition and the resident had a low grade temp. [DIAGNOSES REDACTED]. Still ongoing today, if not worse. An additional [DIAGNOSES REDACTED]. Per staff the resident was taking in oral fluids but the resident was dry and had poor skin turgor. There was no change in the antibiotic treatment order and the NP ordered additional labs and IV fluids. The 8/15/17 at 2:37 PM Progress Note documented the resident had confusion, restlessness, poor appetite, and tolerated the house health shake. The resident continued on [MEDICATION NAME] the NP was notified regarding the increased confusion. Orders were received for IV fluids which were given and for a chest x-ray for wheezing. The 8/15/17 at 10:48 PM Progress Note indicated the resident continued to be confused that evening and was given a second bag of IV fluids. The resident was assisted at dinner with very minimal intake. The 8/16/17 at 12:08 PM Progress Note revealed at the beginning of shift the resident was very confused, restless, not able to follow simple commands or verbalized needs. The resident talked in fragments and had difficulty expressing discomforts. The resident continued with IV fluids, was in bed, appeared lethargic, did not respond to auditory stimuli and still showed altered metal status. The vital signs were stable, and the resident was described as pallor looking, weak. The NP was notified and the resident was sent to the hospital at approximately 12:00 PM. The 8/16/17 at 12:40 PM NP Progress Note indicated the resident continued to be quite confused and restless. The chest x-ray was negative and the resident continued on [MEDICATION NAME] IV fluids. The physical exam noted the resident's lips were dry (an indication of dehydration). The resident was quite restless, disoriented and kept pulling her/his incontinence brief and covers off. There was concern for an acute kidney injury and the NP adjusted a medication due to the resident's renal function. The NP sent the resident to the hospital for further evaluation. The 8/16/17 to 9/12/17 Hospital Records noted the resident had a history of [REDACTED]. The resident was noted with an altered mental status likely secondary to a UTI and elevated sodium level. The resident's elevated sodium level was likely related to the poor oral intake and the UTI. Family reported the resident was not agitated or angry at baseline, could generally carry on a normal conversation and UTIs presented with an altered mental status. However, per family the resident was more confused, agitated, and angry over the last two days. The resident reported painful urination but had difficulty stating any other information. Facility staff reported the resident had decreased intake and received IV fluids at the facility. The physician noted the resident's throat had very dry mucous membranes. Discharge [DIAGNOSES REDACTED]. On 12/11/17 at 11:03 AM Witness 2 (Complainant) stated while at the facility Resident 2 developed a UTI (could not recall the date) which was common for the resident. The facility reported the resident needed antibiotics then reported the antibiotics were not working and she/he needed IV fluids. Two days later the NP reported the facility called for an ambulance for the resident as she/he was doing badly, would not keep her/his clothes on or the IV in place, and was crazy. Per Witness 2, Staff 25 (Enhanced Care Unit Program Coordinator) tried to get the facility to send the resident out to the hospital sooner. On 12/11/17 at 1:03 PM Staff 25 (Enhanced Care Unit Program Coordinator) stated Resident 2 was prone to multiple UTIs and she/he exhibited a clear status change at the end of July. The resident fell , became quickly confused, stayed in bed more, and was very disoriented. Mental health staff requested a UA be obtained at the end of July and in August due to concerns the resident had a UTI but it was not done for two weeks. By the time the resident's change in condition was addressed the resident was in full [MEDICAL CONDITION] pulling out her/his IV. On 12/18/17 at 1:44 PM Staff 19 (CNA/CMA) stated the resident was more tired with the more recent admission compared to a previous stay in the facility. Staff 19 described the resident as very weak, not herself/himself and declining. The resident's fatigue worsened before the hospitalization and she/he used the wheelchair rather than walking with a walker. On 12/18/17 at 3:12 PM Staff 4 (Staffing Coordinator/CNA) stated the resident declined during her/his last two weeks in the facility which nurses monitored. The resident's oral intake declined, however, the resident consumed fluids. On 12/19/17 at 10:04 AM Staff 16 (CNA) stated from 8/2/17 to 8/12/17 the resident appeared to have a change of condition and was not at her/his baseline as she/he was pretty confused, was not able to stand up, and did not accept a lot of food. On 12/19/17 at 10:14 AM Staff 21 (LPN) stated the resident was alert and during the last two weeks in the facility the resident became weak and declined in oral intake. Staff 21 stated she was off for a few days and upon return learned the resident was not taking in fluids and was sick for a few days. Staff 21 talked to Witness 3 (NP) and IV fluids were started. Later she sent the resident to the hospital. On 12/19/17 at 10:45 AM Staff 10 (LPN) stated during the resident's last two weeks in the facility the resident declined, was still walking but was walking with weakness and exhibited confusion. The resident always asked for water but with the decline the resident did not do well with both eating or drinking. The resident became weak and CNA staff had to assist the resident with oral intake. On 12/19/17 at 1:32 PM Staff 20 (LPN/RCM) stated she was not the resident's RCM at the time of the hospitalization . In 8/2017 the resident initially looked like herself/himself then started declining and was not eating as much. Staff 20 did not recall any details regarding the 8/2/17 lab, she obtained the ordered UA, but was not aware of the C&S results. Staff 20 stated if an organism was found resistant to the antibiotic she reported that information to the physician or the NP who then usually changed the antibiotic. On 12/20/17 at 5:35 AM Staff 3 (CNA) stated the resident was initially only occasionally incontinent but became incontinent all of the time. The resident went from holding a conversation to no longer able to do that and was confused. On 12/20/17 at 9:33 AM Witness 3 (NP) stated Resident 2 had chronic UTIs and kidney disease. The resident declined over the last two weeks in the facility but she was unable to provide specific information of that decline. Witness 3 stated she did not know who ordered the 8/2/17 labs and why they were ordered nor did she recall being notified about the elevated WBC as one that high would catch her eye. At times she treated residents with antibiotics for a UTI and a pending C&S based on how the resident presented and changed the antibiotic once the C&S was finalized. Per Witness 3 there was not time to change the antibiotics before the resident was hospitalized . When Witness 3 was informed the C&S was finalized on 8/14/17 and the resident was not sent to the hospital until 8/16/17 Witness 3 stated the facility was supposed to notify her of the C&S results. Witness 3 stated the resident was dehydrated, she was worried about the dehydration and the resident becoming septic and the resident was sent to the hospital. The resident's change in condition including the changes noted by mental health staff and request for follow up labs was discussed with Staff 2 (DNS) on 12/20/17 at 10:30 AM and 12/21/17 at 11:44 AM. Staff 2 stated the resident's RNCM at that time no longer worked for the facility. Per Staff 2 Witness 3 (NP) ordered the 8/2/17 labs, however, she did not know why they were ordered. The lack of documented notification of the 8/2/17 WBC, follow up of the resident's changes from 8/2/17 until the 8/11/17 UA, notification of the C&S results regarding the Cipro, and the resident's decline in oral intake was discussed. Staff 2 stated she was not in the facility during that time. No additional documentation was provided. Per interview mental health staff reported the resident exhibited changes in condition with a possible UTI at the end of July. There was no documentation in the clinical record of those concerns. Labs were obtained on 8/2/17 with no documentation why they were ordered. The 8/2/17 lab results revealed elevated white blood counts indicative of a possible infection. There was no documented follow up of the resident's status related to the elevated labs including notification to the physician or NP until 8/11/17, nine days later. Per interview and documentation during this timeframe the resident declined in areas including continence, oral intake, ambulation, communication, and had increased confusion. On 8/14/17 the NP [MEDICATION NAME] treatment of [REDACTED]. The resident continued to worsen, became dehydrated despite fluids given both orally and via IV and was sent to the hospital due to concerns for dehydration and [MEDICAL CONDITION]. Per interview the resident had [MEDICAL CONDITION] at the time of discharge to the hospital evidenced by her/his behaviors. The hospital noted the resident's altered mental status secondary to the UTI and elevated sodium level. The resident had difficulty with communication and reported painful urination. Despite the oral and IV fluids given at the facility the resident was noted with dehydration at the hospital. The hospital discharge [DIAGNOSES REDACTED]. b. The facility's Revised 6/2017 Alert Charting Recommendations directed staff to complete alert charting for falls each shift for 72 hours, including monitoring the resident for delayed trauma. The 7/18/17 at 3:28 PM Progress Note disclosed Resident 2 was found on the floor. There was no documented alert charting related to the fall on 7/19/17 and 7/20/17. On 12/19/17 at 10:14 AM Staff 21 (LPN) stated staff were to complete alert charting for 72 hours after a fall. When asked about the lack of alert charting on 7/19/17 and 7/20/17 Staff 21 stated I think there was alert charting. However, if the fall was not recorded she would not know there was a fall. On 12/19/17 at 12:31 PM Staff 17 (LPN) stated she had no information regarding the 7/18/17 fall alert charting. The lack of alert charting for the 7/18/17 fall was discussed in interviews on 12/11/17 at 1:02 PM and 12/20/17 at 10:30 PM. Staff 2 (DNS) stated alert charting was completed every shift for 72 hours. No additional documentation was provided. 2. Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 9/2017 and 10/2017 Physician order [REDACTED]. The 9/15/17 at 7:04 AM Progress Note disclosed the resident was sitting off the floor. The resident reported trying to get up and slipped off the bed. The facility's correlating investigation did not address the use of the alarm. On 12/19/17 at 1:32 PM Staff 20 (LPN/RCM) stated she thought the resident still used the pad alarm when in bed but would check to see if it was still a current intervention for the resident. On 12/20/17 at 10:30 AM Staff 2 (DNS) stated the use of alarms was discontinued in the facility but could not state when that change occurred. Staff 2 stated the resident did not have an alarm in place and she was not aware the resident had current physician orders [REDACTED].

