Every finding on record at Gracelen Care Center

Based on observation, interview and record review, it was determined the facility failed to accurately document an elopement assessment for 1 of 1 sampled resident (#1) reviewed for elopement. This placed residents at risk for inaccurate medical records. Findings include:Resident 1 admitted to the facility on [DATE] with diagnosis including monoplegia of upper limb following nontraumatic intracerebral hemorrhage (stroke) affecting left dominant side.On 5/13/26 at 12:16 PM, Resident 1 was observed to ambulate independently without an assistive device.Resident 1's care plan initiated on 4/30/26 documented Resident 1:-Had an alteration in neurological status related to monoplegia of the upper limb following a nontraumatic intracranial hemorrhage affecting left dominant side;-Was independent for ambulation and transfers and did not use an assistive device; and-Was alert and oriented times three. Resident 1's 4/29/26 hospital Occupational Therapy Note indicated with independent activities of daily living tasks in unfamiliar/novel environments, [Resident 1] struggles much more. For example, during a basic tea-making task, [Resident 1] needed mod-max direct verbal cues for safety, sequencing and decision-making.Resident 1's 4/30/26 Elopement Assessment completed by Staff 6 (RN) documented Resident 1: -Was not cognitively impaired with poor decision-making skills;-Did not ambulate independently with or without the use of assistive device; and-Did not have a diagnosis of dementia, cognitive impairment or a diagnosis impacting gait and mobility.Resident 1's 5/7/26 admission MDS documented Resident 1 was independent for mobility without an assistive device.The facility's elopement assessment incorrectly documented Resident 1 as non-ambulatory, no deficits in gait, mobility or decision-making, which was inconsistent with Resident 1's care plan, Occupation Therapy Notes and comprehensive MDS assessment.On 5/13/26 at 12:38 PM, Staff 6 stated she inaccurately documented Resident 1's 4/30/26 elopement assessment.On 5/13/26 at 2:18 PM, Staff 2 (DNS) stated Resident 1's 4/30/26 elopement assessment was inaccurate.

Based on interview and record review it was determined the facility failed to report an incident of suspected physical abuse in a timely manner for 2 of 4 sampled residents (#s 6 and 7) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 6 was admitted to the facility in 11/2024 with diagnoses including major depressive disorder.Resident 7 was admitted to the facility in 1/2026 with diagnoses including senile degeneration of the brain with anxiety and agitation.On 2/14/26 at 6:27 PM, a FRI was submitted which indicated on 2/14/26 at 10:00 AM, Resident 7 struck Resident 6 with her/his reader stick after Resident 6 wandered into Resident 7's room looking for her/his items. A Progress Note on 2/14/26 at 12:28 PM, indicated Staff 7 (Social Services Director) noticed Resident 7 received assistance with a bandage to her/his knee. When asked, Resident 7 stated she/he was hit by another resident after she/he entered Resident 7's room and approached her/him.On 3/10/26 at 12:26 PM, Staff 2 (DNS) stated she was aware of the incident of potential abuse between Resident 6 and Resident 7 and acknowledged allegations needed to be reported within 2 hours of the incident occurring. Staff 2 acknowledged the incident of potential abuse was not reported within the 2-hour time frame. On 3/10/26 at 2:40 PM, Staff 7 stated she wrote the incident report involving Resident 6 and Resident 7 and informed both Staff 1 (Facility Administrator) and Staff 2 of the incident on 2/14/26 after completing the incident report at approximately 12:00 PM.

Based on interview and record review it was determined the facility failed to ensure a resident's change of condition was assessed in a timely manner for 1 of 1 sampled resident (#7) reviewed for accidents. This placed residents at risk for a delay of care and unmet treatment needs. Findngs include:Resident 7 was admitted to the facility in 11/2024 with diagnoses including end stage kidney disease and diabetes.Provider Notes dated 11/15/24 and 11/29/24 indicated Resident 7 was alert but tired on exam. Resident 7 was able to answer questions appropriately. Resident 7's 11/29/24 admission MDS indicated the resident had moderate cognitive impairment.A CMA Medication Administration Note dated 12/8/24 at 8:42 AM Staff 26 (CMA) indicated the following:-Resident 7 was unable to stay awake long enough to drink fluids despite cueing and redirection.-Staff 43 (RN) completed an assessment and directed Staff 26 to wait 20 minutes before reattempting medication administration.-Upon the second attempt, Resident 7 continued to fall asleep.-Medications could not be administered, and Staff 43 was notified for reassessment. Review of Resident 7's medical record on 12/8/24 between 8:42 AM and 1:51 PM revealed no documentation Staff 43 performed a reassessment, checked blood sugars, or contacted the on-call provider. A blood pressure reading was recorded at 1:51 PM and no other vital signs were recorded.In a 12/8/24 at 2:27 PM Nursing Note the charge nurse documented Resident 7 was sent out to the hospital at 2:20 PM per the family's request.A 1/4/25 Hospitalist Progress Note, revealed Resident 7 had been admitted to the hospital on [DATE] with sepsis (a body's extreme reaction to infection) due to a urinary tract infection.On 10/14/25 at 9:14 AM Witness 3 (Family Member) stated they visited Resident 7 on 12/8/24, were alarmed by the resident's appearance and requested the resident be sent to the hospital. On 10/16/25 at 10:02 AM Staff 26 stated they observed Resident 7 to be lethargic and difficult to rouse on 12/8/24 at approximately 8:00 AM. Staff 26 reported their concerns to Staff 43 because Resident 7 was not at baseline for mental alertness, and they requested a reassessment after the resident was unable to take her/his medications. Staff 26 stated Staff 43 only looked at the resident but did not perform a physical assessment, speak to the resident, take vital signs, a blood sugar check, or contact the on-call provider. Staff 26 stated Resident 7's changed mental status persisted through the morning and despite their multiple reports of concern, Staff 43 did not take further action.On 10/17/25 at 10:39 AM Staff 24 (CNA) stated they were assigned to Resident 7 during the day shift on 12/8/24. Staff 24 stated the resident was usually pretty alert, but throughout the day she/he was difficult to rouse and minimally responsive. Staff 24 stated they expressed their concerns to Staff 43 several times throughout the morning. Staff 43 was unavailable for interview.On 10/17/25 at 1:05 PM Staff 7 (LPN) stated if staff reported signs of altered mental status, such as inability to stay awake or follow direction, the resident should be assessed right away as it may indicate a change of condition. Staff 7 stated they would perform a head-to-toe assessment, take a full set of vital signs and check blood sugar levels if the resident was diabetic. Staff 7 stated depending on the findings they would contact the on-call provider for further direction.On 10/17/25 at 1:20 PM Staff 41 (NP) stated they rounded on Resident 7, who was normally alert, and they would expect an immediate call if there were a change in the resident's mentation such as not able to be aroused or the inability to follow direction and take medications. Staff 41 stated they expected an assessment by the licensed nurse and blood sugar levels checked.On 10/20/25 at 9:27 AM Staff 42 (NP) stated they were on-call on 12/8/24 and did not receive a notification of Resident 7's change of change in mental status.On 10/20/25 Staff 4 (LPN Resident Care Manager) stated they expected the nurse to assess the resident, obtain a set of vital signs, and based on findings contact the on-call provider when a change of condition was reported to them. Staff 4 reviewed Resident 7's medical record and acknowledged there was no documentation by Staff 43 of an assessment, vital signs, blood sugar checks or communication with the on-call provider on 12/8/24. On 10/20/25 Staff 2 (DNS) stated if staff expressed concerns to the charge nurse about a resident's change of condition, such as signs of altered mental status, they expected the nurse to perform a full assessment, take vital signs, if appropriate check blood sugar levels, and contact the on-call provider. Staff 2 acknowledged there was no documentation to indicate an assessment was performed, vital signs taken, blood sugar levels were checked, or the on-call provider was notified for Resident 7 on 12/8/24 by Staff 43 after they were notified of the resident's change of condition.

