Every finding on record at Gateway Care and Retirement

Based on observation, interview and record review it was determined the facility failed to properly store food and failed to maintain sanitary conditions in 1 of 1 kitchen. This placed residents at risk for foodborne illness and contaminated food. Findings include:The facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy dated 10/2017 indicated Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. After using tobacco, eating or drinking; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; e. After handling soiled equipment or utensils; f. During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; and/or g. After engaging in other activities that contaminate the hands, contact between food and bare (ungloved) hands is prohibited, and hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.The facility's Food Receiving and Storage Policy dated 2001 indicated Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.The facility's Preventing Foodborne Illness - Food Handling policy dated 07/2014 indicated Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized.On 7/10/25 at 9:53 AM, during the kitchen inspection, the following was observed:-A three-tiered cart was sticky with an unknown substance, covered in food debris, and had clean food storage containers on it.-Two dietary employees were not wearing hair nets while moving through the kitchen and preparing for lunch.-Spill of white sticky substance in the reach-in freezer on the bottom shelf with aluminum foil stuck to it.-Opened, undated and unsealed bags of stuffing and Oreo pieces.-Staff 21 was observed not washing hands with soap and water before donning gloves after touching raw chicken.-A bag of brown and decaying celery on the bottom shelf in the reach-in refrigerator #1.-A food storage container of cream of mushroom soup labeled with no date in the reach-in refrigerator #2.-Raw chicken breast stored over pasteurized eggs and not on the bottom shelf in the reach-in refrigerator #2.-An unknown employee entered the kitchen through the back door from the outdoor area with the dumpsters and did not wash hands or put on a hairnet before walking through the kitchen and exiting.On 7/10/25 at 10:15 AM, Staff 21 (Cook) stated he was unsure what the spills in the reach-in freezer were and confirmed the foil was stuck to the bottom. He also stated the kitchen staff did not have a process for labeling opened foods, and things were not stored properly. Staff 21 stated raw chicken should not be on top of eggs, and raw meats should be stored on the bottom shelf. He stated all food in the reach-in fridge should be dated, labeled, and thrown away three days after it's prepared, and confirmed the cream of mushroom dated 7/2 had passed that threshold.On 07/10/25 at 10:20 AM, Staff 21 threw the celery away and stated it should not be served because it was bad.On 7/10/25 at 10:31 AM, Staff 22 (Dietary Manager) stated employees were to wear a hairnet at all times in the kitchen and confirmed they were not. She stated all food items should be labeled and dated. Staff 22 stated staff were to wash their hands when they enter the kitchen, between tasks and when going from raw food to cooked food. Staff 22 confirmed the cream of mushroom soup was past its serve-by date. She stated raw chicken should be on the bottom shelf, and storing it above pasteurized eggs put residents at risk of cross-contamination and foodborne illness. Staff 22 stated hairnets were to be worn at all times, and hands were to be washed upon entering the kitchen.On 7/10/25 at 11:02 AM, Staff 1 (Administrator) stated he expected staff to follow food safety guidelines and the facility's kitchen policies.

Based on observation, interview, and record review it was determined the facility failed to ensure the call light sytem was functional for 4 of 24 sampled residents (#s 2, 29, 43 and 304) reviewed for a functional call light system. This placed residents at risk for delayed care needs. Findings include: On 5/5/25 at 11:16 AM, Resident 29 was observed in her/his room watching the television. Per the resident's request, the surveyor pressed the call light. After multiple attempts of pressing the call light, the call light did not activate. On 5/5/25 at 1:00 PM, Resident 43 stated the call light in her/his room was broken. The resident told staff four times the call light was not functional. Resident 43 proceeded to press the call light. The call light did not activate. The resident's roommate pressed her/his call light and staff entered the room. Resident 43 was incontinent of bowel and bladder and required the call light to communicate the need for a brief change. On 5/5/25 at 1:30 PM, additional call lights were tested by the survey team and Residents 2 and Resident 304's call lights were not functional. Interviews were conducted on 5/5/25 from 2:00 PM through 2:05 PM with Staff 27 (CNA), Staff 28 (CNA), and Staff 29 (CNA), all three staff stated they were unaware of call lights not being functional. Staff 27, 28 and 29 stated they notified Staff 4 (Maintenance Director) of any broken equipment. On 5/5/25 at 2:27 PM, Staff 4 stated all staff were able to report broken equipment by using the facility's electronic system. Staff 4 stated two weeks ago the call lights stopped working, but he assumed it was fixed. Staff 4 stated no call light issues were reported to him recently. On 5/5/25 at 2:28 PM, Staff 1 (Administrator) stated Staff 4 was notified about all broken equipment. Staff 1 stated the call light system was an ongoing problem. The call light system stopped working two weeks ago when there was a power outage. Staff 1 stated once the power returned, the call light system seemed to be working again. Staff 1 stated the facility did not conduct an audit to ensure all rooms had functional call lights.

Based on observation, interview and record review it was determined the facility failed to store all medications and biologicals under proper temperature controls and ensure expired medications were identified and disposed of for 1 of 1 medication storage rooms and 1 of 2 medication carts This placed residents at risk for reduced medication efficacy and receiving outdated medications. Findings include: 1. The facility's 11/2020 Medication Storage Policy indicated the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. -Medications requiring refrigeration are stored in a refrigerator located in a secured room. 2. The Centers for Disease Control (CDC) 7/31/24 Vaccine Storage and Handling Toolkit noted the following: Exposure of vaccines to temperatures outside the recommended ranges can decrease their potency and reduce the effectiveness and protection they provide. -Temperature monitoring of the storage unit at least two times each workday. -Recording temperature readings on a log. -Store routinely recommended vaccines in a refrigerator between 35 degrees F and 46 degrees F. On 5/8/25 at 11:39 AM, an observation of the medication storage room refrigerator revealed an internal temperature reading of 50 degrees F, verified by Staff 21(Regional Nurse Consultant). Staff 21 located the refrigerator thermometer on the top shelf of the door and moved it onto an inner, middle shelf. On 5/8/25 at 12:16 PM, an observation of the mediation storage room refrigerator revealed an internal temperature of 50 degrees F, verified by both Staff 21 and Staff 22 (Central Supply). Staff 21 stated the medication refrigerator temperatures should be monitored at least once daily, twice daily when vaccines are stored in the refrigerator and temperatures were to be recorded on temperature data logs. No temperature data logs were located for the medication storage room refrigerator. On 5/8/25 at 2:06 PM Staff 21 stated she had asked the nurse if she had checked the refrigerator temperature that morning and the nurse stated she had not. An inventory of the medication room refrigerator with Staff 21 revealed vaccines were stored in the refrigerator. On 5/9/25 at 8:31 AM, Staff 21 stated she had spoken with the pharmacist for the facility and was instructed to dispose of all vaccines due to temperature concerns. On 5/9/25 at 2:14 PM, Staff 2 (DNS) stated nurses were to monitor and document medication refrigerator temperatures twice daily. Staff 2 was unable to locate any temperature logs for the refrigerator and acknowledged she was responsible for ensuring the refrigerator logs were completed. 2a. The facility's 11/2020 Medication Storage Policy indicated discontinued or outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 5/8/25 at 9:12 AM, review of medication cart on Hall 2 revealed a bottle of naloxone which expired in 3/2025. Staff 23 (CMA) acknowledged the medication had expired and should have been removed and destroyed. On 5/8/25 at 11:39 AM, review of the medication storage room revealed the following expired medications: -One bottle of stool softener, expired 10/2024. -One bottle of fiber laxative expired 10/2024. -Six 6 bottles of Ammonium Lactate moisturizing lotion - no expiration date on the bottles. Staff 21 (Regional Nurse consultant) acknowledged the expired medications. On 5/9/25 at 2:14 PM Staff 2 (DNS) stated she was responsible for auditing for expired medications and the expired medications should have been removed and destroyed.

Based on observation, interview and record review it was determined the facility failed to ensure a comfortable and homelike environment was maintained and reasonable care for the protection of resident property from loss or theft was maintained for 3 of 8 sampled residents (#s 30, 33 and 308) reviewed for environment and personal property. This placed residents at risk for discomfort, lack of a homelike environment and loss of personal items. Findings include: The facility's 2/2021 Homelike Environment Policy directed the following: -Residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. -Staff were to provide person-centered care that emphasized the residents' comfort, independence and personal needs and preferences. -The facility staff and management would maximize the characteristics of the facility to reflect a personal and homelike setting. These characteristics included a clean, sanitary and orderly environment, personalized furniture and room arrangements and a clean bed that was in good condition. 1. Resident 33 was admitted in 11/2023 with diagnoses including depression. Resident 33's 11/15/24 Activity Care Plan revealed the resident enjoyed watching television in her/his room. Resident 33's 11/17/24 Annual MDS indicated the resident was cognitively intact. On 5/5/25 at 10:20 AM, Resident 33 was observed in her/his room in bed. A television hung in the middle of the wall towards the foot of the resident's bed positioned between Resident 33's side of the room and her/his roommate's side of the room. A privacy curtain was pulled between the two sides of the room and partially obscured the television from Resident 33's position in bed. Resident 33 stated she/he enjoyed watching television, especially sports programming, but she/he was rarely able to since she/he shared a television with her/his roommate who did not like sports and her/his roommate had the remote to the shared television. The resident stated she/he could not always see the television because of the position of the privacy curtain which separated her/his side of the room from her/his roommate's and Resident 33 was unable to independently move the privacy curtain. Observations of Resident 33 from 5/6/25 through 5/8/25 between 9:17 AM to 4:10 PM revealed the resident was in her/his room in bed. The shared television was always on and played a movie or talk show. The privacy curtain was observed to be either partially or fully extended so the resident was unable to see the entire television screen. On 5/8/25 at 12:07 PM, Resident 33 stated she/he did not like to get into watching a program on television because there were times when the privacy curtain would need to be fully extended and she/he was unable to watch the entire program. Resident 33 further stated she/he did not have a remote control for the shared television and did not feel comfortable asking her/his roommate to tune the television to programs of interest, including sports. On 5/8/25 at 11:45 AM, Staff 19 (CNA) stated Resident 33 spent her/his day in bed watching television. Staff 19 stated the resident liked to watch soap operas and game shows on television and she/he did not have a remote to the shared television. On 5/8/25 at 12:07 PM, Resident 5, Resident 33's roommate, stated she/he had the only remote control to the resident's shared television. Resident 5 stated she/he very seldom put sports programming on the television even though she/he knew Resident 33 enjoyed it. On 5/8/25 at 12:13 PM, Staff 13 (CNA) stated Resident 33 spent all day in bed watching television. Staff 13 stated the resident was unable to independently adjust the privacy curtain in her/his room and would complain about not being able to see the television in its entirety. On 5/8/25 at 1:57 PM, Staff 9 (Activity Director) stated residents who shared a television were supposed to have their own remote control and he was responsible for replacing remote controls when they went missing. Staff 9 stated he was unaware Resident 33's remote control was missing. On 5/8/25 at 2:02 PM, Staff 8 (Social Services Director) stated she was unsure how resident television preferences were prioritized for residents who shared a television but thought residents who shared a television maintained their own remote control. Staff 8 stated she had not asked either Resident 33 or Resident 5 about their specific television preferences or if either resident was satisfied with how their individual television preferences were encouraged and allowed. On 5/8/25 at 2:13 PM, Staff 1 (Administrator) stated he was unsure of the facility's system related to residents who shared a television, including which residents maintained remote controls, how both residents were able to watch preferred programming and how rooms should be set up in order to allow full visualization of the television. Staff 1 stated he expected all residents to be able to see their television in its entirety and to be able to watch television programs of interest as interested. 51845 2. Resident 30 was admitted to the facility on [DATE] with diagnoses including diabetes. Observations of Resident 30's room from 5/5/25 through 5/8/25, the foot board on the bed was slightly slanted to the right. The standing fan in the room was covered with white lint and was dusty. On 5/5/25 at 9:45 AM, Resident 30 stated the bed had been broken since 2/2025. Resident 30 stated she/he notified staff multiple times and also called the ombudsman. On 5/7/25 at 12:50 PM, Staff 24 (CNA) stated the bed had been broken for a while and she did not consider the bed to be safe because the foot of the bed was broken and was stuck in an elevated position. Staff 24 stated it was difficult to use the features on the bed and to move the bed away from the wall when performing ADLs. Staff 24 acknowledged the screen of the fan was covered with white lint and the fan was dusty. On 5/7/25 at 2:04 PM, Staff 4 (Maintenance Director) stated he was aware of Resident 30's broken bed, and indicated the facility ordered a new bed on 2/12/25. Staff 4 stated he was unsure who was responsible to clean the fans in the facility. On 5/8/25 at 4:04 PM, Staff 1 (Administrator) stated he was unsure who cleaned the standing fans in the facility. He acknowledged the fan was dusty. Staff 1 proceeded to touch the fan, and his finger was covered with white lint. 50928 3. The facility's 8/2022 Personal Property Policy indicated the following: -Resident belongings are treated with respect by facility staff, regardless of perceived value. -The residents personal belongings and clothing are inventoried and documented upon admission and updated as necessary. Resident 308 admitted to the facility in 4/2025 with diagnoses including cellulitis (bacterial infection) of the lower limb. A review of Resident 308's medical record revealed no evidence of an inventory list of personal property. On 5/6/25 at 9:12 AM, Resident 308 stated upon admission to the facility, the staff took her/his personal items which included a Portland State jacket, two pairs of jeans, and three t-shirts to be washed in the laundry room. Resident 308 stated she/he had no opportunity to inventory her/his clothing, and they had been missing for 23 days. Resident 308 stated staff were aware of the missing items and had not attempted to resolve the issue. On 5/9/25 at 11:57 PM, Staff 13 (CNA) stated she had been working the day Resident 308 admitted and stated the resident's items came from the hospital in two red plastic bags and were taken immediately to the laundry room to be cleaned before an inventory list could be completed. On 5/7/25 at 12:22 PM, Staff 8 (Social Services Director) stated an inventory list of Resident 308's personal belongings had not been created and she was aware of the resident's missing items. On 5/7/25 at 3:27 PM, Staff 1 (Administrator) was aware Resident 308 personal items were missing and acknowledged they had not been replaced.