Based on observation, interview and record review it was determined the facility failed to assess changes in condition and skin status and notify the physician in a timely manner for 2 of 3 sampled residents (#s 1 & 2) reviewed for changes in condition. Resident 1 was hospitalized in critical condition, placed on hospice and died . Resident 2 was hospitalized . 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission Nursing Database indicated Resident 1 was alert to self, confused, aphasic (a disorder that affects speech) and there was no redness to the right lower extremity. The [DATE] updated In Room Care Plan noted Resident 1 required two person assistance with bed mobility and incontinence care and weekly skin checks. The ,[DATE] and ,[DATE] TARs from [DATE] to [DATE] only noted one weekly skin check completed on [DATE]. There was no documented result of that skin check. The [DATE] physician progress notes [REDACTED]. A [DATE] Progress Note disclosed Resident 1 began antibiotic treatment for [REDACTED]. The [DATE] 8:57 pm Progress Note revealed Resident 1 had an oxygen saturation level of 87%, an elevated heart rate of 115 and a low grade temperature of 99.1 degrees. The [DATE] 10:29 pm Progress Note described Resident 1 as restless at times during the shift, calling out. The [DATE] 2:20 pm Progress Note described Resident 1 as "irritable, agitated at times....Slept in long intervals. Poor appetite for lunch." The [DATE] 11:56 am and 12:16 pm Progress Notes indicated Resident 1 yelled throughout the day. "Spoke to RCM and reported patient is declining, having poor appetite, appears tired, irritable, not cooperating with transfers as (Resident 1) was previously, coughing, restless, refusing to sit up in w/c (wheelchair)." A PRN pain medication was given which helped the resident sleep but upon waking she/he started yelling again. The resident refused to have blood pressure taken as she/he kept constantly moving her/his arms. The [DATE] 10:03 pm Progress Note revealed the physician ordered STAT labs, which revealed an abnormal sodium level of 178. The physician was contacted, who sent the resident to the hospital. The [DATE] Hospital History and Physical and physician progress notes [REDACTED]. The resident appeared to be extremely dehydrated, "...clinically appears dry...Possible considerable dehydration has been going on for weeks..." The resident was in septic shock and had a "quite low" blood pressure in the emergency room . On the right lower extremity there was a red area underneath the resident's right knee to the right toes. The calf was swollen and very tender to palpation. An ultrasound obtained in the emergency room revealed an acute [MEDICAL CONDITION] (blood clot). The creatinine and BUN (labs that evaluate kidney function) were elevated and the sodium level was "extremely high. Anticipate d/t (due to) lack of free water and dehydration with profound AKI (acute kidney injury)." The resident was critically ill and admitted to the Intensive Care Unit and comfort measures were recommended. At the time of the survey there was no documented evidence the physician was notified timely regarding the resident's changes from [DATE] to [DATE]. There was no documented assessment of the resident's changes in condition, hydration status nor the right lower extremity. In interview on [DATE] at 9:59 am Witness 3, Friend, stated when she visited Resident 1 on [DATE], the resident looked very sick. The resident was not responding to voices she/he knew for a long time, did not look right and was "ashy colored." The resident was discharged from the hospital on hospice care on [DATE] and died on [DATE]. In interview on [DATE] at 9:00 am Witness 1, Complainant stated when Resident 1 was admitted to the hospital on [DATE], her/his BUN, creatinine and sodium levels were elevated. The elevated sodium was a flag that the resident was severely dehydrated and the BUN and creatinine indicated the resident was dehydrated over time, which the physician stated was at least five, up to 14 days. The kidney injury was a "direct result" from dehydration, because the toxicity of the elevated sodium level was so extreme. Per Witness 1 "...they waited so long to send (Resident 1) in we couldn't save (Resident 1)." In interview on [DATE] at 2:51 pm, Staff 15, LPN stated from [DATE] to [DATE] the resident was lethargic and the resident's legs did not look red or swollen. Staff 15 stated she could not recall if she notified the physician regarding the resident's lethargy. In interview on [DATE] at 3:10 pm Staff 8, RN stated [DATE] was the first time the resident's oxygen saturations dropped below 90%. Staff 8 stated she did not assess the resident's legs. Interviews on [DATE] at 11:55 am, 1:10 pm and 2:30 pm and on [DATE] at 9:35 am with Staff Staff 22, CNA, Staff 24, CNA, Staff 29, CNA and Staff 30, CNA the following information was revealed: *Staff 22, Staff 24 and Staff 29 stated the resident had a decline in fluid intake and increase in sleeping and lethargy the week prior to the [DATE] hospitalization . *Staff 22 stated the resident used a sit to stand lift for transfers, however, the days prior to the hospitalization the resident could not longer use the lift. *The changes in fluid intake and lethargy were reported to the nurse. *No redness or swelling to the right lower leg was observed. In interview on [DATE] at 11:37 am Staff 10, LPN stated the resident started having changes a couple days prior to being hospitalized on [DATE], including not being cooperative, was more tired and needed help with transfers. On [DATE] the resident was very irritable and everything bothered the resident, which she reported to Staff 4, RNCM but not to the physician. The resident was on thickened liquids and consumed fluids during the week prior to the hospitalization . On [DATE] and [DATE] it was hard to get the resident to drink fluids, however, she did not assess the resident for dehydration. Staff 10 stated she did not assess the resident's legs/skin and assumed CNAs would tell her if something was wrong, which did not occur. When asked about the [DATE] weekly skin check, Staff 10 stated she probably didn't get to it. In interview on [DATE] at 3:39 pm Staff 13, LPN stated on [DATE] and [DATE] the resident declined in intake of food and fluids. Staff 13 stated there may have been some redness on the resident's ankle but he was not sure. On [DATE] the resident was quiet which was not her/his usual. Staff 13 received the physician's orders [REDACTED]. When asked if the resident appeared dehydrated, Staff 12 stated he made an assumption based on the lab. In interview on [DATE] at 11:12 am Staff 4, RNCM stated she was not aware of the resident's changes prior to [DATE] and no staff reported redness or swelling of the resident's legs. On [DATE] she assessed the resident, her/his skin color was not at baseline, however, she did not assess her/him for dehydration. She had the physician call for STAT labs and learned the next morning the labs showed kidney failure and the resident was sent to the hospital. Staff 4 reviewed the resident's progress notes and stated the physician should have been notified of the resident's changes on [DATE]. In interviews on [DATE] at 1:45 pm and 4:09 pm Staff 2, DNS stated regarding the resident's right lower extremity "someone should have seen something" and acknowledged there was no documented assessment of the resident's skin. Staff 2 acknowledged the resident's dehydration and change of condition was not addressed timely. An IV for fluids should have been started "but no one was paying attention." Refer to F327 2. Resident 2 was admitted to the facility 2014 with [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. On [DATE] a wound physician ordered routine labs to be drawn on [DATE], including a CBC (complete blood count, a lab test that evaluates overall health and disorders including infection) and a BMP (basic metabolic panel, a lab test that evaluates metabolism and kidney function). There was no documented evidence those labs were obtained as ordered. A [DATE] Progress Note revealed that at around 4:00 pm the resident had an increased temperature of 101.9 degrees. At around 10:00 pm the resident was diaphoresing (sweating) and lethargic. The resident had a temperature of 101.6 degrees, a blood pressure of ,[DATE] and a pulse of 53. Another nurse came in to verify and the resident had a blood pressure of ,[DATE]. "Called RCM", who requested Staff 8, RN check the resident's urine, which was "dark yellow with some white particulate matter floating" in the resident's urine bag. The physician was contacted, who advised staff to continue to monitor the resident. The [DATE] 2:51 pm Progress Note disclosed at 7:30 am the resident had a blood pressure of ,[DATE], a pulse of 106, respirations of 28 and an oxygen saturation level of 88%. Oxygen was administered. There was no urine in the urine bag and after irrigating, there was output of dark urine. At 9:45 am the resident had a blood pressure of ,[DATE] and she/he was alert and oriented to time, place and situation. "Will continue to monitor....urinary output and encourage patient to drink water." Staff 