Based on interview and record review it was determined the facility failed to assess, monitor, and treat pressure ulcers for 1 of 1 sampled resident (#7) reviewed for wound care. This placed residents at risk for unassessed wounds, unmet treatment needs and worsening pressure ulcers. Findings include:The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment:- Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing;- Document the results of all wound assessments;- Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor; - Select a uniform, consistent method for measuring wound length, width, depth or wound area to facilitate meaningful comparisons of wound measurements across time; - Ensure pressure ulcers are correctly differentiated from other skin injuries, particularly incontinence associated dermatitis or skin tears.Resident 7 was admitted to the facility in 11/2024 with diagnoses including end stage kidney disease and diabetes.Resident 7's 11/13/24 Nursing admission Database completed by Staff 23 (LPN) indicated the resident had an unstageable sacral (a bone at the base of the spine) wound; no further description, measurements or staging of the wound was provided.Resident 7's 11/29/24 admission MDS indicated the resident had moderate cognitive impairment and was at risk for pressure injury development related to decreased mobility, end stage kidney disease, incontinence and diabetes.Review of Resident 7's medical record revealed there was no comprehensive assessment conducted of the resident's wound to capture characteristics such as location, stage, measurements, tissue type(s), color, wound edges, undermining or tunneling, draining or odor, or documentation of notification to the facility provider the resident had a sacral wound. No evidence was found that wound care or treatment was provided to the resident between 11/13/24 through 11/19/24 (six days).Resident 7 was hospitalized [DATE] through 11/23/24 with hypoglycemia (low blood sugar). Resident 7's 11/23/24 Hospital After Visit Summary directed the resident to receive the following daily wound care orders:1. Sacrum:-Cleanse the sacrum with normal saline;-Apply Venelex ointment (a medicated treatment for wounds) over the entire wound bed;-Cover with a sacral foam dressing;-Change daily. 2. Left and right heels:-Paint with betadine swab (a medicated applicator) daily for antimicrobial (to reduce germs) and to keep dry.Review of Resident 7's 11/2024 TAR revealed Resident 7 did not receive sacral wound care treatment from 11/23/24 through 11/27/24 (five days) and did not receive left heel wound care from 11/23/24 through 12/5/24 (13 days). There was no evidence found that treatment for the right heel wound was ever initiated. On 10/14/25 at 9:14 AM Witness 3 (Family Member) stated Resident 7 admitted to the facility with a sacral wound, which worsened during her/his stay. On 10/15/25 at 1:12 PM Staff 41 (Former NP) stated facility staff were expected to notify them of all wounds so treatment orders could be initiated as soon as possible. Witness 41 did not recall being notified of Resident 7's sacral wound.On 10/16/25 at 2:46 PM Staff 23 (LPN) stated they completed Resident 7's initial skin assessment upon admission which noted a sacral wound. Staff 23 stated they were responsible for entering wound care orders into the resident's record, and they believed Staff 4 then took photos and a wound care provider was to round on the resident. Staff 23 stated resident's wound did not improve while at the facility. On 10/20/25 at 9:39 AM Staff 29 (LPN) stated when a resident was admitted to the facility with wounds but without treatment orders, they would promptly notify the Resident Care Manager, who was responsible for assessment and the initiation of care. Staff 29 stated when a resident was admitted with wound treatment orders the admitting nurse and their counterpart were responsible for verifying and entering the orders into the resident's record. On 10/20/25 at 10:30 AM Staff 4 (LPN Resident Care Manager) stated they expected the admitting nurse to thoroughly assess and photograph all wounds within the first eight hours of admission and make a referral to the wound clinic. Staff 4 stated they expected wound care orders to be implemented the same day as receipt. Staff 4 acknowledged no assessment of Resident 7's wound was performed upon admission on [DATE] and there was no documentation in the TAR or progress notes of wound care treatment provided between 11/13/24 and 11/19/24. Staff 4 acknowledged Resident 7 was readmitted to the facility on [DATE] with treatment orders for wounds to the sacrum and both heels. Staff 4 acknowledged treatment for the sacral wound was not initiated until 11/28/24, treatment for the left heel was not initiated until 12/6/24 and there was no record of treatment provided for the right heel.

Based on observation, interview and record review it was determined the facility failed to ensure equipment was properly secure to prevent falls for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in Resident 1 experiencing an avoidable fall, resulting with a fractured hip which required surgery. The facility identified the failed practice; an avoidable accident related to improper use of a shower gurney (a specialized piece of equipment designed to bathe individuals who are unable to sit upright during a shower). The facility removed the device from use until staff were trained, and competency was demonstrated. Corrective actions were completed on 1/17/25. This failed practice was identified as past noncompliance. Findings include:Resident 1 admitted to the facility in 2023 with diagnosis including movement disorder and chronic incomplete quadriparesis (form of paralysis affecting all four limbs with some motor function and sensation preserved). Resident 1's 8/23/24 Annual MDS revealed the resident was cognitively intact and was dependent on staff for bathing. A FRI was submitted to the State Agency on 11/11/25 at 9:43 AM to report Resident 1 experienced a fall in the shower at 7:50 AM. A 1/11/25 at 10:09 AM Progress Note by Staff 2 (LPN) revealed Resident 1 fell in the shower, 911 was called and the resident was sent to the hospital. At 5:38 PM the hospital called the facility and Resident 1 was admitted to the hospital with a left hip fracture. A care plan dated 1/11/25 indicated Resident 1 was dependent on one staff member for assistance during showers. A 1/17/25 facility investigation revealed on 1/11/25 Staff 3 (CNA) provided Resident 1 with a routine shower in the facility's shower room. The investigation determined the staff failed to ensure the shower gurney was properly locked for safety which caused Resident 1‘s head to lower and fall to the floor. Resident 1 re-admitted to the facility on [DATE] with a diagnosis including a post-surgical repair of the left hip.On 8/28/25 at 9:35 AM Resident 1 recalled her/his 1/11/25 fall in the shower in detail and believed the fall was a freak accident. Resident 1 stated Staff 3 followed her/his care plan and tried to make her/his head more comfortable when the shower gurney head went down. Resident 1 stated she/he did not experience pain at the time of the incident. On 8/28/25 at 10:34 AM Staff 3 stated she provided Resident 1 a shower on 1/11/25 which resulted in a fall. Staff 3 recalled she tried to put a towel under Resident 1's head, the head of the shower gurney (a specialized piece of medical equipment designed to bathe individuals who are unable to stand or sit upright during a shower) fell backwards and the resident fell to the floor. Staff 3 reported the shower gurney was a new piece of equipment and believed it appeared and felt safe when she transported Resident 1 to the shower room. After the fall Staff 3 stated she learned the gurney had a safety clip that should have been in secured however, she was not trained on how to use the equipment prior to its use. On 8/28/25 at 11:00 AM Staff 2 stated she was called to the shower room after Resident 1 had fallen to the floor. She recalled when she arrived at the shower room, the head and lower part of the leg section of the shower gurney had fallen down and Resident 1 was on the floor. Staff 2 called 911, the resident was sent to the hospital and had surgery for a hip fracture. On 8/28/25 at 11:09 AM Staff 4 (Maintenance Director) stated the shower gurney used in Resident 1's 1/11/25 fall was a new piece of equipment and was different from the other shower chairs used in the facility. He stated he inspected the shower gurney after the incident and observed the medal pin was not locked in the pin bar which was necessary for safety. Staff 4 immediately removed the shower gurney from the facility, education was provided, and he was unaware of any other falls from equipment in disrepair or misused. Observations were made of the facility's shower chairs and gurneys on 8/28/25 at 11:14 AM with Staff 4. Staff 4 demonstrated the shower equipment movements and how to place them in locked position. No shower equipment was found in disrepair. On 8/28/25 at 11:40 AM Staff 2 (DNS) confirmed Resident 1's 1/11/25 fall in the shower resulted in hospitalization and hip surgery. Staff 2 confirmed she completed the 1/17/25 investigation which concluded the fall was due to staff not properly securing the shower gurney. She expected all staff to use the shower equipment properly and all parts should be locked while providing a shower. On 1/17/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined staff was not trained for the proper use of the new shower gurney. The Plan of Correction included: 1. Staff educated on shower equipment use. 2. The new shower gurney was removed from the facility until staff were trained and competency was demonstrated. 3. The Maintenance Director inspected all the shower equipment to ensure safety. 4. If new shower equipment was purchased, which was different than current shower equipment used, the Maintenance Director would conduct training prior to the use of the new equipment. 5. The Maintenance Director conducts monthly inspection of all shower equipment. The facility's implementation of corrective actions was verified through the survey process. Observations conducted throughout the facility on 8/28/25 revealed no concerns with use of shower equipment.