Based on observation, interview and record review it was determined the facility failed to ensure food was served at an appetizing temperature for 1 of 2 sampled residents (#11) reviewed for food. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: Resident 11 was admitted to the facility in 4/2023 with diagnoses including chronic ulcer of the buttock and malnutrition. A 2/28/25 care conference note revealed Resident 11 complained she/he often received cold meals. A physician's order from 3/14/25 revealed Resident 11 had been put on contact precautions. On 5/5/25 at 10:16 AM Resident 11 stated she/he had often received cold meals and when asking staff to reheat her/his food staff refused and stated they had been informed meals for residents on contact precautions could not be reheated and did not offer to bring her/him a new meal. An observation on 5/6/25 at 11:47 AM revealed staff delivered a lunch tray to Resident 11. Resident 11 stated the chicken she/he had received was cold. An observation on 5/7/25 at 12:23 PM revealed staff delivered a lunch tray to Resident 11. Resident 11 stated her/his Salesbury steak was cold and she/he was not going to bother asking for the meal to be reheated as staff had already explained they had been instructed to not reheat her/his meals. On 5/7/25 at 9:01 AM Staff 14 (CNA) and 5/8/25 at 9:50 AM Staff 32 (CNA) stated they were not allowed to reheat food for residents on precautions. Both staff stated they had not received any other instruction on how to address cold meals being delivered to resident's rooms who were on contact precautions. On 5/7/25 at 12:28 PM a lunch tray was sampled by the survey team. The meal consisted of Salesbury steak, roasted potatoes, and steamed vegetables. The meat and vegetables were cold. On 5/8/25 at at 11:36 AM Staff 33 (Dietary Manager) was aware of Resident 11's cold food complaints from her/his care conference from 2/2025 and the resolution was to buy hot plates for meal service. Staff 33 indicated this had not been done. On 5/9/25 at 10:07 AM Staff 1 (Administrator) stated the expectation for meal service was for meals to be served at appropriate temperatures and if complaints of cold food were received from residents on contact precautions, he excepted staff to replace a cold meal with a hot meal.

Based on interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents (#305) reviewed for smoking safety. This placed residents at risk for burns and accidents. Findings include: The facility 10/2024 Smoking Policy indicated the following: -No resident will be allowed to store any smoking materials in their room. All smoking materials will be stored in a secure designated area. Resident 305 was admitted to the facility in 4/2025 with diagnoses including gastric ulcer with perforation (an open hole in the lining of the stomach which allows leakage of contents into the stomach cavity). The 4/26/25 Admission MDS indicated Resident 305 revealed no cognitive impairment. A 4/21/25 Smoking Assessment indicated Resident 305 was to smoke safetly with supervision. An observation on 5/5/25 at 10:29 AM revealed Resident 305 sitting at the edge of her/his bed with a bag of tobacco in her/his hand and was prepared to roll her/his own cigarette. Resident 305 stated the facility had been aware she/he rolled her/his own cigarettes and allowed her/him to keep smoking items in her/his room unsecured. On 5/7/25 at 9:01 AM Staff 13 (CNA) stated residents were required to keep all smoking items at the nurse's station in a secture location. Staff 13 stated it was the policy for residents to return smoking items to the nurse's station after the designated smoking time. On 5/7/25 at 9:15 AM Staff 12 (Agency LPN) stated it was required for residents to leave all smoking items in a secured box located at the nurses station. An observation on 5/7/25 at 1:01 PM revealed Resident 305 sleeping in bed with a bag of tobacco placed next to her/his head. On 5/7/25 at 3:34 PM Staff 5 (RCM) confirmed it was against the facility's smoking agreement for residents to have smoking supplies in their rooms. Staff 5 stated she was unaware Resident 305 was holding her/his own smoking items in her/his room.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents were provided assistance with toenail care for 2 of 4 sampled residents (#s 2 and 30) reviewed for foot care. This placed residents at risk for discomfort and inadequate foot care needs. Findings include: The facility's October 2022 Foot Care Policy indicated the following: -Residents are provided with foot care and treatment in accordance with professional standards of practice. -Residents are assisted in making appointments with transportation to and from specialists (e.g., podiatrists) as needed. -Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice. 1. Resident 30 was admitted to the facility in 10/2023 with diagnoses including urinary tract infection and diabetes. A review of Resident 30's 2/5/25 Admission MDS revealed she/he was cognitively intact and was dependent for the completion of her/his ADLs. A physician order dated 2/2/25 indicated a podiatry appointment to be scheduled as needed. A progress note dated 11/5/24 indicated Resident 30 wanted her/his toenails trimmed. A review of Resident 30's 4/2025 and 5/2025 TAR revealed no evidence the resident's nails were trimmed. On 5/5/25 at 10:03 AM Resident 30 stated her/his toenails needed to be cut but was told she/he needed a podiatry appointment. On 5/7/25 at 12:18 PM Resident 30 was observed wearing socks and her/his toenails were poking through the fibers of the socks. Resident 30 stated the length and shape of her/his toenails made it difficult to wear compression hose. Resident 30 further stated her/his toenails caused her/him to have corns and discomfort because they rubbed against her/his other toes. On 5/8/25 at 9:16 AM Staff 19 (CNA) stated Resident 30 required assistance from a nurse to trim her/his toenails because she/he was diabetic. Staff 19 stated she did not recall if Resident 30's toenails were long. On 5/8/25 at 11:07 AM Resident 30's toenails were observed to be yellowed, thick and extended beyond the ends of her/his toes. Staff 10 (RN) observed Resident 30's toenails and acknowledged the resident needed a podiatry appointment due to the length and thickness of Resident 30's nails. Staff 10 further stated she did not know where the ball got dropped with regard to Resident 30's need for toenail care. On 5/8/25 at 12:37 PM Staff 2 (DNS) Staff 2 acknowledged Resident 30 did not receive toenail care timely. Staff 2 stated she expected podiatry care to be provided to dependent residents in their rooms if it was needed. 49377 2. Resident 2 was admitted to the facility in 3/2019 with diagnoses including chronic obstructive pulmonary disease. A Physician order dated 1/7/25 indicated Resident 2 was to have a podiatry consult, as needed. Resident 2's 2/7/2025 Quarterly MDS indicated the resident was cognitively intact, had lower body impairment on both sides and was dependent on assistance from one staff for grooming. No documentation was found in Resident 2's health record to indicate the resident was seen by a podiatrist or was provided toenail care in 4/2025 or 5/2025. On 5/5/25 at 3:32 PM Resident 2's toenails were observed. The nails on both big toes were approximately 1 inch in length and curved around the tip of the toes. The additional toenails were approximately a quarter inch in length and jagged. Resident 2 stated she/he was interested in receiving toenail care; however, staff had not offered it. On 5/6/25 at 3:29 PM Staff 31 (CNA) and on 5/7/25 at 9:03 AM Staff 20 (CNA) acknowledged toenail care was the responsibility of the CNAs, both acknowledged they had not provided Resident 2 with toenail care. On 5/8/25 at 9:58 AM and at 10:36 AM Staff 6 (RCM/LPN) stated CNAs were responsible for non-diabetic resident's finger and toenail care. Staff 6 observed Resident 2's toenails and acknowledged her/his nails were too long and should have been trimmed.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 1 sampled resident (#33) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 6/2018 Activity Program Policy indicated the following: -Activities were offered based on the comprehensive resident-centered assessment and the preferences of each resident. -The activities program was ongoing and included facility-organized group activities, independent individual activities and assisted individual activities. -Individualized and group activities were to reflect the personal preferences, schedules, choices and rights of the residents. -All activities were documented in the resident's medical record. Resident 33 was admitted in 11/2023 with diagnoses including depression. Resident 33's 11/15/24 Activity Care Plan revealed the following: -The resident enjoyed dancing, music, television, reading, spiritual activities, word finds and crossword puzzles. -In room activities were to be offered, which included television, music, books, newspapers and magazines. Resident 33's 11/17/24 Annual MDS indicated the resident was cognitively intact. The MDS also indicated having books, newspapers and magazines to read, listening to music, being around animals, going outside to get fresh air when the weather was good and participating in religious services or practices were important activities to the resident. A review of Resident 33's Activity Task Records from 4/9/25 through 5/8/25 revealed the resident did not participate in any in-or-out-of-room activities or receive a one-to-one visit. The facility's 5/2025 Activity Calendar revealed the following scheduled activities: 5/5/25: -10:30 Dining Room Deco -2:00 Bingo -3:30 Table Games 5/6/25: -10:30 Resident Shopping -2:00 Bingo -3:30 Jeopardy 5/7/25: -10:30 Garden Club -2:00 [NAME] Elephant -3:00 No Judgement Zone Karaoke 5/8/25: -10:00 Spiritual Hour with [NAME] -2:00 Bingo -3:30 Pizza Party On 5/5/25 at 10:20 AM, Resident 33 was observed in her/his room in bed. No books, magazines or newspapers were visible in the the resident's room. Resident 33 stated she/he enjoyed watching television, especially sports programming, but she/he was rarely able to since she/he shared a television with her/his roommate who did not like sports and her/his roommate had the remote to the shared television. Resident 33 further stated she/he also loved flowers and to garden and read. Observations of Resident 33 from 5/6/25 through 5/8/25 from 9:17 AM to 4:10 PM revealed the resident to be in her/his room in bed. The shared television was always on and played a movie or talk show. No books, magazines, newspapers, plants or flowers were visible in the the resident's room. On 5/8/25 at 11:28 AM, Staff 18 (CNA) stated Resident 33 spent her/his time in her/his room in bed. Staff 18 stated Resident 33 enjoyed reading books but she could not remember the last time she saw the resident with a book. Staff 18 stated she thought the resident liked to watch movies on television but was not sure what kind of movies. Staff 18 stated it had been a long time since the resident went outside to get fresh air, she had never heard music on in the resident's room and was unsure if the resident received religious visits from the facility's pastor. Staff 18 further stated the resident liked to chat and joke with staff. On 5/8/25 at 11:45 AM, Staff 19 (CNA) stated Resident 33 spent her/his day in bed watching television. Staff 19 stated the resident liked to watch soap operas and game shows on television but she/he did not have a remote to the shared television. Staff 19 stated she had never seen books, newspapers or magazines in the resident's room and did not think the resident liked to read. Staff 19 stated she thought Resident 33 enjoyed religious visits but had never seen the facility's pastor visit the resident. Staff 19 stated the resident enjoyed visits from staff and was always up for talking. On 5/8/25 at 12:07 PM, Resident 5, Resident 33's roommate, stated she/he had the only remote control to the resident's shared television. Resident 5 stated she/he very seldom put sports programming on the television even though she/he knew Resident 33 enjoyed it. On 5/8/25 at 12:13 PM, Staff 13 (CNA) stated she thought Resident 33 enjoyed music but it had been months since the resident listened to music. Staff 13 stated she did not know if the resident enjoyed religious visits and she had never observed the facility's pastor visit the resident. Staff 13 further stated the resident would never kick you out because she/he was a very happy and chatty person. On 5/8/25 at 1:19 PM, Staff 9 (Activity Director) stated he brought Resident 33 her/his mail every day but he did not provide the resident with one-to-one room visits. Staff 9 stated it had been a while since he last offered the resident a book and he had not offered the resident an opportunity to listen to music since shortly after her/his admission to the facility. Staff 9 stated he was unsure of the resident's music and television preferences and had never offered the resident an opportunity to go outside. Staff 9 acknowledged the resident enjoyed gardening but stated he had never brought any plants or flowers into the resident's room. Staff 9 further stated the resident's preferences included religious visits but she/he had not been offered an opportunity to receive a religious visit since 11/2024. On 5/8/25 at 2:17 PM, Staff 2 (DNS) stated she expected Resident 33 to receive an individualized activity program based on her/his likes and dislikes which included one-to-one in-room visits.