5, RNCM documented in the [DATE] 10:42 am Progress Note that the resident was working with physical therapy, "....has not been feeling well for the past couple of days. Participation fluctuates, possible decline since week prior..." At 8:16 pm the resident reported she/he had no appetite and did not consume dinner. Staff 6, RN, documented in the [DATE] 6:29 am Progress Note "CNA reports less than 200 ml from Foley this shift, and that urine is brown discoloration. Will notify next shift for follow-up." Staff 9, LPN documented in the [DATE] 2:11 pm Progress Note that the resident had 250 ml output of "dark brown" urine. The resident's appetite had diminished. At 6:21 pm Staff 11, LPN documented the "urine continues dark." Staff 6, RN documented in the [DATE] 3:59 am Progress Notes "Urine output thus far about 75 ml, light brown and cloudy...will fax MD and ask for BMP to r/o (rule out) dehydration." Staff 5, RNCM documented in the [DATE] 11:51 am Progress Note that Resident 2 had a decline over the past week, including intake. "...Awaiting lab results at this time." The 1:11 pm Progress Note indicated the wound physician evaluated the resident. The [DATE] wound physician progress notes [REDACTED]. Requested STAT draw today. Has had a fever up to 102F and been intermittently more delirious, actively hallucinating today and seeing white spots/lines/bursts...Not eating much still...sickly appearance...urine tan, cloudy...Resident is very confused today and STAT labs revealed severe infection with worsening renal function so sending to hospital for septic workup." The physician diagnosed the resident with [MEDICAL CONDITION]. The [DATE] Hospital History and Physical noted Resident 2 presented with altered mental status, failure to thrive, dark colored urine and abnormal labs. Per facility report, the resident had chronic failure to thrive, however, the oral intake declined even more over the past week. In the emergency room the resident had a blood pressure of ,[DATE] and [MEDICAL CONDITION](a faster than normal heart rate) in the 120's. The resident's abdomen was noted to be firm and distended. The resident was diagnosed with [REDACTED]. The likely cause of the urinary tract infection was possibly due to malplacement of the resident's Foley catheter. Per the emergency room report, the catheter was not fully inserted, with minimal urine drainage. Once that catheter was changed, approximately 1 liter of urine came out that was very dark and foul smelling. The resident had a significant worsening of her/his baseline [MEDICAL CONDITION] and [MEDICAL CONDITION] (high potassium) due to acute [MEDICAL CONDITION] and dehydration. The resident was admitted to the Intensive Care Unit for medical management. The ,[DATE] TAR lacked documented evidence the resident's Foley catheter was changed. The resident was re-admitted to the facility on [DATE]. On [DATE] at 11:55 am Resident 2 was observed in bed. There was clear, yellow urine in the resident's catheter. When asked about the [DATE] hospitalization , Resident 2 stated a facility nurse removed the catheter and someone else tried to put a new catheter in place, which was very painful. In interview on [DATE] Staff 13, LPN stated he and a former orientee RN went to the resident's room and the orientee RN changed the resident's catheter. Staff 13 did not recall the date the catheter was changed but thought it was prior to the resident becoming ill. There were no problems with the catheter placement and the resident voiced no concerns. In interview on [DATE] at 6:05 am Staff 31, CNA stated a couple of days (could not state when) before the [DATE] hospitalization the resident complained of groin pain and the catheter was changed. The pain resolved but there was blood in the urine after the catheter change. From [DATE] to [DATE] the resident's urine "was really really dark", which she reported to the nurse. The resident was anxious and kind of depressed, which was different for the resident. In interview on [DATE] at 2:45 pm Staff 33, NA stated on [DATE] the resident's urine bag was changed before his shift and he did not notice any urine in the bag during his shift. Staff 33 stated he assumed someone else changed the bag for him, however, he did not check with other staff to see if they had changed the urine bag. In interview on [DATE] at 12:24 pm, Staff 28, CNA stated on [DATE] the resident was confused and complained of being tired, which was different for the resident. Staff 28 stated she reported the change in confusion to the nurse. In interview on [DATE] at 1:26 pm, Staff 25, CNA, stated the resident started refusing meals and fluids a few days prior to the [DATE] hospitalization and complained of being tired, which he reported to the nurse. In interview on [DATE] at 2:18 pm Staff 20, CNA stated three or four days before the [DATE] hospitalization , she told the nurse the resident was acting different. The resident was crying, confused and could not correctly recall the date. In interview on [DATE] at 1:50 pm Staff 11, LPN stated on [DATE] the resident's urine was very dark and it was reported by day shift there were bloody clots in the urine. Staff 11 stated she thought the resident was dehydrated which caused the "dark, dark urine." She gave the resident sips of water numerous times but did not see an improvement in the urine. When asked if she/he was feeling ill, the resident reported she/he was tired, which was a new complaint. Staff 11 stated she assumed day shift called the physician. In interview on [DATE] at 2:05 pm Staff 9, LPN stated between [DATE] and [DATE] the resident's urine was brown. On [DATE] the resident's oxygen saturation level was down to 88%, the blood pressure was lower than normal and the resident was a little confused. Staff 9 stated she could not recall if she faxed the physician regarding the resident's status. On [DATE] the resident went from being conversant to having trouble answering questions. They received the resident's labs, which were critical and the resident was sent out to hospital. In interviews on [DATE] at 9:48 am and 10:10 am Staff 6, RN stated brown urine was indicative of kidney injury. When he worked the [DATE] - [DATE] night shift he was told the resident had "dark urine." However, during the shift the resident only had 100 cc of brown urine, which was a sign the resident was dehydrated and had possible kidney injury. Staff 6 stated he reported his concerns to Staff 9, LPN, the day shift nurse. When he learned the next day the resident's status was not dealt with he faxed the physician regarding labs. Staff 6 stated he did not do a full assessment of the resident for dehydration, but had a "gut feeling." In interview on [DATE] at 4:34 pm, Staff 5, RNCM stated the physician should have been contacted on [DATE] regarding the resident's status. Staff 2 was interviewed on [DATE] at 3:40 pm and [DATE] at 4:09 pm and 4:42 pm. After reviewing the resident's lab results and Progress Notes, Staff 2 stated the resident was septic, in [MEDICAL CONDITION] and was dehydrated. The resident's low blood pressure on [DATE] was a sign [MEDICAL CONDITION] and the physician should have been informed that day. Per Staff 2, had the labs been drawn on [DATE] as ordered, they would have shown the resident was in an infectious process at that time. Additionally Staff 6, RN should have informed the physician himself regarding concerns of dehydration and kidney injury, rather than passing the information along to another staff member. Staff 2 spoke with the wound physician, who confirmed he diagnosed the resident [MEDICAL CONDITION] during the [DATE] visit. Refer to F327

Based on interview and record review it was determined the facility failed to assess residents for possible dehydration and ensure proper fluid intake for 2 of 4 sampled residents (#s 1 & 2) reviewed for hydration. Resident 1 was hospitalized in critical condition, placed on hospice and died . Resident 2 was hospitalized . 