Based on interview and record review it was determined the facility failed to ensure RN coverage for 8 consecutive hours 7 days per week for 8 of 62 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: A review of the Direct Care Staff Daily Reports for 7/1/24 through 7/31/24 and 6/19/25 through 7/24/25 revealed there were eight days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period:-7/7/24-7/13/24-7/14/24-7/21/24-7/22/24-7/28/24-7/29/24-7/13/25On 7/25/25 at 9:12 AM Staff 16 (Staffing Coordinator) acknowledged the facility did not have adequate RN coverage on the above dates and understood the need to staff the facility with an RN in order to provide residents with care and assessments they needed. On 7/25/25 9:44 AM Staff 1 (Administrator) stated she expected the facility to be staffed appropriately with RN coverage to ensure residents received appropriate care and services.

Based on interview and record review it was determined the facility failed to report an incident of potential abuse to the State Agency within the required timeframe for 1 of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's 6/12/18 Abuse Prevention Policy and Procedure revealed it was the policy of the facility that all suspected or alleged cases of abuse shall be reported according to State and Federal regulations. On 7/21/25 at 6:55 PM Witness 3 (Family Member) stated Resident 1 moved rooms because her/his former roommate, Resident 8, shoved her/him into a wall. Witness 3 reported the physical altercations to facility staff immediately. On 7/25/25 at 10:18 AM Staff 21 (RN) stated she did not contact the State Agency to report the allegation of abuse. Staff 21 stated the incident occurred prior to the start of her shift at 6:00 PM and the information was reported to her during shift change. Staff 21 stated she called Staff 1 (Administrator) and Staff 2 (DNS) to report the allegation more than two hours after she was aware of the allegation. On 7/25/25 at 11:32 AM Staff 1 confirmed no report of an allegation of abuse was made to the State Agency which involved Resident 1 and Resident 8. Staff 1 expected all allegations of abuse to be reported to the State Agency within the required two-hour time frame.

Based on interview and record review it was determined the facility failed to complete a thorough investigation of an allegation of abuse for 1 of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for abuse and inaccurate investigations. Findings include:The facility's 6/12/18 Abuse Prevention Policy and Procedure revealed all suspected or alleged cases of abuse shall be thoroughly and completely investigated. The procedure directed staff as soon as a report of alleged or suspected abuse was received, the investigation would begin and be completed within five days. Resident 1's 7/18/25 progress note revealed she/he had been moved to a new room following an altercation with her/his former roommate. On 7/21/25 at 6:55 PM Witness 3 (Family Member) stated Resident 1 moved rooms because her/his former roommate, Resident 8, shoved her/him into a wall. Witness 3 reported the altercation to staff immediately. On 7/25/25 at 10:18 AM Staff 21 (RN) stated staff told her of an incident which occurred prior to the start of her shift at 6:00 PM, between Resident 1 and Resident 8. Staff 21 spoke to Witness 3 who indicated Resident 8 shoved Resident 1 into a wall. On 7/25/25 at 11:32 AM Staff 1 (Administrator) confirmed a thorough investigation had not been completed for the 7/18/25 allegation of possible abuse between Resident 1 and Resident 8 timely. Staff 1 expected all allegations of abuse to be thoroughly investigated.

Based on observation, interview and record review it was determined the facility failed to implement the care plan for 2 of 5 sampled residents (#s 3 and 59) reviewed for accidents. This placed residents at risk for avoidable injury. Findings include:1. Resident 59 was admitted to the facility in 10/2024 with diagnoses including stroke and anxiety. A Fall Risk assessment dated [DATE] determined Resident 59 was at high risk for falling. The 5/21/25 Care Plan identified Resident 59 a high fall risk for falls. Interventions included a fall mat to be placed at bedside when the resident was in bed. On 7/24/25 at 8:32 AM Resident 59 was observed asleep in bed without a fall mat in place. On 7/24/25 at 8:34 AM Staff 7 (CNA) stated Resident 59 was at risk for falls but did not have any fall interventions in place. On 7/24/25 at 8:59 AM Staff 3 (Resident Care Manager-LPN) stated Resident 59's Care Plan included having a fall mat in place when the resident was in bed. Staff 3 confirmed Resident 59's care plan were not being implemented, and all CNAs were expected to implement and follow the care plan. 2. Resident 3 was admitted to the facility in 7/2023 with diagnoses including dementia and stroke. Resident 3’s 7/2/25 care plan revealed she/he was a fall risk with interventions including placement of a fall mat when she/he was in bed. On 7/23/25 at 3:22 PM and 7/25/25 at 9:51 AM, Resident 3 was observed in bed sleeping with no fall mat on the floor. On 7/25/25 at 10:12 AM, Staff 11 (CNA) was not sure of the fall interventions for Resident 3. On 7/25/25 at 10:17 AM, Staff 13 (CNA) acknowledged Resident 3 was a fall risk but did not know about her/his fall interventions. On 7/25/25 at 10:38 AM, Staff 3 (Resident Care Manager-LPN) stated Resident 3 was a fall risk, had a history of falling, and expected CNA staff to place a fall mat by Resident 3’s bed when she/he was in bed. Staff 3 observed Resident 3 in bed and acknowledged the absence of a fall mat on the floor and was unable to locate a fall mat in Resident 3's room.

Based on observation, interview and record review it was determined the facility failed to provide care planned interventions to prevent falls for 1 of 4 sampled residents (#48) reviewed for falls. This placed residents at risk for injury from falls. Findings include:Resident 48 admitted on 1/2025 with diagnoses including fibromyalgia (health condition which causes pain and tenderness throughout the body).The Quarterly MDS dated [DATE] indicated Resident 48 was cognitively impaired and she/he had a history of falls.The Quarterly MDS dated [DATE] indicated Resident 48 used a FWW (front wheel walker) and wheelchair to assist with ambulation.A review of Resident 48's medical record revealed the resident fell on 1/27/25, 5/11/25, 5/20/25 and 6/4/25.The 5/19/25 care plan indicated Resident 48 was to have a call don't fall sign within eyesight of the resident and was to have a FWW.On 7/21/25 at 9:55 AM and 1:03 PM, Resident 48 was observed leaning behind her/his wheelchair and used it to ambulate to the restroom. Resident 48 stated she/he was not offered a FWW to use. Random observations of Resident 48's room from 7/21/25 through 7/24/25 revealed no visual sign in her/his room and no FWW.On 7/24/25 at 1:59 PM, Staff 17 (CNA) stated there used to be a sign in Resident 48's room, but it was not currently posted. The sign was to remind Resident 48 to use her/his call light before getting out of bed. Staff 17 stated Resident 48 pushed her/his wheelchair and used it to ambulate. Staff 17 stated she/he was not given a FWW. On 7/25/25 at 10:14 AM, Staff 18 (CNA) stated there was no sign in Resident 48's room to remind the resident to utilize her/his call light prior to getting out of bed.On 7/25/25 at 10:38 AM, Staff 5 (LPN) stated Resident 48 walked behind the wheelchair to ambulate. Staff 5 stated she/he was not offered a FWW.On 7/25/25 at 10:44 AM, Staff 3 (Resident Care Manager- LPN) acknowledged the care plan indicated there was supposed to be a sign to remind Resident 48 to utilize the call light prior to getting out of bed. Staff 3 stated Resident 48 used a FWW to ambulate and was unaware Resident 48 used her/his wheelchair to ambulate.

Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were three errors in 25 opportunities resulting in a 12% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: The 2019 Insulin Lispro Solostar Pen Manufacturer Instructions for Use and the 2022 How to Use Lantus Pen Manufacturer Instructions specified the following:- to inject your dose, clean site with an alcohol swab, keep the pen straight, insert the needle into your skin, use the thumb to press the injection button all the way down. When the number in the dose window returns to zero as you inject, slowly count to 10 before removing (counting to 10 will makes sure residents received the full insulin dose), release the button and remove the needle from your skin.The facility's 3/2025 Insulin Administration Policy specified the following:-Depress the plunger and remove the needle after approximately five seconds.The 2024 What Happens If I Take CREON Without Food Manufacturer Instructions specified the following:-Creon needs to be taken with every meal and snack to work as expected. The digestive enzymes in CREON need to mix with food and enter the stomach and the small intestine at the same time.The facility's 4/2019 Administering Medications Policy specified the following:- Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).1.Resident 3 was admitted to the facility in 2/2024 with diagnoses including type 2 diabetes mellitus (impaired insulin production).Resident 3's 7/2025 MAR included the following:- Insulin lispro injection solution, inject five units subcutaneously with meals.- Insulin glargine solution pen-injector, inject 46 units subcutaneously in the morning.On 7/23/25 at 7:36 AM, Staff 8 (LPN) was observed during Resident 3 and 52's medication administration. Staff 8 prepared five units of lispro insulin and injected Resident 3‘s arm and immediately removed the needle from the skin. Staff 8 did not perform the safety steps as indicated in the manufacturer's instructions.On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 3 insulin administration and the improper use of the insulin pens, which were not held for 10 seconds before needle removal from the resident's skin, and the safety steps were not followed prior to administration. Staff 2 stated she expected staff to follow the safety steps for administering insulin. 2. Resident 52 was admitted to the facility in 12/2022 with diagnoses including type 2 diabetes mellitus (impaired insulin production).Resident 52's 7/2025 MAR included the following:- Insulin glargine solution pen-injector, inject 19 units subcutaneously two times a day.On 7/23/25 at 7:36 AM, Staff 8 (LPN) was observed during Resident 52's medication administration. Staff 8 prepared 19 units of glargine insulin and injected Resident 52's arm and immediately removed the needle from the skin. Staff 8 did not perform the safety steps as indicated in the manufacturer's instructions.On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 52's insulin administration and the improper use of the insulin pens, which were not held for 10 seconds before needle removal from the resident's skin, and the safety steps were not followed prior to administration. Staff 2 stated she expected staff to follow the safety steps for administering insulin. 3. Resident 60 admitted to the facility in 11/2024 with diagnoses including type 2 diabetes mellitus (impaired insulin production).Resident 60's 7/2025 Physician Orders included the following:- Creon delayed release capsule, give one capsule by mouth with meals for digestion.On 7/24/25 at 11:48 AM, Staff 19 (CMA) was observed during Resident 60's medication administration. Staff 19 administered the scheduled medication without offering a snack or meal, and no food was observed in the resident's room. Staff 19 stated it was difficult to coordinate scheduled medications with meals or when meal trays arrived. She mentioned having one hour before and after the scheduled medication times to administer medications.On 7/25/25 at 11:25 AM, Staff 2 (DNS) was informed about Resident 60's Creon not administered with a snack or meal. Staff 2 stated she expected staff to implement and follow physician orders.

Based on observation, interview and record review it was determined the facility failed to ensure medication storage was free from expired biologicals for 1 of 1 medication rooms and treatment carts were locked and secured appropriately for 2 of 2 treatment carts observed (West Hall and East Hall) during random observations for medication and treatment cart storage and medication rooms. This placed residents at risk for unsafe access to stored medications and diminished treatment efficacy. Findings include:The facility's 11/2020 Storage of Medications Policy specified the following: - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1.On [DATE] at 11:15 AM, one open, vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) dated [DATE] was observed inside the refrigerator located in the medication storage room. On [DATE] at 11:35 PM, Staff 2 (DNS) acknowledged the vial of tuberculin was expired and expected staff to discard tuberculin vial within 30 days of opening. 2. On [DATE] at 8:19 AM, the East Hall treatment cart was unlocked. Staff and residents were observed to be walking by the treatment cart. On [DATE] at 8:32 AM, Staff 4 (LPN) acknowledged the unlocked treatment cart. The contents inside of the cart included insulin, insulin pens, needles, and resident prescribed oral medications. Staff 4 stated he was supposed to lock the treatment cart before walking away from the treatment cart.3. On [DATE] at 8:30 AM, the [NAME] Hall treatment cart was unlocked. The treatment cart contained insulin supplies, dressings, creams, and resident tube feeding medications. On [DATE] at 8:38 AM, Staff 6 (RN) stated the [NAME] Hall treatment cart was supposed to locked when unattended. On [DATE] at 10:15 AM, Staff 2 (DNS) stated she expected medication and treatment carts to be locked when staff were not in view of them.4. On [DATE] at 12:27 PM, the East Hall treatment cart was unlocked. The contents in the cart included insulin, insulin pens, needles, lubricants, and resident prescribed oral medications. Residents and staff were observed walking past the unlocked treatment cart. On [DATE] at 12:43 PM, Staff 5 (LPN) and Staff 2 (DNS) acknowledged the East Hall treatment cart was unlocked. Both stated treatment carts should not be unlocked when left unattended.

Based on observation, interview and record review it was determined the facility failed to perform hand hygiene for 1 of 1 sampled resident (#11) reviewed for wound care. This placed residents at an increased risk of infected wounds. Findings include:Resident 11 was admitted to the facility in 2025 with diagnoses including quadriplegia (partial or complete paralysis of all four limbs).The 2024 CDC Clinical Safety: Hand Hygiene for Health care workers specified the following:-Clean your hands immediately after glove removal to prevent the spread of germs and potential infections.A review of Resident 11's Quarterly MDS dated [DATE] indicated the resident was admitted with four pressure ulcers.A review of Resident 11's Annual MDS dated [DATE] indicated the resident acquired an in-facility pressure ulcer.A review of Resident 11's 7/2025 MAR indicated daily wound care to the sacrum (a bone at the base of the spine) and the right ischium (a bone forming the lower and back part of the hip bone) pressure ulcers.On 7/23/25 at 11:01 AM, During wound care to the ischium wound, Staff 8 (LPN) was observed to perform peri-care, removed gloves and donned new gloves. Staff 8 proceeded to cleanse wound, removed gloves and donned new gloves. Staff 8 proceeded to apply dressing, removed gloves and donned new gloves. No hand hygiene was observed in between donning and doffing of gloves.On 7/23/25 at 11:10 AM, During wound care to the sacral wound, Staff 8 was observed to cleanse wound, removed gloves and donned new gloves. No hand hygiene was observed in between donning and doffing of gloves.On 7/23/25 at 11:15 AM, Staff 8 stated he performed hand hygiene before and after care the wound care treatments. He acknowledged the lack of hand hygiene after removing gloves during wound care. On 7/25/25 at 11:25 AM, Staff 2 (DNS) stated she expected staff to perform hand hygiene after removal of gloves when performing wound care.