Based on observation, interview, and record review it was determined the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 1 of 4 sampled resident (#29) reviewed for ADLs. This placed resident at risk for lack of personal hygiene and ADL care needs. Findings include: Resident 29 was admitted to the facility in 2016 with diagnoses including schizophrenia (***a serious mental health that affects how people think, feel and behave. It could be a mix of hallucinations, delusions, and disorganized thinking and behavior). The 4/26/25 Quarterly MDS indicated Resident 29 required moderate to supervised assistance for all ADLs. The 5/7/25 care plan indicated Resident 29 required at least one staff member to ensure ADL care was completed. During observations from 5/5/25 through 5/7/25 Resident 29 was observed wearing a hospital gown and no socks. The resident's hair was unkempt; tangled, wadded in the back, and looked greasy. Attempts to interview Resident 29 were not successful. On 5/7/25 at 1:25 PM, Staff 20 (CNA) stated Resident 29 was independent with ADLs. He stated the resident was able to get out of bed independently and complete her/his own ADLs. On 5/8/25 at 9:18 AM, Staff 25 (CNA) stated she normally set up supplies for Resident 29 because the resident was independent with her/his ADLs. On 5/9/25 at 1:47 PM, Staff 7 (RNCM) stated Resident 29 required supervision for all ADLs and was not independent.

Based on observation, interview and record review it was determined the facility failed to revise, update and implement the care plan for 1 of 5 sampled residents (#48) reviewed for accidents. This placed resident at risk for unmet nutritional needs. Findings include: Resident 48 was admitted to the facility in 4/2025 with diagnoses including dysphagia (difficulty swallowing) and a stroke. Resident 48's 4/15/25 care plan revealed Resident 48 had aspiration precautions related to nutrition as follows: one-on-one assist, slow rate, small bites, fully upright, cups with sip lids, straws okay if supervised to use, pinch straw to reduce sip size. Resident 48's 4/22/25 revised care plan revealed although Resident 48 was independent with eating, she/he required one-person extensive assist, one-on-one supervision, and eating aides (plate guard, sipping lids on all cups, no straws). On 5/7/25 at 8:28 AM, Resident 48 was observed sitting in a wheelchair in her/his room with a plate of food on the table in front of her/him and spooning food into her/his mouth chewing and swallowing without difficulty. The resident chewed and swallowed her/his food without difficulty. There were no staff observed to be in or around her/his room. Resident's table included a tumbler of water with a straw and lid, but no lids on an empty cup or a cup of white liquid. On 5/8/25 at 8:10 AM, Resident 48 was observed sitting in a wheelchair in her/his room with a plate of food on the table in front of her/him and eating independently. There was no lid on a cup of white liquid or on a cup of juice. There were no staff observed to be in or around her/his room. At 8:15 AM, Resident 48 coughed and cleared her/his throat without difficulty and continued to eat. On 5/8/25 at 11:41 AM, Staff 13 (CNA) stated Resident 48 was able to eat independently and drink on her/his own. Staff 13 acknowledged Resident 48 was on aspiration precautions for swallowing, but did not need assistance with eating. Staff 13 stated Resident 48 was to be observed and staff were to listen in on her/him. Staff 13 stated she followed the care plan and kardex (a portable plan of care) for Resident 48. On 5/8/25 at 12:13 PM, Staff 14 (CNA) stated Resident 48 needed supervision when eating, but staff did not need to assist her/him with eating. Staff 14 reviewed Resident 48's kardex which showed Resident 48 required one-person assistance with eating and supervision. On 5/8/25 at 12:42 PM, Staff 17 (SLP) stated Resident 48 had been on standard aspiration precautions, which included ensuring she/he was upright in a chair and taking slow, small bites of food. Staff 17 acknowledged the resident graduated to set-up with intermittent supervision while eating. Staff 17 stated she could not provide a date when Resident 48 had transitioned to this level of supervision but forgot to update the care plan. Staff 17 stated since she had not yet sent an update regarding Resident 48 no longer requiring one-on-one assistance, she would expect staff to continue following the guidance outlined in the current care plan. On 5/9/25 at 10:27 AM, Staff 2 (DNS) stated her expectations included staff to follow the care plan and kardex which included following Resident 48's aspiration precautions. Staff 2 stated she expected staff to continue following the care plan and kardex until they were appropriately updated.

Based on interview and record review it was determined the facility failed to report results of abuse investigations to the State Survey Agency within the required time frame for 2 of 4 sampled residents (#s 7 and 19) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 7 was admitted to the facility in 12/2019 with diagnoses including chronic combined systolic and diastolic heart failure (a condition where the heart struggles to both contract and relax properly) and heart attack. A review of Resident 7's health record revealed she/he was cognitively intact and smoked cigarettes. Resident 19 was admitted to the facility in 1/2015 with diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot deliver sufficient oxygen to the blood) and diabetes. A review of Resident 19's health record revealed she/he was cognitively intact and smoked cigarettes. A 9/20/24 FRI related to resident to resident abuse between Resident 7 and Resident 19 during a smoke break was submitted to the State Agency on 9/27/24 (one day late). On 5/9/25 at 3:49 PM Staff 24 (Former Administrator) stated she remembered the incident but was unsure why the investigation was submitted late. On 5/12/25 at 11:47 AM Staff 1 (Administrator) acknowledged the facility's investigation was not submitted within five business days and stated it was his expectation for investigations to be submitted timely.

Based on observation, interview, and record review it was determined the facility failed to implement care plan interventions to prevent an elopement for 1 of 4 sampled residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement and injury. Findings include: Resident 1 was admitted to the facility in 2/2024, with diagnosis including nontraumatic intracerebral hemorrhage (bleeding of the brain without external trauma). Resident 1's 2/29/24 Care Plan indicated the resident presented as a high risk for elopement with interventions to implement a Code Pink protocol. Code Pink was defined as a medical emergency for residents who have wandered away from the facility and was at risk of harm and/or protecting themselves. Resident 1 was revealed to have convulsions related to seizure disorder. Resident 1's 12/5/24 Elopement Assessment identified she/he was a high risk for elopement. A 4/23/24 facility Progress Note revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located per facility report to have been found at a nearby hospital. Resident 1 identified to have wandered unsupervised from the facility after being observed smoking in the back park lot of the facility. A 2/2/25 facility Incident Report revealed Resident 1 had an unwitnessed exit from the facility. Resident 1 was located per the facility's investigation to have been found at a nearby hospital. The facility's video footage revealed the resident independently entered the facility's door code and exited the facility. The resident's BIMS score was revealed to be 9 out of 15, which indicated significant cognitive impairment. A 2/3/25 Hospital Record revealed the resident presented to the emergency department after being found wandering the hospital's parking lot. Additional records revealed Resident 1 was assessed and determined to have no significant abnormalities or acute findings before being transferred back to the facility. On 2/6/25 at 12:35 PM, Staff 5 (CNA) indicated she was unaware that Resident 1 was an elopement risk and did not provide 30 minute checks for Resident 1 as she believed Resident 1 was independent. Staff 5 stated she was aware Resident 1 had left the facility and did not report the resident had left the facility until shift exchange. On 2/6/25 at 2:12 PM, Staff 2 (DNS) and Staff 3 (Clinical Management Specialist) confirmed and acknowledged the facility failed to implement care plan interventions to prevent Resident 1's elopement.