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Admission Nursing Database indicated Resident 1 was alert to self, confused and aphasic (a disorder that affects speech). The [DATE] Diet Order & Communication revealed Resident 1 received honey thickened fluids. The [DATE] updated In Room Care Plan noted Resident 1 had difficulty swallowing due to an aspiration risk. The resident was to be assisted with fluids and given small sips of liquids. The [DATE] physician progress notes [REDACTED]. A [DATE] Progress Note disclosed Resident 1 began antibiotic treatment for [REDACTED]. The [DATE] 8:57 pm Progress Note revealed Resident 1 had an oxygen saturation level of 87%, an elevated heart rate of 115 and a low grade temperature of 99.1 degrees. The [DATE] 10:29 pm Progress Note described Resident 1 at restless at times during the shift, calling out. The [DATE] 2:20 pm Progress Note described Resident 1 as "irritable, agitated at times....Slept in long intervals. Poor appetite for lunch." The [DATE] 11:56 am and 12:16 pm Progress Notes indicated Resident 1 yelled throughout the day. "Spoke to RCM and reported patient is declining, having poor appetite, appears tired, irritable, not cooperating with transfers as (Resident 1) was previously, coughing, restless, refusing to sit up in w/c (wheelchair)." A PRN pain medication was given which helped the resident sleep but upon waking she/he started yelling again. The resident refused to have blood pressure taken as she/he kept constantly moving her/his arms. The Vitals Report for meal/fluid intake for [DATE] to [DATE] lacked consistent documentation regarding the resident's fluid intake. During that timeframe, only 380 ml of fluids were documented as given. The [DATE] 10:03 pm Progress Note revealed the physician ordered STAT labs, which revealed an abnormal sodium level of 178. The physician was contacted, who sent the resident to the hospital. The [DATE] Hospital History and Physical and physician progress notes [REDACTED]. The resident appeared to be extremely dehydrated, "...clinically appears dry...Possible considerable dehydration has been going on for weeks..." The resident was in septic shock and had a "quite low" blood pressure in the emergency room . The creatinine and BUN (labs that evaluate kidney function) were elevated and the sodium level was "extremely high. Anticipate d/t (due to) lack of free water and dehydration with profound AKI (acute kidney injury)." The resident was critically ill and admitted to the Intensive Care Unit and comfort measures were recommended. At the time of the survey there was no documented assessment of the resident's hydration status prior to the [DATE] hospitalization . In interview on [DATE] at 9:59 am Witness 3, Friend, stated when she visited Resident 1 on [DATE], the resident looked very sick. The resident was not responding to voices she/he knew for a long time, did not look right and was "ashy colored." The resident was discharged from the hospital on hospice care on [DATE] and died on [DATE]. In interview on [DATE] at 9:00 am Witness 1, Complainant stated when Resident 1 was admitted to the hospital on [DATE], her/his BUN, creatinine and sodium levels were elevated. The elevated sodium was a flag that the resident was severely dehydrated and the BUN and creatinine indicated the resident was dehydrated over time, which the physician stated was at least five, up to 14 days. The kidney injury was a "direct result" from dehydration, because the toxicity of the elevated sodium level was so extreme. Per Witness 1 "...they waited so long to send (Resident 1) in we couldn't save (Resident 1)." Interviews on [DATE] at 11:55 am, 1:10 pm and 2:30 pm and on [DATE] at 9:35 am with Staff Staff 22, CNA, Staff 24, CNA, Staff 29, CNA and Staff 30, CNA the following information was revealed: *Staff 22, Staff 24 and Staff 29 stated the resident had a decline in fluid intake and increase in sleeping and lethargy the week prior to the [DATE] hospitalization . *Staff 22 stated the resident used a sit to stand lift for transfers, however, the days prior to the hospitalization the resident could not longer use the lift. *The changes in fluid intake and lethargy were reported to the nurse. In interview on [DATE] at 11:37 am Staff 10, LPN stated the resident started having changes a couple days prior to being hospitalized on [DATE], including not being cooperative, was more tired and needed help with transfers. On [DATE] the resident was very irritable and everything bothered the resident, which she reported to Staff 4, RNCM but not to the physician. The resident was on thickened liquids and consumed fluids during the week prior to the hospitalization . On [DATE] and [DATE] it was hard to get the resident to drink fluids, however, she did not assess the resident for dehydration. In interview on [DATE] at 3:39 pm Staff 13, LPN stated on [DATE] and [DATE] the resident declined in intake of food and fluids. On [DATE] the resident was quiet which was not her/his usual. Staff 13 received the physician's orders [REDACTED]. When asked if the resident appeared dehydrated, Staff 12 stated he made an assumption based on the lab. In interview on [DATE] at 11:12 am Staff 4, RNCM stated she was not aware of the resident's changes prior to [DATE]. On [DATE] she assessed the resident, her/his skin color was not at baseline, however, she did not assess her/him for dehydration. She had the physician call for STAT labs and learned the next morning the labs showed kidney failure and the resident was sent to the hospital. Staff 4 reviewed the resident's progress notes and stated the physician should have been notified of the resident's changes on [DATE]. In interviews on [DATE] at 1:45 pm and 4:09 pm Staff 2, DNS acknowledged the resident's dehydration and change of condition was not addressed timely. Staff 2 stated the amount documented for fluid intake from [DATE] to [DATE] was not enough to sustain life. When a resident was on thickened fluids it was hard to get the fluids in them. An IV for fluids should have been started "but no one was paying attention." 2. Resident 2 was admitted to the facility 2014 with [DIAGNOSES REDACTED]. The [DATE] In-Room Care Plan noted the resident was independent for meals. On [DATE] a wound physician ordered routine labs to be drawn on [DATE], including a CBC (complete blood count, a lab test that evaluates overall health and disorders including infection) and a BMP (basic metabolic panel, a lab test that evaluates metabolism and kidney function). There was no documented evidence those labs were obtained as ordered. A [DATE] Progress Note revealed that at around 4:00 pm the resident had an increased temperature of 101.9 degrees. At around 10:00 pm the resident was diaphoresing (sweating) and lethargic. The resident had a temperature of 101.6 degrees, a blood pressure of ,[DATE] and a pulse of 53. Another nurse came in to verify and the resident had a blood pressure of ,[DATE]. "Called RCM", who requested Staff #8, RN check the resident's urine, which was "dark yellow with some white particulate matter floating" in the resident's urine bag. The physician was contacted, who advised staff to continue to monitor the resident. The [DATE] 2:51 pm Progress Note disclosed at 7:30 am the resident had a blood pressure of ,[DATE], a pulse of 106, respirations of 28 and an oxygen saturation level of 88%. Oxygen was administered. There was no urine in the urine bag and after irrigating, there was output of dark urine. At 9:45 am the resident had a blood pressure of ,[DATE] and she/he was alert and oriented to time, place and situation. "Will continue to monitor....urinary output and encourage patient to drink water." Staff 5, RNCM documented in the [DATE] 10:42 am Progress Note that the resident was working with physical therapy, "....has not been feeling well for the past couple of days. Participation fluctuates, possible decline since week prior..." At 8:16 pm the resident reported she/he had no appetite and did not consume dinner. Staff 6, RN, documented in the [DATE] 6:29 am Progress Note "CNA reports less than 200 ml from Foley this shift, and that urine is brown discoloration. Will notify next shift for follow-up." Staff 9, LPN documented in the [DATE] 2:11 pm Progress Note that the resident had 250 ml output of "dark brown" urine. The resident's appetite had diminished. At 6:21 pm Staff 11, LPN documented the "urine continues dark." Staff 6, RN documented in the [DATE] 3:59 am Progress Notes "Urine output thus far about 75 ml, light brown and cloudy...will fax MD and ask for BMP to r/o (rule out) dehydration." Staff 5, RNCM documented in the [DATE] 11:51 am Progress Note that Resident 2 had a decline over the past week, including intake. "...Awaiting lab results at this time." The Vitals Report for meal/fluid intake for [DATE] to [DATE] lacked consistent documentation regarding the resident's fluid intake. During that timeframe, only 480 ml of fluids were documented as given. The 1:11 pm Progress Note indicated the wound physician evaluated the resident. The [DATE] wound physician progress notes [REDACTED]. Requested STAT draw today. Has had a fever up to 102F and been intermittently more delirious, actively hallucinating today and seeing white spots/lines/bursts...Not eating much still...sickly appearance...urine tan, cloudy...Resident is very confused today and STAT labs revealed severe infection with worsening renal function so sending to hospital for septic workup." The physician diagnosed the resident with [MEDICAL CONDITION]. The [DATE] Hospital History and Physical noted Resident 2 presented with altered mental status, failure to thrive, dark colored urine and abnormal labs. Per facility report, the resident had chronic failure to thrive, however, the oral intake declined even more over the past week. In the emergency room the resident had a blood pressure of ,[DATE] and [MEDICAL CONDITION](a faster than normal heart rate) in the 120's. The resident's abdomen was noted to be firm and distended. The resident was diagnosed with [REDACTED]. The likely cause of the urinary tract infection was possibly due to malplacement of the resident's Foley catheter. Per the emergency room report, the catheter was not fully inserted, with minimal urine drainage. Once that catheter was changed, approximately 1 liter of urine came out that was very dark and foul smelling. The resident had a