Based on observation, interview, and record review it was determined the facility failed to protect a resident's right to be free from mental abuse by staff for 1 of 5 sampled residents (#8) reviewed for abuse. This placed residents at risk for further mental abuse. Findings include: On 9/5/24 the State Survey Agency received a public complaint which alleged Resident 8 was spoken to rudely and threatened by a CNA. Resident 8 was admitted to the facility in 9/2024, with diagnoses including vascular dementia and a hip fracture. Resident 8's 9/9/24 Admission MDS indicated she/he was cognitively intact. On 12/17/24 at 9:00 AM, Staff 5 (CNA) stated Staff 3 (CNA) stated to her and Staff 4 (CNA) tell Resident 8 that you will put them in a room by herself/himself with the door closed and no call light if Resident 8 was on the call light too much. Staff 5 stated Staff 3 informed them she knew Resident 8 from the hospital and saying those things worked there. Staff 5 stated they immediately reported to management. On 12/19/24 @ 8:03 AM, Staff 4 (CNA) stated Staff 3 (CNA) stated to her and staff 5 (CNA) tell Resident 8 that you will put them in a room by herself/himself with the door closed and no call light if Resident 8 was on the call light too much. Staff 4 stated Staff 3 informed them she knew Resident 8 from the hospital and saying those things worked there. Staff 4 stated her, and Staff 5 reported the incident immediately to management. On 12/19/24 at 9:51 AM, this surveyor attempted to reach Staff 3 via phone. Staff 3 refused to speak to this surveyor. On 12/19/24 at 10:40 AM, Resident 8 stated she/he recalled being threatened by a staff member for using the call light too much. Resident 8 stated they told me if I used the call light too much I would have been put in a room by myself and would not receive any help no matter how much I called. Resident 8 stated Staff 3 (CNA) did also turn off the lights one time. Resident 8 screamed and Staff 3 turned the lights back on. Resident 8 stated it was a terrifying few moments. On 12/13/24 at 2:49 PM, Staff 1 (DNS) and Staff 2 (Administrator) confirmed the incident occurred.

Based on interview and record review it was determined the facility failed to document the basis for transfer and failed to include code and health status to the receiving provider for 1 of 3 sampled residents (#7) reviewed for hospitalization . This placed residents at risk for inaccurate health care. Findings include: Resident 7 was admitted to the facility in 8/2024, with diagnoses including traumatic brain injury and delirium. Resident 7's 10/3/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 7's medical record revealed no documentation to indicate the basis for the transfer and if appropriate information was communicated to the receiving hospital. There was no information demonstrating why the facility could not meet the resident's needs and whether the discharge was initiated by the resident or the facility. On 12/19/24 at 10:40 AM, Staff 1 (DNS) was informed of the findings of this investigation and acknowledged the discharge information was not documented in Resident 7's medical record.

Based on observation and interview it was determined the Dietary Manager failed to obtain the required certification to provide dietary management services for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: From 4/2/24 through 4/8/24 between the hours of 8:00 AM and 5:00 PM, Staff 33 (Dietary Manager) was observed providing Dietary Manager services in the facility kitchen. On 4/5/24 at 11:31 AM Staff 33 stated he had been the Dietary Manager since 4/2022 and had not completed the required certification required for his position as Dietary Manager. On 4/8/24 at 11:04 AM Staff 1 (Administrator) confirmed she was aware Staff 33 had not obtained the required certification.

Based on observation, interview and record review it was determined the facility failed to protect the residents' rights to be free from physical abuse by Residents (#s 3, 18, 26 and 46) for 4 of 4 sampled residents (#s 3, 4, 18, and 46) reviewed for physical abuse. This placed residents at risk for physical abuse. Findings include: 1. Resident 26 was admitted to the facility in 11/2022 with diagnoses including dementia and behavioral disturbance. Resident 26's 3/8/24 Quarterly MDS indicated a BIMS score of 6 (severe cognitive impairment) and no behaviors. Resident 4 was admitted to the facility in 2/2024 with diagnoses including dementia. Resident 4's 2/8/24 5 Day MDS indicated a BIMS score of 15 (cognitively intact) and no behaviors. On 3/14/24 the facility submitted a FRI which indicated Resident 26 punched Resident 4 on the right shoulder once and twice to the right side of the face. On 4/4/24 at 5:15 PM Staff 13 (LPN) stated he witnessed Resident 26 hit Resident 4 pretty hard on the right shoulder and the right side of her/his face twice. On 4/8/24 at 10:35 PM Staff 1 (Administrator) confirmed the 3/14/24 incident between Resident 26 and Resident 4 occurred. 43691 2. Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 3's 11/9/23 MDS indicated a BIMS of 1 which indicated severe cognitive impairment. Resident 18 was admitted to the facility in 12/2020 with diagnoses including dementia with behavior disturbance and delusional disorder. Resident 18's 10/2/23 Aggression/Violence Risk Assessment indicated a moderate risk for aggressive/violent behavior. On 7/25/22 the facility submitted a FRI which indicated Resident 18 and Resident 3 were overheard yelling at each other. When Staff 32 (CNA) went to check on the residents, they were observed hitting each other and staff intervened to separate Resident 18 and Resident 3. On 4/2/24 to 4/8/24 from 8:00 AM through 5:00 PM Resident 3 was observed walking throughout the facility without supervision and Resident 18 was observed sitting in her/his wheelchair around other residents during dining and activities. On 4/2/24 interviews were attempted with Resident 3 and Resident 18. Both residents were determined to be not interviewable. On 4/4/24 at 9:20 AM Staff 32 recalled the incident and stated she had to rush in to intervene when Resident 3 and Resident 18 were hitting each other. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 18 occurred. 3. Resident 3 was admitted to the facility in 12/2020 with diagnoses including dementia with agitation. Resident 3's 11/9/23 MDS indicated a BIMS of 1 which indicated severe cognitive impairment. Resident 46 was admitted to the facility in 12/2023 with diagnoses including alcohol dependence with alcohol-induced persisting dementia. Resident 46's 1/3/24 MDS indicated a BIMS of 3 which indicated severe cognitive impairment. A 3/10/24 FRI indicated Resident 3 punched Resident 46 on his back after Resident 46 sat on Resident 3's bed. In response, Resident 46 punched Resident 3 in the stomach. Staff intervened to separate the residents. On 4/2/24 to 4/8/24 from 8:00 AM through 5:00 PM Resident 3 was observed walking throughout the facility without supervision and Resident 46 was observed sitting in her/his room with the door open across the hall from Resident 3's room. On 4/2/24 interviews were attempted with Resident 3 and Resident 18. Both residents were determined to be not interviewable. On 4/5/24 at 9:27 AM Staff 31 (Housekeeping) stated she witnessed the incident. Staff 31 stated she saw Resident 46 walk with a cup and attempted to set the cup down on Resident 3's bed. Resident 3 observed this, got upset and started hitting Resident 46. Resident 46 immediately responded by hitting Resident 3. Staff 31 stated she had to get assistance from another staff member to intervene with the incident. On 4/5/24 at 1:36 PM Staff 1 (Administrator) confirmed the incident of abuse between Resident 3 and Resident 46 occurred.