Based on interview and record review, it was determined the facility failed to ensure residents were free from abuse for 1 of 5 sampled residents (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: On 5/10/24, the Past Non-Compliance was corrected when the facility completed a root cause analysis of the incident and determined there was abuse. The Plan of Correction included: 1. Residents were placed on alert charting for psychosocial mood and behaviors. 2. The effected resident was evaluated for psychosocial harm by a licnesed provider and continued to receive mental health services on a regular basis. 3. All staff were educated for abuse, neglect including reporting abuse and neglect. 4. All residents were assessed for psychosocial distress with no noted safety or abuse concenrs. Adjustments have been made to the effected resident's care plan to ensure residents mood and behavior are continuously monitored by the facility. Resident 1 was admitted to the facility in 3/2024, with diagnoses including acute hypoxic (low oxygen) respiratory failure and history of manic episodes. Resident 1's 3/26/24 Admission MDS revealed Resident 1 had no cognitive impairment. Resident 1's 4/15/24 Care Plan revealed Resident 1 with problematic manners characterized by ineffective coping and verbal aggression related to anger, anxiety, and mood disorder. A facility reported incident dated 5/10/24 revealed Witness 1 (Provider) was reported to have gripped the front of Resident 1's shirt and dragged her/him and slammed her/him onto her/his bed and was held down. Witness 1 was reported to have yelled and taunted at Resident 1 during the encounter which including calling Resident 1 a sissy. This incident was further revealed to have been witnessed by two staff members who were reported to have stopped the altercation before Witness 1 was escorted out of the building. On 5/16/24 at 10:23 AM, Resident 1 stated that during a routine visit, Witness 1 began arguing with Resident 1 which led to a physical confrontation between the two. Resident 1 stated Witness 1 held her/him down to the bed by her/his shirt and called her/him a sissy. Resident 1 stated during the altercation she/he felt that her/his pride had been effected but confirmed no harm had occurred during the event. On 5/16/24 at 10:35 AM, Witness 1 (Provider) stated that during a routine medical visit he had a physical confrontation with Resident 1. Witness 1 confirmed that as an act of self-defense he pushed and held Resident 1 to her/his bed. Witness 1 stated that during the altercation, he lost his temper and confirmed yelling at Resident 1 while he held Resident 1 to the bed. Witness 1 denied hitting or intentionally hurting Resident 1. On 5/16/24 at 10:56 AM, Staff 3 (RCM) stated Resident 1 was grabbed and flung on her/his bed by Witness 1 and held down. Staff 3 stated Witness 1 called Resident 1 a little sissy during the altercation. Staff 3 stated that Resident 1 was held down on the bed by Witness 1 for at least two minutes. Staff 3 stated she stopped the altercation and escorted Witness 1 out of the facility. On 5/16/24 at 11:09 AM, Staff 4 (CNA) stated she witnessed Resident 1 being grabbed by the shirt, pushed on the bed, and held to the bed by Witness 1. Staff 4 confirmed Witness 1 had held Resident 1 for several minutes before being confronted by facility staff. On 5/16/24 at 11:58 AM, Staff 6 (CNA) stated Resident 1 had no change in psychosocial mood or behavior during the altercation. Staff 6 stated Resident 1 had no loss of appetite and no decline as a result of the event. A review of a 5/16/24 Facility Investigation Summary revealed the facility determined abuse was substantiated based on resident and witness statements. On 5/17/24 at 10:38 AM, Staff 1 (Administrator) and Staff 2 (DNS) verified the incident occurred on 5/10/24 between Resident 1 and Witness 1.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed and medical conditions were assessed for 3 of 3 sampled residents (#s 1, 2 and 5) reviewed for physician orders and weight. This placed residents at risk for worsening health conditions and unmet needs. Findings include: 1. Resident 5 admitted to the facility on [DATE] with diagnoses including pneumonia, acute respiratory disease, acute heart failure, hypertension, and vascular disease. Resident 5's 2/25/24 physician order directed staff to give 40 mg of Furosemide (diuretic medication) every 24 hours PRN for edema (fluid retention), shortness of breath, weight gain of three lbs (pounds) in 24 hours or a weight gain of more than five lbs in one week. Review of Resident 15's health record revealed the following weights: - Admission weight: 2/15/24 at 243.8 lbs; - Gained three lbs in 24 hrs on; - 2/19/24 at 244.6 lbs to 2/20/24 at 248.3 lbs; - 3/14/24 at 252.8 lbs to 3/15/24 at 261.6 lbs; - 3/19/24 at 261.4 lbs to 3/20/24 at 266.2 lbs. - Gained five lbs in one week on; - 2/26/24 at 246.2 lbs to 3/4/24 at 252.2 lbs; - 3/12/24 at 253.8 lbs to 3/19/24 at 261.4 lbs. Discharge/hospitalization weight: - 3/25/24 at 267.2 lbs. Resident 5's 2/2024 and 3/2024 MAR revealed the order for 40 mg of Furosemide (diuretic medication) every 24 hours PRN for edema (fluid retention), shortness of breath, weight gain of three lbs in 24 hours or weight gain of more than five lbs in one week was given on 3/21/24 and 3/25/24. No other dates were identified when the medication was given. On 4/25/24 at 2:53 PM Staff 2 (DNS) acknowledged she expected all physician orders to be followed. Staff 2 confirmed Resident 5 experienced weight gain with no PRN Furosemide given according to the physician order. No additional information was provided. 2. Resident 1 admitted to the facility in 3/2023 with diagnoses including pain and depression. Resident 1's health record revealed weights were taken on the following dates: - 1/16/24 at 242.9 lbs (pounds); - 3/23/24 at 199 lbs. (43.9 lbs loss). On 2/28/24 Resident 1 was reviewed with the NAR (Nutrition At Risk) team. The NAR team indicated Resident 1's weight was stable with no changes. A 3/28/24 Weight Warning progress note indicated Resident 1's weight was 199 lbs on 3/23/24 which indicated significant weight loss. A 4/4/24 Nutrition Assessment indicated Resident 1's weight was 199 lbs. No changes in nutritional status and no indication of significant weight loss were identified or assessed. On 4/25/24 at 10:20 AM Staff 2 (DNS) stated the CNAs were expected to obtain resident's weights. She would expect the CNAs to report to the CN (Charge Nurse) if a resident weight was out of normal range, the CN would reweigh the resident, and if the weight was accurate, the CN would report to the RNCM. The RNCM would then take the resident's weight concern to the NAR team to evaluate the information. Resident 1's heath record revealed no attempts to assess, evaluate, provide a justification or referral for NAR team for the significant weight loss recorded on 3/23/24. On 4/25/24 at 2:06 PM Staff 2 acknowledged Resident 1's Weight Warning progress note on 3/28/24. Staff 2 stated the Weight Warning alert trigger in the progress note was cleared by the RD and she was unaware of why it would have been cleared with no follow up. Staff 2 stated she would have expected this weight loss to have been assessed and followed up on to find the root cause. No additional information was provided to indicate the facility assessed, evaluated, or provided a justification for Resident 1's significant weight loss. 3. Resident 2 admitted to the facility in 3/22/24 with diagnoses including heart disease. Record review of Resident 2's health record revealed the following weights: - 3/24/24 at 156.6 lbs (pounds); - 3/25/24 at 156.0 lbs; - 3/26/24 at 154.9 lbs; - 4/2/24 at 162.2 lbs; - 4/6/24 at 162.4 lbs; - 4/9/24 at 168.0 lbs; - 4/10/24 at 170.8 lbs (16 days with a 14.8 lbs weight gain). Resident 2's 3/25/24 Nutritional Assessment revealed no concerns identified her/his nutritional status. Review of Resident 2's health record revealed no assessment, justification or indication for the reason for the weight gain. On 4/25/24 at 10:20 AM Staff 2 (DNS) stated the CNAs were to obtain the resident's weights. She would expect the CNAs to report to the CN (Charge Nurse) if a resident weight was out of normal range, the CN would reweigh the resident, if the weight was accurate, the CN would report to the RNCM. The RNCM would then take the resident's weight concern to the NAR (Nutrition At Risk) team to evaluate the information. Review of Resident 2's health record revealed no information regarding the weight gain. On 4/25/24 at 3:05 PM Staff 2 acknowledged Resident 2's weight gain and stated she would expect the facility to assess the weight gain. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure safety interventions were in place to prevent elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This put residents at risk for potentially avoidable accidents. Findings include: The facility's undated Wandering and Elopements Policy indicates: If a resident is missing, initiate the elopement/missing resident emergency procedure: -Determine if the resident is out on an authorized leave or pass; -If the resident was not authorized to leave, initiate a search of the building(s) and premises; and -If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). Resident 1 was admitted to the facility in 11/2023 with diagnoses including peripheral vascular disease (a circulatory condition charactarized by reduced blood flow to the limbs) and cellulitis (a bacterial skin infection). A review of Resident 1's 11/28/23 care plan revealed she/he used a four-wheeled walker for ambulation. A review of Resident 1's 3/4/24 Elopement Risk Evaluation revealed she/he was cognitively impaired with poor decision-making skills and she/he ambulated independently. A 3/24/24 nursing progress note at 5:59 PM by Staff 9 (LPN) indicated Resident 1 was out of the facility. On 4/1/24 at 12:19 PM Staff 3 (CNA) stated Resident 1 left the faciity on [DATE]. She added,[She/ He didn't tell anybody [she/he] was leaving. [She/he] stayed out for two days, went to the hospital, and then readmitted here. No documentation was found in Resident 1's electronic health record or in the facility's Resident Sign Out Log to indicate she/he left the faciity on [DATE]. On 4/1/24 at 12:42 PM Staff 6 (RN) stated she provided wound care to resident 1 on 3/24/24 at about 1:00 PM and then gave a report to Staff 9, the oncoming nurse at shift change. Staff 6 stated residents who are alert and oriented are allowed to leave the facility if they sign out and provide staff information about where they are going and when they will be back. She added Resident 1 previously left the facility and was gone all night. Staff 6 stated she called the police when this happened but she did not recall the date. On 4/2/24 at 1:39 PM Staff 9 stated she did not know when Resident 1 left on 3/24/24 but called Staff 2 (DNS) to tell her Resident 1 was out of the facility. On 4/2/24 at 1:45 PM Staff 2 stated she told the night shift nurse to hold off on calling the police because this was a recent change in behavior for Resident 1. On 4/2/24 at 1:57 PM Staff 10 (Assistant Administrator) stated Resident 1 left the faciity on the afternoon of 3/24/24 and was out of the facility all day on 3/25/24. She stated she expected the care plan to reflect a resident's behavior of leaving the facility without telling staff or signing out. No evidence was found in Resident 1's Care Plan to indicate staff developed interventions related to Resident 1's behavior of leaving the facility without informing staff. On 4/2/24 at 2:05 PM Staff 1 (Administrator) acknowledged the facility staff did not know where Resident 1 was from 3/24/24 to 3/26/24 and stated, We should have called the police, updated [Resident 1's] Care Plan with the behavior of [her/him] leaving the facility and documented that we were educating him. She also stated, We have some gaps in the documentation that we need to address as a system.

Based on observation, interview and record review it was determined the facility failed to adhere to transmission based precautions for 1 of 1 sampled residents (#107) reviewed for transmission based precautions and failed to process and transport laundry to prevent potential cross contamination for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for infection. Findings include: 1. Resident 107 was admitted to the facility in 11/2023 with diagnosis including leg fracture. On 12/1/23 at 8:28 AM signage posted outside Resident 107's room indicated the resident was on transmission based precautions and staff were to don a mask, gloves, face shield and a gown when providing care. Staff 14 (CMA) donned gloves and an N95 mask then entered Resident 107's room to administer medications including a nasal spray and an inhaler. Staff 14 acknowledged she did not don a face shield or gown before entering the resident's room. 43690 2. The facility's 9/2022 Laundry and Bedding, Soiled Policy Statement indicated the following: -Clean linen was to be stored separately, away from soiled linens, at all times. -Clean linen was to be kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination. On 11/30/23 at 9:19 AM, the following observations were made of the laundry room: -Wet clean linens were observed in an uncovered metal bin, dirty linens was observed to pass within inches of the uncovered bin. -Both washers had a pink/brown substance on top of them where there was an opening for detergent to go in. -A chemical dispensing container for the washers on the wall above the eye wash station had areas of a pink/brown substance on the outer and inner parts of the plastic container. -Clean linens were observed folded on a counter and hanging on racks across from the washers and were not covered. On 11/30/23 at 10:07 AM Staff 1 (Adminstrator) and Staff 8 (Regional Nurse Consultant) acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure resident call lights were answered timely for 1 of 4 sampled residents (#36) reviewed for sufficient nurse staffing. This placed residents at risk for untimely assistance with ADL needs. Findings include: Resident 36 was admitted to the facility in 10/2022 with diagnosis including stroke. On 11/28/23 at 10:56 AM Resident 36 stated it took staff 20 minutes to two hours to answer her/his call light, typically at night. A review of Resident 36's call light record from 11/1/23 through 11/29/23 revealed the following call light response times: - On 11/1/23 at 9:31 PM, the response time was 39 minutes. - On 11/4/23 at 10:02 PM, the response time was 25 minutes. - On 11/7/23 at 10:37 PM, the response time was 25 minutes. - On 11/9/23 at 8:46 PM, the response time was 27 minutes. - On 11/11/23 at 9:07 PM, the response time was 25 minutes. - On 11/14/23 at 9:00 PM, the response time was 28 minutes. - On 11/16/23 at 2:07 AM, the response time was 24 minutes. - On 11/19/23 at 6:28 AM, the response time was 26 minutes. - On 11/19/23 at 10:01 PM, the response time was 1 hour and 5 minutes. On 11/30/23 at 11:35 AM Resident 36's call light record was reviewed with Staff 4 (Assistant Administrator) who stated the facility's expectation was for call lights to be answered within 15 minutes.

Based on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 2 of 2 sampled residents (#s 3 and 205) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment. Findings include: 1. Resident 205 was admitted to the facility in 11/2023 with a diagnosis including cardiac arrest. On 11/28/23 and 9:30 AM Resident 205 stated her/his overbed light cord was too short and she/he could not independently use the light without the extension of the plastic bag provided. On 12/1/23 at 1:16 PM Staff 6 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short. Staff 6 observed the plastic bag tied to the cord and stated the cord needed the proper extensions on them. 46053 2. Resident 3 was admitted to the facility in 10/2023 with a diagnosis of cellulitis (a bacterial skin infection). A review of Resident 3's 10/18/23 Admission MDS revealed she/he was cognitively intact. On 11/29/23 at 8:13 AM a plastic trash bag was observed to be tied to the pull cord of her/his overbed light. On 11/30/23 at 9:07 AM Resident 3 stated she/he could not reach the cord so a caregiver tied the plastic trash bag to the cord as an extender. She/he stated she/he preferred to use a longer cord rather than a plastic trash bag to turn her/his light on and off. On 12/1/23 at 1:16 PM Staff 6 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short.

Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization for 1 of 1 sampled resident (#33) reviewed for hospitalization . This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: Resident 33 was admitted to the facility in 10/2023 with diagnoses of atrial fibrillation and abdominal pain. An 11/10/23 Nursing Note indicated Resident 33 was sent to the hospital. No evidence was found in the resident's clinical record to indicate the Office of the State Long Term Care Ombudsman was notified of Resident 33's hospitalization . On 12/4/23 at 9:54 AM Staff 11 (Social Services Director) stated he was unaware the Office of the State Long Term Care Ombudsman's office was to be notified when a resident was sent to the hospital. On 12/4/23 at 9:57 AM Staff 1 (Administrator) stated that historically the facility did not send out written hospital notifications to the Office of the State Long Term Care Ombudsman.

Based on observation, interview and record review it was determined the facility failed to comprehensively assess a resident's dental status for 1 of 1 sampled resident (#46) reviewed for dental. This placed residents at risk for lack of dental care and weight loss. Findings include: Resident 46 was admitted to the facility in 10/2023 with diagnosis including infection. On 11/28/23 at 9:37 AM Resident 46 stated he was missing most of his teeth and needed to see a dentist. The facility told her/him they would refer her/him to a dentist but she/he had not heard anything since then. Resident 46's 10/24/23 Oral/Dental Status assessment indicated the resident did not have any dental issues. On 11/29/23 at 1:29 PM Staff 13 (RNCM) verified she completed the 10/24/23 assessment but she did not physically or visually examine the resident's teeth. Staff 13 and the surveyor then examined Resident 46's teeth. The resident only had one tooth in her/his upper gums and a few bottom front teeth. The teeth all appeared decayed and discolored. Resident 46 told Staff 13 her/his teeth bothered her/him and she/he was unable to eat her/his favorite foods. Staff 13 told Resident 46 she would get a dental referral for her/him. Staff 13 acknowledged the assessment was not accurate.