significant worsening of her/his baseline [MEDICAL CONDITION] and [MEDICAL CONDITION] (high potassium) due to acute [MEDICAL CONDITION] and dehydration. The resident was admitted to the Intensive Care Unit for medical management. The resident was re-admitted to the facility on [DATE]. At the time of the survey there was no documented assessment of the resident's hydration status prior to the [DATE] hospitalization . In interview on [DATE] at 6:05 am Staff 31, CNA stated a couple of days (could not state when) before the [DATE] hospitalization the resident complained of groin pain and the catheter was changed. The pain resolved but there was blood in the urine after the catheter change. From [DATE] to [DATE] the resident's urine "was really really dark", which she reported to the nurse. The resident was anxious and kind of depressed, which was different for the resident. In interview on [DATE] at 2:45 pm Staff 33, NA stated on [DATE] the resident's urine bag was changed before his shift and he did not notice any urine in the bag during his shift. Staff 33 stated he assumed someone else changed the bag for him, however, he did not check with other staff to see if they had changed the urine bag. In interview on [DATE] at 12:27 pm, Staff 28, CNA stated on [DATE] the resident was confused and complained of being tired, which was different for the resident. Staff 28 stated she reported the change in confusion to the nurse. In interview on [DATE] at 1:26 pm, Staff 25, CNA, stated the resident started refusing meals and fluids a few days prior to the [DATE] hospitalization and complained of being tired, which he reported to the nurse. In interview on [DATE] at 2:18 pm Staff 20, CNA stated three or four days before the [DATE] hospitalization , she told the nurse the resident was acting different. The resident was crying, confused and could not correctly recall the date. In interview on [DATE] at 1:50 pm Staff 11, LPN stated on [DATE] the resident's urine was very dark and it was reported by day shift there were bloody clots in the urine. Staff 11 stated she thought the resident was dehydrated which caused the "dark, dark urine." She gave the resident sips of water numerous times but did not see an improvement in the urine. When asked if she/he was feeling ill, the resident reported she/he was tired, which was a new complaint. Staff 11 stated she assumed day shift called the physician. In interview on [DATE] at 2:05 pm Staff 9, LPN stated between [DATE] and [DATE] the resident's urine was brown. On [DATE] the resident's oxygen saturation level was down to 88%, the blood pressure was lower than normal and the resident was a little confused. Staff 9 stated she could not recall if she faxed the physician regarding the resident's status. On [DATE] the resident went from being conversant to having trouble answering questions. They received the resident's labs, which were critical and the resident was sent out to hospital. In interviews on [DATE] at 9:48 am and 10:10 am Staff 6, RN stated brown urine was indicative of kidney injury. When he worked the [DATE] - [DATE] night shift he was told the resident had "dark urine." However, during the shift the resident only had 100 cc of brown urine, which was a sign the resident was dehydrated and had possible kidney injury. Staff 6 stated he reported his concerns to Staff 9, LPN, the day shift nurse. When he learned the next day the resident's status was not dealt with he faxed the physician regarding labs. Staff 6 stated he did not do a full assessment of the resident for dehydration, but had a "gut feeling." In interview on [DATE] at 4:34 pm, Staff 5, RNCM stated the physician should have been contacted on [DATE] regarding the resident's status. Staff 2 was interviewed on [DATE] at 3:40 pm and [DATE] at 4:09 pm and 4:42 pm. After reviewing the resident's lab results and Progress Notes, Staff 2 stated the resident was septic, in [MEDICAL CONDITION] and was dehydrated. The resident's low blood pressure on [DATE] was a sign [MEDICAL CONDITION] and the physician should have been informed that day. Per Staff 2, had the labs been drawn on [DATE] as ordered, they would have shown the resident was in an infectious process at that time. Additionally Staff 6, RN should have informed the physician himself regarding concerns of dehydration and kidney injury, rather than passing the information along to another staff member.

Based on interview and record review the facility failed to respond timely to pain for 1 of 1 resident (#1) who had a fracture. This resulted in unaddressed pain. Finding include: Resident 1 was admitted to the facility in February 2013 with [DIAGNOSES REDACTED]. On [DATE] the Physician ordered routine [MEDICATION NAME] 650 mg three times a day. On [DATE] a Quarterly MDS (minimum date set) assessment identified the resident was able to make her/himself understood, usually understood others, and had disorganized thinking. The assessment indicated the resident required extensive assistance with bed mobility and transfers. The assessment identified the resident received scheduled pain medication and had no pain within the past 5 days. The resident's In Room Care Plan, dated [DATE], indicated staff were to notify licensed staff for any complaints of pain. The plan identified the resident had an order for [REDACTED]. On [DATE] at 8:46 am a nursing note identified the resident was taken off alert charting related to the fall (on [DATE]) and had "no signs of delayed trauma noted at this time." There were no documented nursing notes for this resident from [DATE] through [DATE]. On [DATE] at 9:29 pm a nursing note written by Staff 4, RN, identified per the resident's family, the resident complained of right thigh pain. The note indicated the area had no redness or swelling when assessed and the resident was in bed comfortably sleeping. On [DATE] at 9:29 pm a nursing note written by Staff 4 indicated a CNA (Staff 10) reported the resident was complaining of pain in her/his right thigh during care. No swelling or redness was noted. On [DATE] at 2:49 am a nursing note written by Staff 5, LPN, identified the resident complained of right thigh and hip pain during care. On [DATE] at 3:19 am a nursing note written by Staff 5 indicated a request for an x-ray was faxed to the resident's Physician related to right hip pain with movement. The resident was given 650 mg [MEDICATION NAME] for pain with minimum results. On [DATE] at 8:54 am a nursing note written by Staff 3, RNCM, indicated the resident grimaced with movement to the right lower extremity. A fax was sent to the Physician with a request for an x-ray and the facility was waiting for a response. On [DATE] at 2:11 pm a nursing note indicated the facility received the radiology results which showed the resident had an acute right femoral neck fracture. On [DATE] at 10:35 pm a nursing note identified the resident was sent to the hospital around 3:30 pm for evaluation (two days after the resident's pain was first reported) and returned at 7:00 pm with orders for [MEDICATION NAME]. The resident was resting comfortably and had no pain during turning or care. The resident [DATE] MAR (medication administration record) identified the resident received routine [MEDICATION NAME] as previously ordered by the Physician and no as needed [MEDICATION NAME] until [DATE] at 2:00 am with minimum results. No additional as needed pain medication was administered by the facility until [DATE] after the resident returned from the hospital with orders for [MEDICATION NAME] for pain. The MAR indicated [REDACTED]. On [DATE] at 1:04 pm nursing notes identified the resident expired. In interview on [DATE] at 1:05 pm Staff 4 reported on [DATE] the resident's family reported the resident expressed pain when her/his leg was placed on the wheel chair's foot rests. Staff 4 stated she adjusted the resident's foot rests because they were uneven. She reported on [DATE] she did not conduct an ROM (range-of-motion) assessment on the resident to assess for pain or possible injury. In interview on [DATE] at 1:20 pm Staff 3, RNCM, stated the resident's family reported the resident grimaced when they placed her/his foot on the wheel chair foot rests. The family reported this to Staff 4 who documented in the nursing notes the resident's thigh had no swelling or redness. Staff 3 stated she would have expected Staff 4 to conducted a ROM assessment to assess for injury. Staff 3 stated on [DATE] on the night shift a CNA reported the resident complained of pain during care and on [DATE] between 7:30 am and 8:00 am she observed the resident grimaced with movement. In interview on [DATE] at 12:33 pm Staff 13, CNA, who worked on [DATE] during the evening shift, stated when putting Resident 1 to bed, the resident guarded her/his hip and appeared painful when she turned and changed her/him. Staff 13 reported the nurse (Staff 4) was aware of the resident's pain. In interview on [DATE] at 12:53 pm Staff 12, CNA, reported the resident didn't have pain with movement prior to the fracture. In interview on [DATE] at 4:20 pm Staff 11, CNA, reported the resident had pain on [DATE], [DATE], [DATE], and on [DATE] on her/his right hip/thigh