Based on interview and record review it was determined the facility failed to ensure nursing staff competencies for 5 of 5 sampled staff (#s 14, 22, 23, 24 and 25) reviewed for competencies. This placed residents at risk for poor quality of care. Findings include: On 4/4/24 at 3:08 PM and 4/5/24 at 8:40 AM Staff 2 (DNS) and Staff 27 (Staffing Coordinator) were asked to provide evidence of staff competencies for Staff 14 (RN), Staff 22 (LPN), Staff 23 (LPN), Staff 24 (RN) and Staff 25 (RN). On 4/4/24 at 4:40 PM and 4/5/24 at 2:38 PM Staff 2 provided an incomplete competency review for Staff 14. Staff 1 (Administrator) and Staff 27 stated they did not have the requested competencies for Staff 22, Staff 23, Staff 24 and Staff 25. Refer to F880

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNA staff (#s 8, 17, 18 and 19) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 4/5/24 with Staff 27 (Staffing Coordinator) indicated the following employees had not received their annual performance evaluations: -Staff 8 (CNA), adjusted seniority date 10/4/08: no annual performance review was completed. -Staff 17 (CNA), adjusted seniority date 11/22/22: no annual performance review was completed. -Staff 18 (CNA), adjusted seniority date 1/21/20: no annual performance review was completed. -Staff 19 (CNA), adjusted seniority date 10/9/21; no annual performance review was completed. On 4/5/24 at 11:52 AM Staff 27 confirmed annual performance reviews for Staff 8, Staff 17, Staff 18 and Staff 19 were not completed. On 4/8/24 at 10:33 AM Staff 2 (DNS) reported she was aware many CNA staff did not have their annual performance reviews completed including Staff 8, Staff 17, Staff 18 and Staff 19.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate infection control practices for 3 of 11 sampled staff (#s 8, 14 and 15) observed during medication administration and dining. This placed residents at risk for the spread of infection. Findings include: 1. The CDC website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers (a device used to measure blood sugar levels) when shared. Using a glucometer for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). Glucometers should be cleaned and disinfected after every use. The facility's 7/2023 Glucometer Disinfection Policy & Procedure specified glucometers were disinfected after each use with an EPA-registered disinfectant that was effective against viruses. The disinfecting procedure directed staff to wash hands before and after the procedure and to remove and discard gloves and perform hand hygiene prior to exiting the resident room. The facility's 8/2015 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infections. Staff should perform hand hygiene before and after direct contact with residents, before and after handling medications, after contact with objects in the immediate vicinity of residents and after removing gloves. a. Resident 36 was admitted to the facility in 4/2022 with diagnoses including stroke. Resident 41 was admitted to the facility in 3/2022 with diagnoses including type 2 diabetes. On 4/4/24 from 11:55 AM to 12:26 PM Staff 14 (RN) was observed for capillary blood glucose monitoring and insulin administration for Resident 36 and Resident 41. Staff 14 stood at the treatment cart, did not perform hand hygiene, donned gloves, unlocked and opened the cart drawers, obtained Resident 41's insulin pen and obtained blood glucose monitoring supplies including a glucometer. Staff 14 entered Resident 41's room, placed the glucometer on the resident's walker seat and placed the insulin and other supplies directly on the resident's bedside table. Staff 14 used a lancet (a sharp device used to prick the finger to obtain blood) to prick the resident's finger, put a sample of blood on the test strip, plugged the test strip into the glucometer and placed the glucometer onto the resident's bedside table. Staff 14 then lifted Resident 41's shirt and administered the resident's insulin into her/his stomach. Staff 14 gathered all of the used supplies into her right gloved hand and escorted the resident to the dining room. Staff 14 returned to the treatment cart, discarded the used lancet and test strip and placed the used glucometer on the surface of the cart. Staff 14 used her gloved hands to retrieve keys from her shirt pocket, unlocked the cart, typed on the keyboard, opened the cart drawer and placed the glucometer into the cart drawer. Staff 14 did not disinfect the glucometer before or after use. Without changing her gloves or performing hand hygiene, Staff 14 then obtained Resident 36's insulin from the cart and drew up five units of insulin from the resident's insulin vial. At 12:17 PM Staff 14 entered Resident 36's room, picked up the resident's personal glucometer from the resident's table, scanned the resident's implanted glucose monitoring device, replaced the glucometer on the table, lifted the resident's shirt sleeve and administered the five units of insulin into the resident's arm. Staff 14 gathered all of the used supplies into her right gloved hand, returned to the cart, doffed her gloves, did not perform hand hygiene and entered the dining room where she stated she was needed to assist residents. On 4/4/24 at 12:31 PM and 1:33 PM Staff 14 was asked about the frequency of hand hygiene and stated she usually washed her hands after contact with a resident if she was not wearing gloves. Staff 14 stated if she wore gloves then she washed her hands after removing the gloves. Staff 14 was asked about her understanding related to glove use and stated if she got something on the gloves, then she put on a new pair. Staff 14 stated the same gloves should not be worn for other residents. When asked about her understanding related to glucometer use and disinfection, Staff 14 stated she was supposed to wipe it down with alcohol between residents and stated I have not done that at all today. On 4/4/24 at 1:49 PM review of Resident 36's, Resident 41's, and all other diabetic residents' health records revealed no diagnoses including viral bloodborne pathogens. On 4/4/24 at 3:08 PM Staff 2 (DNS) was informed about Staff 14's lack of appropriate infection control practices during insulin administration and blood glucose monitoring. Staff 2 stated she expected staff to disinfect the glucometer between each use with an appropriate virucidal (destroys viruses) disinfecting wipe and to wait for the the adequate amount of time for the product to work. Staff 2 stated she expected staff to follow basic infection control practices, perform hand hygiene between resident contact, before and after glove use, and to change gloves if they were soiled and between residents. b. Resident 6 was admitted to the facility in 4/2017 with diagnoses including vascular disease. Resident 20 was admitted to the facility in 4/2022 with diagnoses including heart failure. On 4/8/24 from 9:09 AM to 9:37 AM Staff 15 (CMA) was observed for medication administration. Staff 15 dispensed Resident 20's medications, entered the resident's room, repositioned the resident by using the bed control, handled items in the resident's immediate environment and then administered the medications. Staff 15 returned to the medication cart, did not perform hand hygiene, and began to dispense Resident 6's medications which included opening a medication capsule with her bare hands. Staff 15 approached Resident 6, obtained the resident's blood pressure and then administered Resident 6's medications. On 4/8/24 at 9:38 AM Staff 15 was asked about the frequency of hand hygiene and stated she should wash her hands after touching a resident or their items and upon entrance and exit of resident rooms. On 4/8/24 at 10:18 AM Staff 2 (DNS) was notified regarding Staff 15's lack of appropriate hand hygiene during medication administration. Staff 2 acknowledged the lack of appropriate infection control practices. 41458 2. On 4/2/24 between the hours of 11:55 AM and 12:30 PM, during the lunch meal in the East dining room, the following observations were made: -12:02 PM an unidentified CNA put on clean gloves and then removed them, positioned a resident upright for eating and placed a bedside table in front of the resident. The staff member then removed a clean pair of gloves from a box of gloves and put them on without completing hand hygiene. Staff 8 (CNA) also removed a pair of clean gloves from a box of gloves and put them on to pass a tray and set-up the resident to eat. Staff 8 removed her gloves, discarded the gloves and then immediately removed another pair of clean gloves from the box of gloves. Both staff put clean gloves on without completing hand hygiene. -12:11 PM Staff 8 repositioned a resident's leg onto leg rests then removed a clean pair of gloves from a box of gloves and put them on without completing hand hygiene. -12:14 PM Staff 8 wore the same pair of gloves while providing eating assistance to two residents at the same time. Staff 8 alternated between one resident and then the other without changing her gloves or completing hand hygiene between residents. -12:18 PM Staff 8 removed her gloves then obtained a clean pair of gloves from a box. Staff 8 put the clean gloves on, retrieved a stool and sat down to assist a resident with eating. Staff 8 did not complete hand hygiene. -12:30 PM Staff 8 assisted two residents with eating, alternating between the two residents while using the same pair of gloves. Resident 8 touched each resident to adjust clothing or sooth the residents. Staff 8 did not change her gloves or complete hand hygiene. On 4/2/24 at 12: 30 PM Staff 8 stated she was supposed to put on gloves, pass a tray, set-up the resident, remove the gloves, complete hand hygiene and put on a new pair of gloves. Staff 8 reported staff were not supposed to use the same gloves between residents. Staff 8 reported she did not consistently change her gloves between residents and did not complete hand hygiene after removing her gloves. She stated, I sometimes get with the motion and just go. On 4/8/24 at 10:33 AM Staff 2 (DNS) stated it was not ok for staff to wear the same gloves between residents and it was her expectation staff complete hand hygiene after removing dirty gloves and prior to putting on clean gloves.

Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant change in condition and head injury for 2 of 3 sampled residents (#s 1 and 3) reviewed for change in condition. This resulted in delayed treatment for Resident 3's significant change in condition and placed residents at risk for unmet needs and delayed treatment. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. An immediate x-ray was ordered. - On 5/24/23: Results from the x-ray found no definitive evidence of lack of bowel motility or obstruction. - On 6/1/23 at 10:20 AM: Resident 3 was found in their bed with brown and yellow emesis (vomit). The resident's temperature was 101.7 (normal is 98.6), blood sugar 404 (normal is 70 to 100), blood pressure 195/85 (normal is 120/80). The resident's current status was reported to Staff 3 (RNCM) who indicated she would contact the resident's family and physician for possible send out [to the hospital]. (No evidence was found to indicate the resident's physician was immediately notified.) On 9/19/23 at 1:18 PM Staff 3 verified there was no evidence the resident's physician was immediately notified of her/his change in condition. On 9/20/23 at 11:01 AM Witness 4 stated he did not recall, or have notes to indicate, the facility notified him of the resident's change in condition on 6/1/23 at or around 10:20 AM. Refer to F684 example 1. 2. Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. On 12/5/22 a Nursing Facility Reported Incident was received which indicated Resident 1 was found with a raised, red lump on the back of her/his head. The (unnamed) RNCM, DNS and Administrator were notified. A review of Resident 1's health record revealed no notification to the physician of the injury. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) verified there was no assessment of the bump, assessment of neurological status, the injury was not monitored or the physician notified. Refer to F684 example 3.

Based on interview and record reviewed it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#6) reviewed for use of physical restraints. This failure resulted in Resident 6 displaying signs of emotional distress and verbalizing feelings of having been raped. Findings include: The facility's Physical Restraint policy and procedure last updated 6/22/23, indicated the following: -Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Emergency use of physical restraints could be used when it was determined the resident or others were in a life threatening or safety threatening situation (fear for the safety of the resident or others due to violent behavior such as attacking others). The emergency use of a restraint is only for the period of imminent danger. -The RCM (Resident Care Manager), DNS and Administrator must be notified of any emergency situation that required the use of a physical restraint. -Restraints shall not be used for staff convenience or discipline. Resident 6 was admitted to the facility in 2021 with diagnoses including dementia with behavioral disturbance and delusional disorder. A 5/9/23 Progress Note written at 1:36 PM by Staff 4 (Former RNCM) indicated Resident 6 required a brief change, was agitated and refused care. Staff 4 indicated all attempts to calm, console, redirect and distract the resident were ineffective so Staff 4 held Resident 6's arms above the wrists to prevent her/him from hitting and scratching CNAs so they could complete the resident's brief change, complete peri-care and change the resident's clothing. Staff 4 documented there was no injury to the staff but the resident was emotionally upset. A 6/9/23 Facility Investigation indicated Resident 6 required extensive assistance with incontinence care and the resident often refused to have her/his briefs changed when soiled. Resident 6 was combative at times during hands on care, and the resident had a history of rape which triggered her/him to become fearful when personal hands-on care was provided. On 5/9/23, Resident 6 was brought to her/his room and resisted having her/his brief changed so Staff 4 physically held Resident 6 down by her/his arms to allow the CNA staff to complete the resident's brief change. The investigation substantiated abuse. The 7/6/23 Annual MDS indicated Resident 6 had severe cognitive impairments, had verbal and physical behaviors directed towards others which did not put the resident at risk for physical injury or illness but significantly interfered with the resident's care. Resident 6 rejected care on a daily basis. The behavioral CAA indicated as a result of prior traumatic events, Resident 6 often refused personal care assistance and could become anxious and agitated at times when staff approached her/him too frequently. Resident 6 was known to strike out if staff were persistent in providing her/him care. On 9/18/23 at 11:15 AM Staff 8 (Social Service Director) stated she assisted with the investigation regarding the 5/9/23 incident which involved Resident 6 and confirmed the resident was physically restrained by Staff 4 during ADL care. Staff 8 stated the resident had a fear of people touching her/him based on her/his past history of being raped and being restrained triggered something with the resident associated with being raped. Staff 8 stated the incident occurred on 5/9/23 but was not identified as a problem until a staff member brought the incident up while Staff 8 was completing staff interviews related to a different incident. Staff 8 stated no resident should ever be treated like that and the practice of physically restraining Resident 6 was immediately stopped. On 9/18/23 at 5:52 PM Staff 9 (Nurse Consultant) reported she reviewed Resident 6's health care record and interviewed staff members regarding the 5/9/23 incident. Staff 9 stated she concluded that no interventions were attempted with Resident 6 prior to Staff 4 physically restraining Resident 6. Staff 9 stated her interviews with staff revealed the practice of physically restraining Resident 6 had been going on for a long time. Staff 9 reported many staff stated they were uncomfortable with the practice of restraining Resident 6 but were told by Staff 5 (Former DNS) they had to do whatever necessary to change the resident's brief. On 9/19/23 at 9:22 AM Staff 4 stated on 5/9/23, Resident 6 was in the common area, her/his brief was soiled and she/he needed to have her/his brief changed. Staff 4 reported the resident was agitated and refused ADL care so she asked two CNAs to walk the resident arm-in-arm to her/his room so ADL care could be provided. Staff 4 stated she went to Resident 6's room to assist with ADL care and the resident was attempting to hit and kick the CNAs so she blocked her/him. Staff 4 stated Resident 6's behaviors continued to escalate so she physically restrained the resident because there was no other way to deal with the situation except to restrain [her/him]. Staff 4 stated there were no other staff in the area so she was unable to attempt other interventions. When asked if staff left Resident 6's room to allow her/him time to calm down, Staff 4 stated no. On 9/18/23 and 9/20/21 between 8:46 AM and 12:42 PM, Staff 6 (CNA), Staff 7 (CNA), Staff 10 (CNA), Staff 11 (RN) and Staff 12 (CNA) reported, prior to the 6/9/23 investigation, it was a regular practice to physically restrain Resident 6 by holding her/him down to change her/his briefs. Staff 12 stated she told Staff 4 and Staff 5 she was uncomfortable restraining Resident 6. Staff 12 stated this practice was approved by Staff 4 and Staff 5 when Resident 6 refused to allow her/his briefs to be changed and Staff 4 and Staff 5 assisted in restraining Resident 6, at times. On 9/20/23 at 1:21 PM and 9/21/23 at 9:09 AM Staff 1 (Administrator) confirmed Resident 6 was physically restrained to allow staff to change her/his brief which constituted abuse. Staff 1 stated there were other interventions in place that should have been utilized. Staff 1 stated Resident 6 had a past history of rape and Resident 6 experienced psychosocial harm as a result of being physically restrained to provide ADL care.