Based on observation, interview, and record review it was determined the facility failed to ensure a supervised resident smoker did not have continued access to smoking materials for 1 of 8 sampled residents (#1). This failure to ensure Resident 1 was supervised while smoking and intoxicated resulted in Resident 1 sustaining second degree [CONDITION(S)] to her/his face, which was determined to be an immediate jeopardy situation in the area of CFR 483.25 Quality of Care. Findings include: Resident 1 was admitted to the facility 10/23/20 with diagnoses including [CONDITION(S)] (a neurological disorder that affects movement and muscle tone), [CONDITION(S)] and bilateral above the knee amputations. On 5/3/22 at 5:00 PM a FRI indicated on 5/3/22 at approximately 3:45 PM Resident 19 went into the facility from the smoking area and reported to staff, Resident 1 burned her/himself. Staff retrieved the DNS and Administrator Assistant to tend to Resident 1 and called 911. Resident 1 was unable to state what occurred and appeared intoxicated. Resident 1 was sent to the hospital. On 5/3/22 at 9:22 PM Staff 28 (LPN) documented in Resident 1's progress notes at approximately 3:45 PM the Administrator Assistant informed Staff 28 that Resident 1 was smoking and her/his face appeared burned. Resident 1 was outside in the smoking area with another resident. The other resident put the fire out. Staff 28 called 911. Resident 1 did not provide a description to what occurred. Resident 1 was agitated, drowsy, had slurred speech, and appeared intoxicated. Resident 1 admitted she/he drank a beer. Resident 1 noted with black areas and increased redness to her/his right side of face and neck with no open areas, and missing hair. Resident 1 stated her/his pain level was 7/10 but then denied pain. When paramedics arrived, the resident was assisted to the stretcher by five people and transported to the hospital. The 5/3/22 hospital discharge summary revealed Resident 1 was intoxicated upon arrival and sustained a second degree burn to her/his face. On 5/4/22 a Smoking Assessment for Resident 1 was completed and she/he was assessed to require supervised smoking. On 5/4/22 at 10:09 AM Resident 1 was observed to have a cord with a key around her/his neck, like a necklace, and she/he accessed smoking materials independently from the smoking lock box. On 5/4/22 at 10:10 AM Staff 10 (CNA) stated supervised smokers did not have access to smoking materials and staff had the key for the smoking materials. Staff 10 stated Resident 1 was a supervised smoker after the incident on 5/3/22. On 5/4/22 at 10:42 AM Resident 1 stated she/he did not remember the incident on 5/3/22 and was thankful another resident put the fire out on her/his face. Resident 1 stated she/he used to be an independent smoker but because her/his face caught on fire she/he had to be supervised, follow the rules and smoking times. Resident 1 was observed to have a key around her/his neck. On 5/4/22 at 1:04 PM Resident 1 was observed to remove the smoke box key from around her/his neck and pass it to a staff in the smoking area. The staff retrieved cigarettes and left the key in the lock box. At 1:16 PM staff provided Resident 1 with another cigarette, locked the lock box and placed the key around Resident 1's neck. On 5/4/22 at 3:15 PM Staff 3 (DNS) and Staff 2 (Assistant Administrator) stated it was difficult to keep Resident 1 from obtaining smoking materials, lighters and alcohol and she/he was often intoxicated. Staff 3 stated Resident 1 was re-assessed as a supervised smoker after the accident on 5/3/22. Staff 3 confirmed supervised resident smokers were not to have a personal key to a smoking lock box with smoking materials. The facility was found to be in an Immediate Jeopardy situation in the area of: CFR 483.25 Quality of Care, Accidents. This placed residents who smoked at risk for injury and constituted substandard quality of care extended survey. On 5/4/22 at 5:20 PM the facility was notified of an immediate jeopardy (IJ) situation related to the facility's failure to keep Resident 1 free from [CONDITION(S)], and access to smoking material while intoxicated. This failure placed residents at risk of injury. On 5/4/22 at 6:09 PM an accepted facility plan to remove the IJ situation was submitted by the facility. The plan included the following: -Resident 1 was reassessed for smoking safety and her/his smoking care plan was reviewed and revised for current needs. -Other residents who had the potential will be reassessed for current smoking needs and will include risks factors such as alcohol/drug use which could impair their abilities. -The facility will no longer continue independent resident smoking. The supervised smoking program was reviewed and amended. Education will be provided to residents and staff regarding the new smoking program. -All smoking lock box keys were obtained from residents and smoking materials were secured by staff. -Audits weekly for 12 weeks to ensure smoking materials were secured by staff and residents' understanding of the changes. On 5/5/22 at 10:28 AM the facility was notified the immediacy was removed based on onsite verification that the IJ immediacy plan was implemented, noncompliance remained at isolated with harm to one resident.

Based on interview and record review it was determined Staff 4 (LPN/RCM) and Staff 25 (LPN) failed to ensure professional standards were followed for 2 of 4 sampled residents (#s 1 & 2) reviewed for medications. Resident 1 had [MEDICATION NAME] Sodium [MEDICATION]) toxicity, increased falls, fell , and fractured her/his thumb. Resident 2 was at risk of complications due to not receiving medications as ordered. Findings include: DIVISION 45 STANDARDS AND SCOPE OF PRACTICE FOR THE LICENSED PRACTICAL NURSE AND REGISTERED NURSE 851-045-0040 Scope of Practice Standards for All Licensed Nurses . (5) Standards related to the licensee's responsibility to accept and implement orders for client care and treatment. (a) The licensee may accept and implement orders from a licensed independent practitioner (LIP) authorized by Oregon statute to independently diagnose and treat . (f) When the licensee has determined that an order or a recommendation is not clear, unsafe, contraindicated for the client, or inconsistent with the overall plan for the client's care, the licensee has the responsibility to decline implementation and contact the health care professional making the order or recommendation . 1. Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 7/2017 Care Plan noted the resident was at risk for falls and required one person assistance with transfers. The 7/18/16 Physician Orders included [MEDICATION NAME] Sodium Extended Capsule (an anti-[MEDICAL CONDITION] medication) 400 mg at bedtime. On 3/20/17 the physician decreased the [MEDICATION NAME] Sodium dosage to 300 mg at bedtime for total 300 mg dose. The Pharmacy E-Rx New Prescription Request noted the dosage as 300 mg ER capsule, one capsule three times a day (900 mg). There was no documented clarification of the conflicting physician orders in the clinical record. The 3/2017 MAR noted the resident received 900 mg of [MEDICATION NAME] Sodium from 3/21/17 to 3/27/17 and 600 mg on 3/28/17. Progress Notes and facility investigations dated 3/24/17 to 3/28/17 documented Resident 1 experienced eight falls/incidents, had balance issues, was increasingly confused, sustained a fractured thumb and required additional CNA assistance. The 3/28/17 at 3:11 pm and 3:16 pm Progress Notes disclosed Resident 1 had two additional falls. The resident spoke in word salad, had abnormal movements of the arms, trunk, and legs, and required assistance from three CNAs with standing and placing the resident in bed due to the resident's instability. The physician was contacted and the resident was sent to the ED (Emergency Department). The 3/28/17 ED Provider Notes revealed the resident presented to the ED with progressively worsening falls and slurred speech. The resident was unsure why she/he fell . Two weeks prior the resident's [MEDICATION NAME] Sodium level was 16. In the ED the resident's [MEDICATION NAME] Sodium level was markedly elevated at 38.5. The ED physician noted the resident's falls were related to the increased [MEDICATION NAME] Sodium level and the resident's symptoms were clearly consistent with [MEDICATION NAME] Sodium toxicity. The resident was admitted to the hospital for treatment and was discharged back to the facility on [DATE]. Staff 2 (DNS), Staff 3 (Nurse Consultant), and Staff 4 (LPN/RCM) were interviewed on 8/11/17 at 3:45 pm regarding the medication error. Staff 4 stated Staff 25 (LPN) received both the physician order for [REDACTED]. Per Staff 4 Staff 25 did not clarify the orders as Staff 25 thought she had the correct order. Staff 2, 3, and 4 stated the conflicting orders should have been clarified. In interview on 8/14/17 at 10:40 am Witness 2 (Physician) stated on 3/13/17 the resident had a [MEDICATION NAME] Sodium level of 15.8 and levels above 20 were considered toxic. On 3/20/17 Witness 2 lowered the resident's dosage from 400 mg to 300 mg daily due to the resident's upward trend in [MEDICATION NAME] Sodium and history with toxicity and sent that order to the facility. The pharmacy orders directed staff to administer 300 mg three times a day and the facility did not follow up on inconsistent instructions. On 3/28/17 the resident had a [MEDICATION NAME] Sodium level of 38.5. Witness 2 stated the toxic [MEDICATION NAME] Sodium level absolutely increased the resident's falls as the toxicity made the resident unsteady on her/his feet, causing the resident to fall. In interview on 8/22/17 at 10:15 am Staff 6 (Former RNCM) stated from 3/24/17 to 3/28/17 Resident 1 had increasing balance issues and multiple falls in a short period of time. The resident sustained [REDACTED]. In interview on 8/22/17 at 11:34 am Staff 25 (LPN) stated she could not recall which [MEDICATION NAME] orders were sent to the facility first as they came fast and she did not clarify the discrepancy in dosage. Staff 25 stated she thought the physician ordered the increase for [MEDICAL CONDITION] related to the resident's [DIAGNOSES REDACTED]. Staff 25 stated when the resident experienced increased falls along with the increased dosage she assumed the falls were from the [DIAGNOSES REDACTED]. In interview on 8/22/17 at 12:08 pm Staff 4 (LPN/RCM) stated from 3/24/17 to 3/28/17 the resident experienced some increase in confusion and falls. In interview on 8/22/17 at 3:09 pm Witness 3 (Family) stated during the 3/2017 falls the resident seemed like she/he was not able to move her/his body right and something was definitely different with the resident. Witness 3 stated the resident fell , fractured her/his thumb and was hospitalized with a very high [MEDICATION NAME] Sodium level. The increase in the medication impacted the resident's stability and once the medication was leveled out the resident improved. Refer to F333, Example 1. 2. Resident 2 was readmitted from a local hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/2/17 hospital Transfer Medication List included Fluconazole (an antifungal medication)100 mg 1 tablet for 7 days. The Fluconzaole was not transcribed onto the 7/2017 MAR and administered to the resident until 7/12/17. The 7/2/17 Transfer Medication List included [MEDICATION NAME]-[MEDICATION NAME] (a medication that relaxes muscles in the airways and increases air flow to the lungs, used to prevent [MEDICATION NAME] with [MEDICAL CONDITION]) 3 ml four times a day. The [MEDICATION NAME]-[MEDICATION NAME] was transcribed onto the 7/2017 and 8/2017 MARs as PRN and was not given four times a day as ordered. The 7/2017 and 8/2017 MARs included [MEDICATION NAME] (a medication used to treat asthma and [MEDICAL CONDITION]) inhaler 45 MCG two puffs every four hours PRN for shortness of breath. The resident received the medication on 7/5/17. There were no orders for the [MEDICATION NAME] inhaler in the 7/2/17 Transfer Medication List. The 7/2/17 Transfer Medication List included [MEDICATION NAME] (an antacid) 20 ml PRN for heartburn. The 7/2017 MAR documented from 7/2/17 to 7/12/17 the PRN [MEDICATION NAME] dosage was 15-30 ml. The 7/2017 MAR included Calcium Tablet 500 mg one tablet PRN four times a day for heartburn/indigestion from 7/2/17 to 7/7/17. There were no 7/2/17 correlating physician orders for the PRN Calcium tablet. In interview on 8/18/17 at 12:09 pm Staff 4 (LPN/RCM) stated when residents were readmitted to the facility the RCM reviewed and adjusted the physician orders and at the time of admission the charge nurse compared the MAR with the physician orders. Staff 4 stated she reconciled the orders upon Resident 2's re-admission and later discovered the [MEDICATION NAME] and Fluconazole medication errors. Staff 4 stated the Calcium tablets and Levalbuteral [MEDICATION NAME] were from previous physician orders and she could not locate a current order for the medication and the [MEDICATION NAME]-[MEDICATION NAME] was not transcribed onto the 7/2017 and 8/2017 MARs as a scheduled medication. Refer to F333, Example 2.