area when touched. She stated on [DATE] the resident was in so much pain, she/he was almost in tears. Staff 11 stated she reported the resident's pain to Staff 7, LPN, and Staff 5, LPN. In interview on [DATE] at 8:39 am Staff 5, LPN, reported during the night shift on [DATE] a CNA (Staff 11) reported the resident was in pain. She stated the resident was in pain and she gave her/him a dose of as needed [MEDICATION NAME] and called for an x-ray. In interview on [DATE] at 9:38 am Witness 1, family member, reported on [DATE] the resident complained of right leg discomfort with movement and on [DATE] the resident was very painful and "just about came unglued" when her/his foot was placed on the wheel chair foot rest. Witness 1 stated she reported the resident's pain to Staff 4. In interview on [DATE] at 9:50 am Witness 2, family member, reported the resident had pain with movement approximately a week prior to going to the hospital on [DATE]. She stated she reported the resident's pain with movement to Staff 8, RN, and Staff 9, RN who stated they would assess the pain, Witness 2 was unaware if an assessment was done. In interview on [DATE] at 3:22 pm Staff 10, CNA, who worked evening shifts, reported Resident 1 did not have pain on [DATE] or on [DATE] and on [DATE] she was told by the day shift aide the resident had pain. She stated on her last round at 9:00 pm when she rolled the resident on her/his side, the resident grimaced in pain and she mentioned it to the nurse. In interview on [DATE] at 6:05 am Staff 7, LPN, reported he was not aware of the resident having pain prior to the discovery of the fracture on [DATE]. In interview on [DATE] at 8:00 am Staff 8, RN, reported he was not aware the resident had pain with movement until [DATE] when he assessed the resident with Staff 5. He stated the resident grimaced in pain when Staff 5 touched her/his right leg. In interview on [DATE] at 12:51 pm Staff 9, RN, who worked on [DATE] and [DATE], reported the resident had no complaints or pain. In interview on [DATE] at 2:24 pm Staff 2, DNS, confirmed a timely and thorough pain assessment was not conducted nor was pain medication administered when the resident experienced pain with movement.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess a pressure ulcer, notify the physician and provide appropriate care and services in a timely manner for 1 of 2 sampled residents (#43) who had a history of [REDACTED]. As a result, the pressure ulcer worsened. Findings include: Resident 43, a long term resident with [DIAGNOSES REDACTED]. According to a 10/15/12 hospital Wound/Ostomy report, the resident had a stage I pressure ulcer to the coccyx about the size of a quarter. The resident was readmitted to facility following the hospitalization . It was documented in the 10/20/12 admission nursing database report the resident had "excoriations at the sacral area" (coccyx and/or tailbone area). There was no information to further describe the specific location, size, and appearance of the excoriations. The nurse progress notes dated 10/20/12 at 2:18 pm identified the sacral area needed a dressing for protection and that a dressing was done per house protocol. There was no evidence the resident's physician was notified or what dressing per house protocol had been done. The 10/22/12 care plan identified the resident to be at risk for skin breakdown and that upon readmission from hospital, the resident had "excoriation/denuding" (an abrasion of the epidermis and removal of a protective layer) on the sacral area. The interventions included to provide a "treatment as ordered." A review of the 10/2012 TAR revealed that from 10/22 to 10/31/12 there was no documented evidence that a treatment had been ordered or provided to the resident's sacral area. A 10/24/12 at 6:53 pm nurse progress note identified "excoriation on buttocks with dressing intact." There was no information as to the exact location or what dressing had been used. An entry in the nurse progress notes dated 10/25/12 at 9:23 am identified alert charting for the skin impairment on the buttocks had been discontinued and that staff would continue to monitor on the TAR until resolved. According to the 10/2012 TAR, there was no evidence that monitoring the buttocks skin impairment had been done. There was no evidence that a comprehensive assessment of the skin issues had been considered. A 10/31/12 physician order [REDACTED]. According to the 11/2012 TAR from 11/01 to 11/29/12 the same treatment to the excoriation on the sacral area had been done as ordered on [DATE]. A 11/10/12 at 2:33 am nursing progress note contained "no (sign or symptoms) of infection noted to wounds to coccyx area." There was no further description of the wounds to the coccyx area. There was no information as to the size, exact location, or wound characteristics. On 11/19/12 at 4:14 pm, a nursing progress note identified a new wound was discovered on the resident's left ischial/gluteal fold area (lower buttock near the upper thigh). A corresponding Skin Grid identified it was suspected to be a deep tissue injury and the probable cause was pressure. The pressure area measured 5.0 cm x 2.0 cm and the wound bed contained slough. There was no documented evidence the resident's physician was notified or that an assessment of potential causal factors and a treatment for [REDACTED]. Nursing progress notes on 11/19/12 at 4:42 pm identified two new Stage 2 pressure ulcers were found on the right sacral area. A treatment was suggested by the nurse in a fax to the physician who approved the same treatment as was ordered on [DATE]. According to the 11/2012 TAR there was no separate documentation to indicate a treatment had been provided for the two new Stage 2 pressure ulcers on the right sacral area. A fax to the physician dated 11/26/12 indicated the wound on the left ischial area appeared larger and had increased drainage (seven days after the left ischial wound was discovered.) The corresponding Skin Grid identified the wound to be 4.8 cm x 5.6 cm and the wound bed contained eschar surrounded by slough. The physician approved the suggested treatment and returned the order to the facility on [DATE]. According to the 11/2012 and 12/2012 TARs, the treatment was initiated on 12/1/12. On 12/17/12 at 9:27 am, the resident was observed sleeping in bed with the head of the bed upright to approximately 90 degrees. The resident was lying on a low air loss alternating pressure air mattress. The control panel indicated the air pressure was set at the softest setting. On 12/17/12 at 10:00 am with Staff 19, RN Charge Nurse, present, the resident's bed covers were pulled pulled back and revealed the resident was lying on the air mattress which had a hammock style appearance. The mattress appeared to be too soft and provided insufficient torso support. Observation of the left ischial/ gluteal fold pressure ulcer revealed an unstageable wound. The wound measured 4.5 cm x 2.7 cm with an island of slough that measured 2.5 cm x 1.5 cm. There were no open areas or excoriation noted to the sacrum/coccyx or buttocks areas. In an interview on 12/17/12 at 10:27 am Staff 26, CNA, said the resident was dependent on staff for all care needs and remained in bed most of the time. The resident was up in the wheel chair for only a short time because of the pressure ulcer. In an interview on 12/17/12 at 10:38 am, Staff 19,RN Charge Nurse, said he was unsure what the inflation setting of the air mattress was for the resident and did not know how to adjust the pressure for proper inflation. Staff 19 said he had monitored whether the mattress was on and working, not the inflation setting. This was discussed on 12/17/12 at 12:20 pm with Staff 2, DNS, who said it was policy that an incident and investigation report be completed when a new pressure ulcer was discovered. The resident was readmitted with excoriation and an open area. Staff had identified it as the sacral area and not the left ischial area. In regards to the air mattresses, Staff 2 stated there was supposed to be about four inches between the air mattress and it's base. Staff would report if an air mattress was not functioning but there was no system for staff to monitor for patient specific settings. In a follow up interview at 3:15 pm, the 11/2012 TAR was reviewed with Staff 19, RN Charge Nurse, who confirmed he had provided a treatment to the sacral area during that month. Staff 19 stated the sacral area and the left ischial/gluteal area meant the same but the documentation on the 11/2012 TAR did not specifically identify the left or right as it should have. The other open areas had since resolved. In an interview on 12/17/12 at 3:37 pm, Staff 10, RNCM, said the left ischial/gluteal fold pressure area was a new pressure ulcer discovered on 11/19/12. Staff 10 confirmed that an assessment, incident report, or investigation had not been done. The physician had been notified about the two new pressure areas on the right sacral area but had not been made aware of the left ischial pressure ulcer until 11/26/12. Staff 10 further stated the care plan had been updated but did not include the air mattress or instructions on how to use it.

Based on interview and record review it was determined the facility failed to provide adequate supervision to ensure care planned interventions were implemented to prevent falls for 1 of 4 sampled residents (#1) who had falls. Resident 1 had a fractured hip and required hospitalization for surgical repair of the fracture. Findings include: Resident 1 was admitted in 12/2008 with [DIAGNOSES REDACTED]. The In Room Care Plan dated 10/6/11 included Resident 1 was at high risk for falls. Interventions included "do not leave in BR (bathroom)." A Nursing Facility Incident Self-Report Form indicated Resident 1 was left in the bathroom alone and fell on [DATE]. The Incident Investigation indicated the resident fell while trying to get from the bathroom to (her/his) bed. The resident complained of head and hip pain. The left hip pain persisted and the resident was sent to the hospital where the resident was diagnosed with [REDACTED]. The Incident Investigation dated 4/3/12 indicated Resident 1 had a history of [REDACTED]. The care plan reflected the resident was not to be left in the bathroom alone. Staff 1, CNA neglected to follow the care plan and left the resident alone in the bathroom. On 4/18/12 at 4:36 pm Staff 2, DNS stated Staff 1, CNA left Resident 1 alone in the bathroom on 4/2/12. Staff 2 stated even though Resident 1 was not assigned to Staff 1 on that day, Staff 1 was aware or should have been aware the resident was not to be left alone in the bathroom. On 4/19/12 at 12:45 pm Staff 1, CNA stated she answered Resident 1's call light on 4/2/12, even though Resident 1 was not assigned to her. The resident asked to go to the bathroom and Staff 1 assisted the resident to the bathroom. Staff 1 left the resident in the bathroom, while she looked for Resident 1's CNA, and again while she cared for another resident. When she last checked the bathroom, Resident 1 was not in the bathroom. Staff 1 stated she learned from other staff the resident fell while leaving the bathroom unassisted.

Based on interview and record review it was determined facility staff failed to implement care plan interventions to prevent falls for 1 of 4 sampled residents (#1) reviewed for falls. Resident 1 was left alone in the bathroom, and fell while leaving the bathroom unassisted. Resident 1 sustained a [MEDICAL CONDITION], and was hospitalized for [REDACTED]. Findings include: The Oregon State Board of Nursing (OSBN) Standards of Care for Certified Nursing Assistants [PHONE NUMBER](6)(d) In the process of client care the CNA shall consistently: Follow the care plan as directed by the licensed nurse. Resident 1 was admitted in 12/2008 with [DIAGNOSES REDACTED]. The In Room Care Plan dated 10/6/11 included Resident 1 was at high risk for falls. Interventions included "do not leave in BR (bathroom)." A Nursing Facility Incident Self-Report Form indicated Resident 1 was left in the bathroom alone and fell on [DATE]. The Incident Investigation indicated the resident fell while trying to get from the bathroom to (her/his) bed. The resident complained of head and hip pain. The left hip pain persisted and the resident was sent to the hospital where the resident was diagnosed with [REDACTED]. The Incident Investigation dated 4/3/12 indicated Resident 1 had a history of [REDACTED]. The care plan reflected the resident was not to be left in the bathroom alone. Staff 1, CNA neglected to follow the care plan and left the resident alone in the bathroom. A written statement from Staff 1, CNA dated 4/3/12 indicated Staff 1 saw Resident 1's call light on. She was not assigned to Resident 1, but did not know who was assigned, and did not want to make the resident wait. Staff 1 decided to help Resident 1 to the bathroom: "It was an accident and it all happened so fast and quiet." On 4/18/12 at 4:36 pm Staff 2, DNS stated Staff 1, CNA left Resident 1 alone in the bathroom on 4/2/12. Staff 2 stated even though Resident 1 was not assigned to Staff 1 on that day, Staff 1 was aware or should have been aware of the care plan to not leave the resident alone in the bathroom. On 4/19/12 at 12:45 pm Staff 1, CNA stated she answered Resident 1's call light on 4/2/12, even though Resident 1 was not assigned to her. Staff 1 assisted the resident to the bathroom. Staff 1 left the resident in the bathroom, while she looked for Resident 1's CNA, and again while she cared for another resident. When she last checked the bathroom, Resident 1 was not in the bathroom. Staff 1 stated she learned from other staff the resident fell when she/he left the bathroom unassisted.

Based on interviews and record review it was determined the facility failed to ensure a resident was free from unnecessary medications for 1 of 2 sampled residents (# 1) with orders for [MEDICATION NAME]es ([MEDICATION NAME] narcotic). The resident required hospitalization . Findings include: Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Review of the resident's current physician orders [REDACTED]. Review of the resident's Interdisciplinary Progress Notes revealed on 3/6/11 the resident was combative, the physician was notified and the resident was tested to rule out a UTI (Urinary Tract Infection). On 3/7/11 the notes revealed the resident did not have any side effects from the antibiotics used for the treatment of [REDACTED]. The resident opened eyes to verbal command and responded to painful stimuli. The resident's oxygen saturation level was 84 percent on room air, oxygen was administered to the resident and the resident's physician was notified. The resident did not improve and the resident was sent to the hospital for evaluation on 3/9/11. Review of the resident's 3/9/11 hospital History and Physical revealed the resident had a decreased level of consciousness likely due from unintentional sedation from medication. The hospital nurse noted the resident had two [MEDICATION NAME]es on. One patch was dated 3/7/11. The report also revealed the resident's family reported the resident was alert and sitting upright on 3/6/11. The note revealed the resident "responds to [MEDICATION NAME] of [MEDICATION NAME] (reverses the affects of Narcotics). The resident was admitted to the Intensive Care Unit for monitoring. Review of the resident's 3/10/11 facility Incident Investigation revealed the resident had increased behaviors on 3/6/11, a urine sample tested positive for an infection and antibiotics were started on 3/7/11. On 3/9/11 the resident was transported to the hospital for evaluation and the hospital staff reported to the facility the resident was found with two [MEDICATION NAME]es. The facility could not determine the staff member who did not remove the old patch before applying a new patch. Staff 2 (RN) applied a patch on 3/4/11 and Staff 1 (LPN) applied a patch on 3/7/11. Review of the 3/13/11 Interdisciplinary Progress Notes revealed the resident was readmitted to the facility from the hospital with [DIAGNOSES REDACTED]. The resident was noted to be non-verbal, lethargic and both sides were flaccid. Review of the 3/22/11 written statement from Staff 1 (LPN) revealed Staff 1 worked with the resident on 3/7/11 and applied a new [MEDICATION NAME] on the resident. Staff 1's statement revealed "I think I took the old one (patch) off but I do not remember for sure." On 4/12/11 Staff 2 (RN) stated she did not remember specific details of the administration of the [MEDICATION NAME] on 3/4/11. The normal process was to remove the old [MEDICATION NAME] before applying the new patch. On 4/12/1 at 9:20 am Staff 3 (RNCM) stated it was assumed Staff 1 (LPN) did not remove the old [MEDICATION NAME] before applying the new patch on 3/7/11. However, the patch may have been left on from 3/4/11. The facility implemented a new process to ensure duplicate therapy did not occur in the future. The staff administering medications signed the MAR indicated [REDACTED].