Based on interview and record review it was determined the facility failed to clarify and follow physician orders for 3 of 4 sampled residents (#s 1, 2 & 3) reviewed for medications. Resident 1 had [MEDICATION NAME] Sodium [MEDICATION]) toxicity, increased falls, fell , and fractured her/his thumb. Residents 2 and 3 were at risk of complications due to not receiving medications as ordered. Findings include: 1. Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 7/2017 Care Plan noted the resident was at risk for falls and required one person assistance with transfers. The 7/18/16 Physician Orders included [MEDICATION NAME] Sodium Extended Capsule (an anti-[MEDICAL CONDITION] medication) 400 mg at bedtime. On 3/20/17 the physician decreased the [MEDICATION NAME] Sodium dosage to 300 mg at bedtime for total 300 mg dose. The Pharmacy E-Rx New Prescription Request noted the dosage as 300 mg ER capsule, one capsule three times a day (900 mg). There was no documented clarification of the conflicting physician orders in the clinical record. The 3/2017 MAR noted the resident received 900 mg of [MEDICATION NAME] Sodium from 3/21/17 to 3/27/17 and 600 mg on 3/28/17. Progress Notes and facility investigations dated 3/24/17 to 3/28/17 documented Resident 1 experienced eight falls/incidents: *The 3/24/17 at 7:10 pm facility investigation noted the resident fell , was very unstable and required two CNA assistance to the bathroom and bed. The resident was described as becoming increasingly confused . *The resident had two falls 40 minutes apart on 3/25/17. The 3/25/17 at 1:38 pm Progress Note disclosed after the second fall the resident's left thumb was positioned out of alignment and appeared dislocated. *The 3/25/17 Immediate Care Notes disclosed the resident felt weak and x-rays revealed a displaced fractured thumb. *The 3/26/17 at 5:00 am facility investigation and 11:39 am Progress Note disclosed the resident was ambulating, lost her/his balance and fell . The resident was toileted after the fall and required stabilization due to leaning backwards and losing her/his balance while standing. *The 3/27/17 at 3:30 am, 2:57 pm, and 7:29 pm Progress Notes disclosed the resident self transferred out of bed, was found on the floor, and appeared to hit her/his head. Resident 1 complained of left hip pain, had issues with weight bearing on the left hip, an unsteady gait and needed two person assistance. *The 3/28/17 at 10:20 am Progress Note revealed Resident 1 almost fell , was caught by staff before hitting the ground, and hit her/his head on the wall. *The 3/28/17 at 3:11 pm and 3:16 pm Progress Notes disclosed Resident 1 had two additional falls. The resident spoke in word salad, had abnormal movements of the arms, trunk, and legs, and required assistance from three CNAs with standing and placing the resident in bed due to the resident's instability. The physician was contacted and the resident was sent to the ED (Emergency Department). The 3/28/17 ED Provider Notes revealed the resident presented to the ED with progressively worsening falls and slurred speech. The resident was unsure why she/he fell . Two weeks prior the resident's [MEDICATION NAME] Sodium level was 16. In the ED the resident's [MEDICATION NAME] Sodium level was markedly elevated at 38.5. The ED physician noted the resident's falls were related to the increased [MEDICATION NAME] Sodium level and the resident's symptoms were clearly consistent with [MEDICATION NAME] Sodium toxicity. The resident was admitted to the hospital for treatment and was discharged back to the facility on [DATE]. Staff 2 (DNS), Staff 3 (Nurse Consultant), and Staff 4 (LPN/RCM) were interviewed on 8/11/17 at 3:45 pm regarding the medication error. Staff 4 stated Staff 25 (LPN) received both the physician order for [REDACTED]. Per Staff 4 Staff 25 did not clarify the orders as Staff 25 thought she had the correct order. Staff 2, 3, and 4 stated the conflicting orders should have been clarified. In interview on 8/14/17 at 10:40 am Witness 2 (Physician) stated on 3/13/17 the resident had a [MEDICATION NAME] Sodium level of 15.8 and levels above 20 were considered toxic. On 3/20/17 Witness 2 lowered the resident's dosage from 400 mg to 300 mg daily due to the resident's upward trend in [MEDICATION NAME] Sodium and history with toxicity and sent that order to the facility. The pharmacy orders directed staff to administer 300 mg three times a day and the facility did not follow up on inconsistent instructions. On 3/28/17 the resident had a [MEDICATION NAME] Sodium level of 38.5. Witness 2 stated the toxic [MEDICATION NAME] Sodium level absolutely increased the resident's falls as the toxicity made the resident unsteady on her/his feet, causing the resident to fall. In interview on 8/22/17 at 4:26 am Staff 26 (CNA) stated when Resident 1 experienced the falls on 3/28/17 at 3:11 pm and 3:16 pm the nurse reported the resident was different than before. In interview on 8/22/17 at 10:15 am Staff 6 (Former RNCM) stated from 3/24/17 to 3/28/17 Resident 1 had increasing balance issues and multiple falls in a short period of time. The resident sustained [REDACTED]. In interview on 8/22/17 at 11:34 am Staff 25 (LPN) stated she could not recall which [MEDICATION NAME] orders were sent to the facility first as they came fast and she did not clarify the discrepancy in dosage. Staff 25 stated she thought the physician ordered the increase for [MEDICAL CONDITION] related to the resident's [DIAGNOSES REDACTED]. Staff 25 stated when the resident experienced increased falls along with the increased dosage she assumed the falls were from the [DIAGNOSES REDACTED]. In interview on 8/22/17 at 12:08 pm Staff 4 (LPN/RCM) stated from 3/24/17 to 3/28/17 the resident experienced some increase in confusion and falls. In interview on 8/22/17 at 3:09 pm Witness 3 (Family) stated during the 3/2017 falls the resident seemed like she/he was not able to move her/his body right and something was definitely different with the resident. Witness 3 stated the resident fell , fractured her/his thumb and was hospitalized with a very high [MEDICATION NAME] Sodium level. The increase in the medication impacted the resident's stability and once the medication was leveled out the resident improved. Refer to F281, Example 1 and F323, Example 1. 2. Resident 2 was readmitted from a local hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/2/17 hospital Transfer Medication List included Fluconazole (an antifungal medication)100 mg 1 tablet for 7 days. The Fluconzaole was not transcribed onto the 7/2017 MAR and administered to the resident until 7/12/17. The 7/2/17 Transfer Medication List included [MEDICATION NAME]-[MEDICATION NAME] (a medication that relaxes muscles in the airways and increases air flow to the lungs, used to prevent [MEDICATION NAME] with [MEDICAL CONDITION]) 3 ml four times a day. The [MEDICATION NAME]-[MEDICATION NAME] was transcribed onto the 7/2017 and 8/2017 MARs as PRN and was not given four times a day as ordered. The 7/2017 and 8/2017 MARs included [MEDICATION NAME] (a medication used to treat asthma and [MEDICAL CONDITION]) inhaler 45 MCG two puffs every four hours PRN for shortness of breath. The resident received the medication on 7/5/17. There were no orders for the [MEDICATION NAME] inhaler in 7/2/17 Transfer Medication List. In interview on 8/18/17 at 12:09 pm Staff 4 (LPN/RCM) stated when residents were readmitted to the facility the RCM reviewed and adjusted the physician orders and at the time of admission the charge nurse compared the MAR with the physician orders. Staff 4 stated she reconciled the orders upon Resident 2's re-admission and later discovered the Fluconazole medication error. Staff 4 stated the Levalbuteral [MEDICATION NAME] was from a previous physician order and she could not locate a current order for the medication and the [MEDICATION NAME]-[MEDICATION NAME] was not transcribed onto the 7/2017 and 8/2017 MARs as a scheduled medication. Refer to F281, Example 2. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/17/17 the physician ordered [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 70 mg weekly. The 7/2017 and 8/2017 MARs lacked documented evidence the medication was administered on 7/17, 7/24, 7/31, and 8/7. The physician discontinued the medication on 8/11/17. In interviews on 8/16/17 at 11:03 am and 8/17/17 at 11:30 am Staff 2 (DNS) stated the [MEDICATION NAME] was not given as ordered and when he spoke with nursing staff they reported the medication did not show up on the MAR. Staff 2 stated staff needed education on how to review and audit the MAR at the end of the shift. In interview on 8/21/17 at 3:13 pm Staff 14 (RN) stated she did not recall administered the [MEDICATION NAME] due to the medication not showing up on the electronic record. In interview on 8/22/17 at 9:58 am Staff 9 (LPN) stated he did not see the [MEDICATION NAME] show up in the electronic record and did not administer the medication.

Based on observation, interview and record review it was determined the facility failed to consider medications related to falls and follow care planned interventions for 3 of 4 sampled residents (#1, 2 & 3) reviewed for falls. Resident 1 had Phenytoin Sodium (anti-seizure medication) toxicity, increased falls, fell , and fractured her/his thumb. Residents 2 and 3 were at risk of continued falls and potential injuries. Findings include: 1. Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The 7/2017 Care Plan noted the resident was at risk for falls and required one person assistance with transfers and the use of a fall mat at the bedside. The 7/18/16 Physician Orders included Phenytoin Sodium Extended Capsule (an anti-seizure medication) 400 mg at bedtime. Potential side effects of Phenytoin Sodium included ataxia (lack of coordination of muscle movements including gait abnormalities), unsteadiness, dizziness and blurred vision. On 3/20/17 the physician decreased the Phenytoin Sodium dosage to 300 mg at bedtime for total 300 mg dose. The Pharmacy E-Rx New Prescription Request noted the dosage as 300 mg ER capsule, one capsule three times a day (900 mg). The 3/2017 MAR noted the resident received 900 mg of Phenytoin Sodium from 3/21/17 to 3/27/17 and 600 mg on 3/28/17. Progress Notes and facility investigations dated 3/24/17 to 3/28/17 documented Resident 1 experienced eight falls/incidents: *The 3/24/17 at 7:10 pm facility investigation noted the resident fell , was very unstable and required two CNA assistance to the bathroom and bed. The resident was described as becoming increasingly confused . *The resident had two falls 40 minutes apart on 3/25/17. The 3/25/17 at 1:38 pm Progress Note disclosed after the second fall the resident's left thumb was positioned out of alignment and appeared dislocated. *The 3/25/17 Immediate Care Notes disclosed the resident felt weak and x-rays revealed a displaced fractured thumb. *The 3/26/17 at 5:00 am facility investigation and 11:39 am Progress Note disclosed the resident was ambulating, lost her/his balance and fell . The resident was toileted after the fall and required stabilization due to leaning backwards and losing her/his balance while standing. *The 3/27/17 at 3:30 am, 2:57 pm, and 7:29 pm Progress Notes disclosed the resident self transferred out of bed, was found on the floor, and appeared to hit her/his head. Resident 1 complained of left hip pain, had issues with weight bearing on the left hip, an unsteady gait and needed two person assistance. *The 3/28/17 at 10:20 am Progress Note revealed Resident 1 almost fell , was caught by staff before hitting the ground, and hit her/his head on the wall. There was no documented evidence in the clinical record the resident's increase in Phenytoin Sodium was considered as a contributing factor to the increase in falls. *The 3/28/17 at 3:11 pm and 3:16 pm Progress Notes disclosed Resident 1 had two additional falls. The resident spoke in word salad, had abnormal movements of the arms, trunk, and legs, and required assistance from three CNAs with standing and placing the resident in bed due to the resident's instability. The physician was contacted and the resident was sent to the ED (Emergency Department). The 3/28/17 ED Provider Notes revealed the resident presented to the ED with progressively worsening falls. In the ED the resident's Phenytoin Sodium level was markedly elevated at 38.5. The ED physician noted the resident's falls were related to the increased Phenytoin Sodium level and the resident's symptoms were clearly consistent with Phenytoin Sodium toxicity. The resident was admitted to the hospital for treatment and was discharged back to the facility on [DATE]. The 7/27/17 at 6:46 pm Progress Note disclosed Resident 1 fell during a self transfer. The correlating facility investigation documented the resident was found sitting on her/his buttocks in front of the bed. Per the investigation the resident was observed in bed prior to the fall, the fall mat was not in place and the alarm did not sound. On 8/11/17 at 12:39 pm Resident 1 was observed in bed. The fall mat was folded up and placed along a wall. In interview on 8/11/17 at 1:33 pm Staff 17 (CNA) stated the resident used a fall mat when in bed. Staff 17 stated she placed the resident in bed after lunch but the floor in the resident's room was wet and she wanted the floor to dry before placing the fall mat. Staff 17 stated she left to provide care for another resident and forgot about the fall mat. Staff 2 (DNS), Staff 3 (Nurse Consultant), and Staff 4 (LPN/RCM) were interviewed on 8/11/17 at 3:45 pm regarding the Phenytoin Sodium administration. Staff 4 stated Staff 25 (LPN) received both the physician order for [REDACTED]. Staff 2, 3, and 4 stated the conflicting orders should have been clarified. In interview on 8/14/17 at 10:40 am Witness 2 (Physician) stated Phenytoin Sodium levels above 20 were considered toxic. On 3/20/17 Witness 2 lowered the resident's dosage from 400 mg to 300 mg daily and sent that order to the facility. The pharmacy orders directed staff to administer 300 mg three times a day and the facility did not follow up on inconsistent instructions. On 3/28/17 the resident had a Phenytoin Sodium level of 38.5. Witness 2 stated the toxic Phenytoin Sodium level absolutely increased the resident's falls as the toxicity made the resident unsteady on her/his feet, causing the resident to fall. In interview on 8/22/17 at 10:15 am Staff 6 (Former RNCM) stated from 3/24/17 to 3/28/17 Resident 1 had increasing balance issues and multiple falls in a short period of time. The resident sustained [REDACTED]. In interview on 8/22/17 at 11:34 am Staff 25 (LPN) stated she did not clarify the discrepancy in dosage and assumed the increase in falls were from the [DIAGNOSES REDACTED]. Refer to F333, Example 1. 2. Resident 2 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 6/2/17 revised falls care plan included the use of non-skid socks/slippers/closed shoes and staff were to assist the resident with placing non-skid socks on when the resident was in bed. The 7/13/17 revised falls care plan directed staff to place the bed in the highest position when the resident was out of bed. The 7/26/17 at 9:42 pm Progress Note disclosed Resident 2 fell and sustained a 3 cm x 0.1 cm laceration on the forehead and a small skin tear on the left forearm. The facility's correlating investigation noted the resident was observed in bed prior to the fall. The resident did not have on non-skid socks. On 8/11/17 from 10:53 am to 11:08 am Resident 2 was observed in her/his wheelchair in the hallway and her/his room. The resident's bed was low to the floor. Staff 8 (LPN) assisted the resident to her/his room and the resident attempted a phone call and looked at a magazine. Staff 8 assisted another resident in the hallway. At 11:05 pm Staff 8 moved Resident 2 to the dining room. At 11:08 pm Staff 8 stated she was not aware of the intervention to keep the resident's bed in the high position when the resident was not in bed. In interview on 8/11/17 at 11:10 am Staff 27 (CNA) stated the resident's bed was to be in the high position when the resident was not in bed as staff did not want the resident attempting to get into bed. Staff 27 stated she noticed the bed was not in the high position as care planned that day but had to assist in the dining room and did not correct the bed height. In interview on 8/22/17 at 11:34 am Staff 25 (LPN) stated the resident only had regular socks on but was care planned for non-skid socks. Staff 25 stated she talked to all the CNAs reminding them to place non-skid socks on the resident. 3. Resident 3 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. The 7/10/17 Fall Care Plan included placing the bed in the lowest position and the use of non skid shoes when up and slippers/socks when in bed. The care plan did not include the use of a fall mat. The 7/22/17 facility fall investigation noted a CNA entered the resident's room to find the resident attempting to get out of bed, was not able to transfer the resident with one person and assisted the resident to the floor. The low bed was not in use. The 8/5/17 at 2:00 am Progress Note disclosed Resident 3 got herself/himself out of bed, walked to the bathroom, and yelled out. A CNA responded, the resident was weak, started to go to the floor and the CNA assisted the resident to the floor. The facility's correlating investigation noted the resident was barefoot. On 8/11/17 at 10:02 am Resident 3 was observed lying in bed with a fall mat in place. In interview on 8/16/17 at 11:03 am Staff 2 (DNS) stated the resident was not care planned for the use of a fall mat and did not know who placed the fall mat in the room. In interview on 8/21/17 at 3:13 pm Staff 14 (RN) stated on 7/22/17 Staff 21 (CNA) told her Resident 3 attempted to climb out of the bed. The bed was to be in the low position due to the resident's fall risk and she did not know the status of the bed height at the time of the fall. In interview on 8/21/17 at 3:58 pm Staff 21 (CNA) stated it was protocol to lower resident beds after providing care. Staff 21 stated she first met the resident when the resident fell on [DATE]. The bed was medium to low height at the time of the fall. In interview on 8/22/17 at 3:40 pm Staff 25 (LPN) stated on 8/5/17 the resident was walking either to or from the bathroom and when the resident started buckling Staff 25 lowered the resident to the floor. Staff 25 stated when the resident was observed prior to the fall her/his socks were on the table. When asked why the resident did not have the socks on while in bed Staff 25 stated the resident did not need the socks on when in bed due to being incontinent and did not walk.