Based on interviews and record review it was determined the facility failed to follow standards of practice for the administration of a [MEDICATION NAME] for 1 of 2 residents (#1). The resident required hospitalization . Findings include: Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. According to the Oregon State Board of Nursing Nurse Practice Act Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER]: "(3) Standards related to the licensed nurse's responsibilities for ethics, including professional accountability and competence. The licensed nurse: (b) Accepts responsibility for individual nursing actions and maintains competence in one's area of practice;" According to Drugs.com "Each [MEDICATION NAME] system may be worn continuously for 72 hours; apply subsequent systems to a different site after removal of the previous system." Review of the resident's current physician orders [REDACTED]. Review of the resident's Interdisciplinary Progress Notes revealed on 3/8/11 at approximately 4:00 pm the resident was noted to be "sleepy and weak". The resident opened eyes to verbal command and responded to painful stimuli. The resident's oxygen saturation level was 84 percent on room air, oxygen was administered to the resident and the resident's physician was notified. The resident did not improve and the resident was sent to the hospital for evaluation on 3/9/11. Review of the resident's 3/9/11 hospital History and Physical revealed the resident had a decreased level of consciousness likely due from unintentional sedation from medication. The hospital nurse noted the resident had two [MEDICATION NAME]es on. One patch was dated 3/7/11. The note revealed the resident "responds to [MEDICATION NAME] of [MEDICATION NAME] (reverses the affects of Narcotics). The resident was admitted to the Intensive Care Unit for monitoring. Review of the resident's 3/10/11 facility Incident Investigation revealed on 3/9/11 the resident was transported to the hospital for evaluation and the hospital staff reported to the facility the resident was found with two [MEDICATION NAME]es. The facility could not determine the staff member who did not remove the old patch before applying a new patch. Staff 2 (RN) applied a patch on 3/4/11 and Staff 1 (LPN) applied a patch on 3/7/11. Review of the 3/13/11 Interdisciplinary Progress Notes revealed the resident was readmitted to the facility from the hospital with [DIAGNOSES REDACTED]. The resident was noted to be non-verbal, lethargic and both sides were flaccid. Review of the 3/22/11 written statement from Staff 1 (LPN) revealed Staff 1 worked with the resident on 3/7/11 and applied a new [MEDICATION NAME] on the resident. Staff 1's statement revealed "I think I took the old one (patch) off but I do not remember for sure." On 4/12/11 Staff 2 (RN) stated she did not remember specific details of the administration of the [MEDICATION NAME] on 3/4/11. The normal process was to remove the old [MEDICATION NAME] before applying the new patch. On 4/12/11 at 9:20 am Staff 3 (RNCM) stated it was assumed Staff 1 (LPN) did not remove the old [MEDICATION NAME] before applying the new patch on 3/7/11. However, the patch may have been left on from 3/4/11. The facility implemented a new process to ensure duplicate therapy did not occur in the future. The staff administering medications signed the MAR indicated [REDACTED]. Refer to F-329

Based on interview and record review it was determined facility nursing staff failed to develop and implement a diabetic management treatment protocol for 1 of 3 residents (Resident # 1) who were diabetic and required insulin. Resident 1 did not receive insulin at the facility and was admitted to the hospital's Intensive Care Unit in a comatose state with a critically high blood sugar level. Findings include: Resident 1 was admitted to the facility from another care setting on Friday, 12/17/2010 with a [DIAGNOSES REDACTED]. A review of the resident's admission documents revealed a 12/2/10 hospital discharge summary which indicated the resident had a [DIAGNOSES REDACTED]. In addition, the admission documents included nursing notes from the prior care setting which indicated CBG levels were taken on the resident. A review of the resident's medical record revealed [REDACTED]. A review of the 12/2010 MAR and TAR revealed the resident did not receive insulin while at the facility nor were CBG readings taken. On Sunday, 12/19/10 the resident was discovered to be non-responsive and was transported to the hospital at 8:30 am. According to a 12/19/10 hospital emergency room report the resident was admitted to the hospital non-responsive with a blood sugar level greater than 500 and in a state of Diabetic Ketoacidosis ([MEDICAL CONDITION] with metabolic acidosis.) The resident was placed in the Intensive Care Unit and required mechanical assistance to breathe. In interviews on 12/23/10 and 1/12/11 Staff 1, DNS, stated she had reviewed the admission information prior to the resident's admission to the facility. Staff 1 stated she reviewed the discharge plan of care and medication sheets which came from the prior care setting; the documents did not include information related to the resident's diabetic management. Staff 1 stated she saw the 12/2/10 hospital records but did not review them closely as they were two weeks old. Staff 1 also stated she did not review the nursing notes from the prior care setting. Staff 1 stated she would not typically review all of a resident's admission documents on the first day of their admission; rather, all the documents would be reviewed the following day when an admission audit was performed. Staff 1 stated she did not work 12/18/10 or 12/19/10. Staff 1 also stated it was a facility practice to complete a nursing order for a CBG on diabetic residents if there were no physician orders for a CBG. Staff 1 did not know why a nursing order for a CBG was not done on Resident 1. In an interview on 1/13/11 Staff 1, DNS, stated an admission audit would be completed on a new resident within 72 hours of a resident's admission. Staff 1 stated if a resident was admitted on a Friday the admission audit would occur the next Monday. In interviews on 12/21/10, 1/11/11 and 1/13/11 Staff 2, RNCM, stated she did not review the admission records on the day the resident arrived as she was busy with another resident. Staff 2 stated Staff 1, DNS, had reviewed the resident's admission documents prior to the resident's admission. Staff 2 stated she did not work on 12/18/10 or 12/19/10. Staff 2 stated she would have started the resident's MDS assessment process and complete the admission audit on Monday 12/20/10.

Based on interview and record review it was determined facility nursing staff failed to develop a diabetic management treatment protocol for 1 of 3 residents (Resident # 1) who were diabetic and required insulin. Resident 1 did not receive insulin at the facility and was admitted to the hospital's Intensive Care Unit in a comatose state with a critically high blood sugar level. Findings include: Review of the Oregon State Board of Nursing, Nurse Practice Act, Scope of Practice Standards for Registered Nurses [PHONE NUMBER] revealed "(1) The Board recognizes that the scope of practice for the registered nurse encompasses a variety of roles, including but not limited to: (C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed; (E) Validating data by utilizing available resources, including interactions with the client and health team members." Resident 1 was admitted to the facility from another care setting on Friday 12/17/2010 with a [DIAGNOSES REDACTED]. A review of the resident's admission documents revealed a 12/2/10 hospital discharge summary which indicated the resident had a [DIAGNOSES REDACTED]. In addition, the admission documents included nursing notes from the prior care setting which indicated CBG levels were taken on the resident. A review of the resident's medical record revealed [REDACTED]. A review of the 12/2010 MAR and TAR revealed the resident did not receive insulin while at the facility nor were CBG readings taken. On Sunday, 12/19/10 the resident was discovered to be non-responsive and was transported to the hospital at 8:30 am. According to a 12/19/10 hospital emergency room report the resident was admitted to the hospital non-responsive with a blood sugar level greater than 500 and in a state of Diabetic Ketoacidosis ([MEDICAL CONDITION] with metabolic acidosis.) The resident was placed in the Intensive Care Unit and required mechanical assistance to breathe. In interviews on 12/23/10 and 1/12/11 Staff 1, DNS, stated she had reviewed the admission information prior to the resident's admission to the facility. Staff 1 stated she reviewed the discharge plan of care and medication sheets which came from the prior care setting; the documents did not include information related to the resident's diabetic management. Staff 1 stated she saw the 12/2/10 hospital records but did not review them closely as they were two weeks old. Staff 1 also stated she did not review the nursing notes from the prior care setting. Staff 1 stated she would not typically review all of a resident's admission documents on the first day of their admission; rather, all the documents would be reviewed the following day when an admission audit was performed. Staff 1 stated she did not work 12/18/10 or 12/19/10. Staff 1 also stated it was a facility practice to complete a nursing order for a CBG on diabetic residents if there were no physician orders for a CBG. Staff 1 did not know why a nursing order for a CBG was not done on Resident 1. In an interview on 1/13/11 Staff 1, DNS, stated an admission audit would be completed on a new resident within 72 hours of a resident's admission. Staff 1 stated if a resident was admitted on a Friday the admission audit would occur the next Monday In interviews on 12/21/10, 1/11/11 and 11/13/11 Staff 2, RNCM, stated she did not review the admission records on the day the resident arrived as she was busy with another resident. Staff 2 stated Staff 1, DNS, had reviewed the resident's admission documents prior to the resident's admission. Staff 2 stated she did not work on 12/18/10 or 12/19/10. Staff 2 stated she would have started the resident's MDS assessment process and complete the admission audit on Monday 12/20/10. Refer to F-309 for additional information.