Based on observation, interview and record review it was determined the facility failed to modify fall interventions and provide adequate supervision to prevent falls for 1 of 4 sampled residents (#12) reviewed for accidents. As a result, the resident was sent to the emergency room and required sutures for a hand laceration. Findings include: Resident 12 was admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. On the Admission MDS dated [DATE] the resident was identified as being at risk for falls and she/he scored a 0/15 on the BIMS assessment, which indicated severe cognitive impairment. Resident 12 was coded as having had a fall in the last month prior to admission, having a fall in the last 2-6 months prior to admission and as having had a fracture related to a fall in the last 6 months prior to entry. The MDS was also coded to show Resident 12 had a fall since admission to the facility. The Falls CAA from the admission MDS identified Resident 12 was at risk for falls due to several factors which included: new environment, dementia diagnosis, history of repeated falls. The CAA directed Resident 12 would be care planned for falls with the goal of improving and minimizing the risks. The fall care plan included the following interventions: Adjust bed height to lowest position; Alarm on bed; Alarm on chair; Encourage resident to use handrails or assistive devices properly; Fall mat at bedside; Reinforce need to call for assistance; To wear non-skid shoes/slippers. These interventions were put in place on 12/28/16 and no revisions were provided. Resident 12 had 11 documented falls since her/his admission to the facility. Review of Fall Assessment-Post Fall forms since admission indicated the following: - On 12/30/16 at 6:15 pm the resident had an unwitnessed non-injury fall (NIF) from her/his wheelchair in the hallway, and the chair safety alarm was not sounding. The incident investigation report indicated the plan was to continue use of the alarm and to educate CNA to replace the alarm if it was not functioning. - On 1/14/17 at 1:10 pm the resident had a witnessed NIF in hall when she/he stood up from the wheelchair. The care plan was not revised to communicate any new approaches to staff. - On 1/17/17 at 8:30 am the resident had a witnessed NIF in the assisted dining room when she/he stood up from her/his wheelchair. The plan was to add to care plan that if Resident 12 was not in the dining room and appeared agitated to place clothing/towels on a bedside table and request her/him to fold them. - On 1/19/17 at 3:50 pm the resident had an unwitnessed NIF in her/his room and was found on the floor. No change was made to the care plan. - On 1/27/17 at 10:50 am the resident had a witnessed NIF in the hall when she/he stood up from her/his wheelchair. Again, no change to the care plan was made. - On 3/6/17 at 6:35 am the resident had an unwitnessed NIF and was found on the floor in her/his room. Per the investigation report, the resident was reminded to use the call light for assistance, despite the facility having identified the resident had severe cognitive impairment. No change to the care plan was made. - On 3/9/17 at 2:30 pm the resident had an unwitnessed NIF and was found on the floor of her/his room. No change to the care plan was made. - On 3/13/17 at 2:40 the resident was found on the floor of her/his room with a goose egg on the back of the head and a skin tear on top of it which was bleeding. After this seventh fall, the investigation report indicated new interventions were added to provide a Velcro seatbelt and the wheelchair footrests were removed to prevent a trip hazard. The use of a wheelchair seatbelt was added to the In-Room Care Plan only, but removal of the foot rests was not added to Resident 12's care plan. - On 3/18/17 at 1:00 pm the resident had an unwitnessed NIF and was found on the floor in the hall. No change to the care plan was made, and follow-up was to encourage Resident 12's daughter to seek placement for the resident in a memory care unit. - On 3/21/17 at 9:00 am the resident was found on the floor of the dining room, was bleeding from a head wound, and was sent to the emergency room for evaluation. The plan was to continue to focus on the daughter's need to find safer placement with no changes to the care plan were made. - On 3/23/17 at 4:45 pm the resident was found on the floor in the hall, bleeding from the right hand. She/he was noted to have two skin tears to the right hand measuring 3.8cm and 2.6cm and the resident was sent to the emergency room where she/he required sutures. The plan continued to focus on the daughter's need to find safer placement and to test for a urinary tract infection. No changes to the care plan were made. There was insufficient documentation to demonstrate the interventions were evaluated for effectiveness or that new interventions were tried after each fall, with the exception of the addition of a Velcro seatbelt after the seventh fall. On 4/3/17 at 3:04 pm Resident 12 was observed to have steri-strips on a head wound/abrasion, and her/his right hand was wrapped in a bandage. On 4/5/17 from 4:58 pm to 5:05 pm Resident 12 was observed attempting to open the doors/drawers of the locked medication cart, taking a bag of plastic tubing off the top of the cart, and attempting to stand up twice while waiting for dinner to arrive. On 4/6/17 at 1:54 pm she/he was observed to use a transfer pole to stand up from bed on her/his own. In a phone interview on 4/3/17 at 12:49 pm Witness 1 (complainant) reported the resident has had many falls. Witness 1 reported the resident was very active and thought Resident 12 would need a 1 to 1 staff assignment to ensure safety. Witness 1 was concerned the resident was not getting what she/he needed to maintain safety at the facility and that other interventions were needed. In a phone interview on 4/4/17 Witness 2 (family member) reported the resident had very poor safety awareness, but was determined and active, so falls were a major concern and indicated feeling unsure if it was safe for Resident 12 to be alone. Witness 2 stated she/he did not recall the facility contacting her/him to discuss changes to the care plan after the falls. In an interview on 4/6/17 at 2:10 pm Staff 2 (CNA) reported Resident 12 enjoyed wheeling around the facility and looking out the window, and that activities would be offered to the resident but she/he usually did not want to participate. When asked about care planned fall interventions for Resident 12, Staff 2 reported safety measures were in place, and that staff frequently checked on the resident. Staff 2 reported there was no specific place/protocol to document the frequent checks. On 4/717 at 3:41 pm Staff 6 (CNA) reported Resident 12 had the care planned safety measures in place, and otherwise staff just knew to keep eyes on her/him. She reported there was no specific place to document that frequent checks had occurred. On 4/10/17 interviews were conducted at 7:38 am and 8:24 am, Staff 3 (LPN) reported if a good movie was on Resident 12 may watch it, but otherwise she/he got bored quickly and would leave activities. She stated staff just know they have to watch the resident frequently. In an interview on 4/10/17 at 8:56 am Staff 1 (RNCM) reported they used to offer the resident folding, drawing or paper-cutting tasks often, but the tasks began to make Resident 12 mad, so they hadn't been offered in a couple of months. She also reported they tried getting Resident 12 involved in bingo once because the resident's daughter had reported the resident used to enjoy it, but Staff 1 could only recall attempting it the one time. Staff 1 did not report any additional interventions the facility had attempted or care plan changes made. On 4/10/17 at 11:08 am Staff 20 (Administrator) was informed of concerns, and acknowledged Resident 12 had multiple falls with no documented changes to the care plan or discussion of new interventions. In an interview on 4/10/17 at 1:28 pm Staff 9 (DNS) acknowledged the concern that Resident 12 had experienced multiple falls, sustained an injury, and there had been no changes or alterations to interventions being used.

Based on observation, interview and record review it was determined the facility failed to provide the appropriate care and services for 1 of 3 sampled residents (#1) who experienced a change of condition. Resident 1 required emergent treatment which included CPR. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. Orders also included a POLST (Physician order [REDACTED]. On [DATE] at approximately 11:00 am, the resident was reportedly sitting in her/his wheelchair and was taken to the assistive dining room. The dining room was directly across from the nurse's station. Staff 4, CNA, Staff 6, CMA and Staff 7, RN Charge Nurse reported during interviews on [DATE] the resident was at her/his baseline when taken to the dining room. Review of the facility IR (Incident Report) revealed at approximately 11:03 am Staff 3, Speech Therapist, reported concern that the resident was slumped in her/his wheelchair and was non-responsive. The resident did not have any oxygen administered at that time. The RN Charge Nurse (Staff 7) was on the phone on an unrelated matter. The Charge Nurse was advised that the resident was not moving. Reportedly she remained on the phone. The resident's oxygen saturation level was 73%. The RN Charge Nurse did not respond and reportedly remained on the phone until 11:13 am. Oxygen was administered and the saturation level improved to 91%. Staff were concerned as the Charge Nurse did not respond to the resident's condition and went to the RNCM's office to seek help for the resident. The RNCM took the resident to her/his room and found the resident without a pulse and started CPR. During CPR the Charge Nurse called 911. On [DATE] at 10:30 am, the Surveyor viewed a facility security video with Staff 1, Administrator and Staff 2, DNS. The video was entirely visual and did not have an audio component. The video included coverage of the nurse's station, the entry into the dining room and the hallway in front of the nurse's station. The video started at "0" seconds: At 31 seconds revealed Staff 3, Speech Therapist, coming out of the dining room. She looked around the hallway but did not interact with anyone. Staff 7, RN Charge Nurse was sitting at the nurse's station and was on the telephone. At 40 seconds Staff 3 (Speech Therapist) re-entered the dining room with an oximeter (device to measure oxygen saturation) in her hand. At 1 minute and 56 seconds Staff 8, CNA left the dining room and went to the nurse's station. She did not interact with anyone. At 2 minutes and 43 seconds Staff 3 returned to the dining room. At 3 minutes and 1 second revealed Staff 3 left the dining room and went directly to the nurse's station. She went directly to Staff 7 and Staff 7 looked up at Staff 3. Both were interacting with each other. At 3 minutes and 13 seconds Staff 4, CNA and Staff 3 are at the nurse's station speaking to Staff 7. Staff 4 leaves reportedly to bring oxygen to the resident. At 3 minutes and 47 seconds Staff 3 continues to speak to Staff 7. Staff 7 had not left her chair at the nurse's station. At 4 minutes and 20 seconds an oxygen concentrator is brought to the dining room. At 4 minutes and 31 seconds Staff 7 was still on phone and Staff 3 was seen going down the hallway. At 5 minutes and 32 seconds Staff 7 hangs up the telephone. At 5 minutes and 39 seconds The RNCM, Staff 5 and Staff 3 head hurriedly towards dining room. Staff 7 enters immediately after they have entered the dining room. At 6 minutes and 10 seconds Staff 7 came out to the nurse's station to obtain a stethoscope. At 7 minutes and 13 seconds staff take the resident to her/his room At 7 minutes and 43 seconds Staff 7 returned to the nurse's station and checked resident's POLST. Staff 7 then ran down hallway toward the resident's room. At 10 minutes Staff 7 called 911 Staff 7 did not enter the dining room to assess the resident for 2 minutes and 38 seconds from the time Staff 3 reported the resident had an oxygen saturation of 73% and that she/he was not responding. She did not call call 911 for seven minutes from that point. In interview on [DATE] at 10:00 am, Staff 2 stated the facility conducted an investigation related to the event on [DATE]. Staff 2 reported during the investigation Staff 7 stated she did not realize the severity of the situation. In interview on [DATE] at 10:45 am, Staff 3 stated she informed the RN (Staff 7) at approximately 11:03 on [DATE] the resident was not moving. "I tried to arouse the resident but couldn't get a response and I left the dining room to get an oximeter." Staff 3 reported the RN (Staff 7) did not respond again when she informed her the resident had an oxygen saturation of 73%. In interview on [DATE] at 12:30 pm, Staff 4, CNA, stated she was on a break and at approximately 11:05 am, a CMA (Staff 6) asked her to to check on the resident. Staff 4 reported she observed the resident slumped to the side of the wheelchair. "I told the Charge Nurse (Staff 7) three times and nothing happened." She reported the Speech Therapist took the resident's oxygen saturation level and it was low. "I couldn't get the Charge Nurse (Staff 7) to respond so the Speech Therapist and I went to get the RNCM (Staff 5) who came right away." In interview on [DATE] at 2:00 pm, Staff 6, CNA, stated she saw the resident slumped to one side in her/his wheelchair at approximately 11:00 am on [DATE]. "I asked the RN (Staff 7) to check on him and she said she would but did not respond to the resident." She further stated she then reported to the RN (Staff 7) that the resident was unresponsive and again, the RN did not respond. Staff 6 reported this was not the first time this had happened. She stated the RN had been asked in the past to check on residents when she had concerns and the RN would not respond. "She would say 'ok' and do nothing." In interview on [DATE] at 2:15 pm, Staff 8, CNA, stated she saw the resident at approximately 11:00 am on [DATE] and noted she/he was slumped in the wheelchair. "The Speech Therapist was telling the RN (Staff 7) the resident was unresponsive and she did nothing." In interview on [DATE] at 2:30 pm, Staff 7 stated at approximately 11:00 am on [DATE] a CMA (Staff 6) told her the resident was slumped to one side. "The speech therapist got an oxygen saturation that was in the low 70's. I went to the resident right away." She reported oxygen was started and the resident's oxygen saturation improved to ,[DATE] %. She stated she was in the dining room and someone got the RNCM (Staff 5) and he came into the dining room. "I called 911 while the resident was still in the dining room and right after the RNCM came in. Staff 7 stated the resident did not have oxygen administered prior to the incident because she/he did not need it it her/his oxygen saturations were greater than 92%. Record review revealed documentation was lacking to indicate any oxygen saturation levels had been done that day. Following the interview the Surveyor read the interview notes to Staff 7 to ensure accuracy of her statements. She stated they were accurate. Staff 7 was then informed the Surveyor viewed a security video that contradicted her statements. She continued to report her account of the events on [DATE] were correct. In interview on [DATE] at 3:00 pm, Staff 1 and Staff 2 stated they re-interviewed Staff 7 on [DATE]. They stated during the initial investigation of the events of [DATE] she reported she thought the situation was non-emergent. During the interview on [DATE] she reported she responded quickly as she knew the situation was serious. Staff 2 stated Staff 7 kept changing her story. Prior to the event of [DATE] the last nursing note was dated [DATE]. The resident's status prior to the event was not documented. Hospital records of [DATE] revealed the resident's cause of death was related to septic shock and acute [MEDICAL CONDITION] with chronic severe obstructive [MEDICAL CONDITION] disease. The medical records also revealed the resident had a subendocardial [MEDICAL CONDITION] infarction. Due to the resident's co-morbidities the POA and physicians made a decision to provide the resident with comfort measures. The resident passed away at 6:00 pm on [DATE].

Based on observation, interview and record review it was determined the facility failed to ensure professional standards were met regarding provision of care and services for 1 of 3 sampled residents (#1) who experienced a change of condition. Resident 1 required emergent treatment. Findings include: Division 45 Scope of Practice Standards for Registered Nurses. [DATE] (2) Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Registered Nurse shall: (d) implement the plan of care by: (A) Implementing treatments and therapy, appropriate of the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. Orders also included a POLST (Physician order [REDACTED]. On [DATE] at approximately 11:00 am, the resident was reportedly sitting in her/his wheelchair and was taken to the assistive dining room. The dining room was directly across from the nurse's station. Staff 4, CNA, Staff 6, CMA and Staff 7, RN Charge Nurse reported during interviews on [DATE] the resident was at her/his baseline when taken to the dining room. Review of the facility IR (Incident Report) revealed at approximately 11:03 am Staff 3, Speech Therapist, reported concern that the resident was slumped in her/his wheelchair and was non-responsive. The resident did not have any oxygen administered at that time. Staff 7, RN Charge Nurse was on the phone on an unrelated matter. Staff 7 was advised by Staff 3 that the resident was not moving. Reportedly she remained on the phone. The resident's oxygen saturation level was 73%. The Charge Nurse did not respond and reportedly remained on the phone until 11:13 am. Oxygen was administered and the saturation level improved to 91%. Staff were concerned as the Charge Nurse did not respond to the resident's condition and went to the RNCM's office to seek help for the resident. The RNCM took the resident to her/his room and found the resident without a pulse and started CPR. During CPR the Charge Nurse called 911. On [DATE] at 10:30 am, the Surveyor viewed a facility security video with Staff 1, Administrator and Staff 2, DNS. The video was entirely visual and did not have an audio component. The video included coverage of the nurse's station, the entry into the dining room and the hallway in front of the nurse's station. The video started at "0" seconds: At 31 seconds revealed Staff 3, Speech Therapist, coming out of the dining room. She looked around the hallway but did not interact with anyone. Staff 7, RN Charge Nurse was sitting at the nurse's station and was on the telephone. At 40 seconds Staff 3, Speech Therapist re-entered the dining room with an oximeter (device to measure oxygen saturation) in her hand. At 1 minute and 56 seconds Staff 8, CNA left the dining room and went to the nurse's station. She did not interact with anyone. At 2 minutes and 43 seconds Staff 3 returned to the dining room. At 3 minutes and 1 second revealed Staff 3 left the dining room and went directly to the nurse's station. She went directly to Staff 7 and Staff 7 looked up at Staff 3. Both were interacting with each other. At 3 minutes and 13 seconds Staff 4, CNA and Staff 3 are at the nurse's station speaking to Staff 7. Staff 4 leaves reportedly to bring oxygen to the resident. At 3 minutes and 47 seconds Staff 3 continues to speak to Staff 7. Staff 7 had not left her chair at the nurse's station. At 4 minutes and 20 seconds an oxygen concentrator is brought to the dining room. At 4 minutes and 31 seconds Staff 7 was still on phone and Staff 3 was seen going down the hallway. At 5 minutes and 32 seconds Staff 7 hangs up the telephone. At 5 minutes and 39 seconds Staff 5, RNCM and Staff 3 head hurriedly towards dining room. Staff 7 enters immediately after they have entered the dining room. At 6 minutes and 10 seconds Staff 7 came out to the nurse's station to obtain a stethoscope. At 7 minutes and 13 seconds staff take the resident to her/his room. At 7 minutes and 43 seconds Staff 7 returned to the nurse's station and checked resident's POLST. Staff 7 then ran down hallway towards the resident's room. At 10 minutes Staff 7 called 911 Staff 7 did not enter the dining room to assess the resident for 2 minutes and 38 seconds from the time Staff 3 reported the resident had an oxygen saturation of 73% and that she/he was not responding. She did not call 911 for seven minutes from that point. The resident was transported to the hospital and admitted to the intensive care unit. The resident passed away at 6:00 pm. In interview on [DATE] at 10:00 am, Staff 2 stated the facility conducted an investigation related to the event on [DATE]. Staff 2 reported during the investigation Staff 7 stated she did not realize the severity of the situation. In interview on [DATE] at 10:45 am, Staff 3 stated she informed Staff 7 at approximately 11:03 on [DATE] the resident was not moving. "I tried to arouse the resident but couldn't get a response and I left the dining room to get an oximeter." Staff 3 reported Staff 7 did not respond again when she informed her the resident had an oxygen saturation of 73%. In interview on [DATE] at 12:30 pm, Staff 4, CNA, stated she was on a break and at approximately 11:05 am, a CMA (Staff 6) asked her to check on the resident. She reported she observed the resident slumped to the side of the wheelchair. "I told the Charge Nurse (Staff 7) three times and nothing happened." She reported the Speech Therapist took the resident's oxygen saturation and it was low. "I couldn't get the Charge Nurse to respond so the Speech Therapist and I went to get the RNCM (Staff 5) who came right away." In interview on [DATE] at 2:00 pm, Staff 6, CNA, stated she saw the resident slumped to one side in her/his wheelchair at approximately 11:00 am on [DATE]. "I asked the RN (Staff 7) to check on him and she said she would but did not respond to the resident." She further stated she then reported to the RN (Staff 7) that the resident was unresponsive and again, the RN did not respond. Staff 6 reported this was not the first time this had happened. She stated the RN had been asked in the past to check on residents when she had concerns and the RN would not respond. "She would say 'ok' and do nothing." In interview on [DATE] at 2:15 pm, Staff 8, CNA, stated she saw the resident at approximately 11:00 am on [DATE] and noted she/he was slumped in the wheelchair. "The Speech Therapist was telling the RN (Staff 7) the resident was unresponsive and she did nothing." In interview on [DATE] at 2:30 pm, Staff 7 stated at approximately 11:00 am on [DATE] a CMA (Staff 6) told her the resident was slumped to one side. "The speech therapist got an oxygen saturation that was in the low 70's. I went to the resident right away." She reported oxygen was started and the resident's oxygen saturation improved to ,[DATE]%. She stated she was in the dining room and someone got the RNCM (Staff 5) and he came into the dining room. "I called 911 while the resident was still in the dining room and right after the RNCM came in." Staff 7 stated the resident did not have oxygen administered prior to the incident because she/he did not need it as her/his oxygen saturations were greater than 92%. Record review revealed documentation was lacking to indicate any oxygen saturation levels had been done that day. Following the interview the Surveyor read Staff 7's interview notes to her to ensure accuracy of her statements. She stated they were accurate. Staff 7 was then informed the Surveyor viewed a security video that contradicted her statements. She continued to report her account of the events on [DATE] were correct. In interview on [DATE] at 3:00 pm, Staff 1 and Staff 2 stated they re-interviewed Staff 7 on [DATE]. They stated during the initial investigation of the events of [DATE] she reported she thought the situation was non-emergent to explain her delay in responding. During the interview on [DATE] she reported she responded quickly as she knew the situation was serious. Staff 2 stated Staff 7 kept changing her story. Refer to F 309