1. Based on interview and record review it was determined the facility failed to promptly transfer a resident to the hospital related to a significant change in condition for 1 of 3 sampled residents (#3) reviewed for change in condition. This resulted in a subsequent decline in condition and delayed treatment for Resident 3. Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. On 9/18/23 at 9:26 AM Witness 3 (Complainant) stated the facility failed to get Resident 3 timely medical attention prior to the resident being transferred to the hospital on 6/1/23. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. An immediate x-ray was ordered. - On 5/24/23: Results from the x-ray found no definitive evidence of lack of bowel motility or obstruction. - On 6/1/23 at 10:20 AM: Resident 3 was found in their bed with brown and yellow emesis (vomit). The resident's temperature was 101.7 (normal is 98.6), blood sugar 404 (normal is 70 to 100), blood pressure 195/85 (normal is 120/80). The resident's current status was reported to Staff 3 (RNCM) who indicated she would contact the resident's family and physician for possible send out [to the hospital]. (No clinical rationale was provided for why the resident was not immediately transferred to the hospital.) - On 6/1/23 at 2:18 PM: Resident 3's blood pressure was 85/55, blood sugar 297 and the resident was unresponsive. Staff 3 gave instructions to send the resident to the hospital. - On 6/2/23: Resident 3 was admitted to the hospital for a large kidney stone. On 9/19/23 at 1:18 PM Staff 3 verified no clinical rational was provided for the decision not to immediately send Resident 3 to the hospital 6/1/23 at or around 10:20 AM. On 9/20/23 at 11:01 AM The 6/1/23 10:20 AM Progress Note was reviewed with Witness 4 and he was asked what orders he would have given to the facility had he been notified. Witness 4 stated he would have instructed the facility to send the resident to the hospital. 2. Based on interview and record review it was determined the facility failed to ensure residents were free from avoidable skin impairment for 1 of 3 sampled residents (#2) reviewed for skin. This placed residents at risk for skin injuries and infection. Findings include: Resident 2 was admitted to the facility in 2023 with diagnoses including failure to thrive. On 5/6/23 a Nursing Facility Reported Incident was received which indicated on 5/5/23 a pack of wipes was left underneath the resident's back which caused a skin injury to the resident's left upper back. The wound was described as an open blister with indentation marks. On 9/19/23 at 2:00 PM Staff 1 (Administrator) verified a pack of wipes was left under Resident 2 which caused a skin injury. 3. Based on interview and record review it was determined the facility failed to assess and monitor a head injury for 1 of 3 sampled residents (#1) reviewed for skin. This placed residents at risk for complications related to head injuries snd unmet needs. Findings include: Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. On 12/5/22 a Nursing Facility Reported Incident was received which indicated Resident 1 was found with a raised, red lump on the back of her/his head. The (unnamed) RNCM, DNS and Administrator were notified. A review of Resident 1's clinical record revealed no assessment to rule out a potential head injury, alert charting for a new head injury, assessment of the resident's neurological status, or notification to the physician of the injury. No ongoing monitoring of the injury or the resident's neurological status was found. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) verified there was no assessment of the bump, assessment of neurological status, the injury was not monitored or the physician notified.

Based on interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters for nutrition for 2 of 3 sampled residents (#s 1 and 3) reviewed for weight loss. This resulted in Resident 1 and Resident 3 having severe weight loss and placed residents at risk for weight loss. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's weight record revealed the following: - On 10/25/21 the resident weighed 177 pounds. - On 11/23/21 the resident weighed 167.2 pounds (a 5.5% weight loss in 29 days). - On 5/4/22 the resident weighed 146.8 pounds (a 17% weight loss over six months). Resident 3's Nutrition At Risk notes revealed the following: - 11/28/21: The resident's 30-day meal intake indicated the resident consumed less than 50% 20 times, 51-75% 24 times, 76-100% 25 times and refused 17 meals. Interventions included a liquid supplement (administration frequency was not specified). The resident required extensive assistance with dining. The Plan was for monthly weights, assistance and encouragement with eating. There was no evidence to indicate the resident's weight loss was addressed or any specific interventions were added to increase the resident's nutritional intake. - 12/13/21: The resident's 30-day meal intake indicated the resident consumed less than 50% 11 times, 51-75% 21 times, 76-100% 53 times and refused 12 meals. Interventions included a liquid supplement (administration frequency was not specified). Resident meal intakes improved with staff assistance The Plan was unchanged from 11/28/21. - 1/25/22: The resident had lost 11.4 pounds or 6.6% from 12/1/21. The resident's 30-day meal intake indicated the resident consumed less than 50% 21 times, 51-75% 27 times, 76-100% 35 times and refused four meals. Interventions included a liquid supplement 240 ml (administration frequency was not specified). The Plan was unchanged from 11/28/21. - 2/15/22: The resident was identified with a seven pound or 4% weight loss since 1/4/22. The resident's 30-day meal intake indicated the resident consumed less than 50% 8 times, 51-75% 33 times, 76-100% 40 times and refused six meals. Interventions included a liquid supplement although administration frequency was not specified). Staff report [the resident] doesn't want to eat but will accept liquid supplement. The Plan included a new intervention for a liquid supplement with meals. No assessment was included related to the indication the resident doesn't want to eat and the resident only refused six meal. - 3/18/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 9 times, 51-75% 29 times, 76-100% 42 times and refused seven meals. Interventions included a liquid supplement (administration frequency was not specified). The resident was identified as having a 18.8 pound or 10.9% weight loss from 10/26/21 to 3/3/22. The Plan included staff assistance and encouragement with intake. No new interventions were included. - 4/21/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 17 times, 51-75% 26 times, 76-100% 31 times and refused 13 meals. Interventions included a liquid supplement which was refused seven times in 14 days . The resident was identified as having a 16.4 pound or 9.7% weight loss from 10/26/21 to 4/2/22. The Plan was unchanged from 3/18/22. - 5/17/22: The resident's 30-day meal intake indicated the resident consumed less than 50% 31 times, 51-75% 17 times, 76-100% 27 times and refused 12 meals. Interventions included a liquid supplement (administration frequency was not specified). The resident was identified as having a 21.7 pound or 12.8% weight loss since 11/3/21. The Plan was updated to include weekly weights for 30 days. No new interventions were included. On 9/20/23 at 11:10 AM Staff 17 (RD) stated the resident admitted to the facility on palliative care and the (unnamed) former Director of Nursing told her it was expected the resident would decline. Staff 17 stated supplements were available, the resident would refuse to eat and they couldn't force her/him to eat. Staff 17 did not provide a clinical rationale for how the resident's condition or being on palliative care was pertinent to the resident's weight loss and lack of additional nutritional interventions. On 9/21/23 at 9:46 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there were no new interventions despite Resident 3's ongoing weight loss, or a rationale for why no new interventions were appropriate. 2. Resident 1 was admitted to the facility in 2018 with diagnoses including Alzheimer's disease. Resident 1's weight record revealed the following: - On 3/2/23 the resident weighed 235 pounds. - On 9/1/23 the resident weighed 208 pounds. This was a 27 pound or 11.5% weight loss over six months. A review of Resident 1's Nutrition At Risk notes revealed the following: - 4/19/23: The resident was identified with an 8 pound weight loss since 3/2/23. The resident was dependent on staff for dining assistance. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 5/4/23: The resident was identified with a 5.8 pound weight loss since 4/4/23 and 12.4 pounds since 2/6/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 5/9/23: The resident was identified with a 4.6 pound weight gain. No new interventions were implemented. - 7/4/23: The resident was identified with a 12.2 pound weight loss since 6/1/23 and 22.8 pounds since 1/5/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 8/3/23: The resident was identified with a 11.2 pound weight loss since 5/2/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. - 9/6/23: The resident was identified with a 2 pound weight loss since 8/1/23 and 27 pounds since 3/2/23. The resident consumed 76-100% for the majority of meals in the prior 30 days. No new interventions were implemented. On 9/20/23 at 11:10 AM Staff 17 (RD) did not provide a clinical rationale for the lack of additional nutritional interventions. On 9/21/23 at 10:04 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed there was no assessment to indicate a rationale for why no new interventions were implemented.

1. Based on observation, interview, and record review it was determined the facility failed to implement infection control measures for a resident with exposed blood and bloodborne pathogens including Viral Hepatitis C for 1 of 1 sampled resident (#52) reviewed for infection control. This failure resulted in an immediate jeopardy situation. Resident 52 walked throughout the facility with an open bleeding head wound, touched various surfaces in common areas and held a bloodstained blanket with bloodstained hands. This placed all residents and staff at risk to contract Viral Hepatitis C, a life-threatening virus. Findings include: According to the CDC website, section titled, Hepatitis C Review, dated 7/28/20, Viral Hepatitis C is highly infectious and is spread through contact with blood from an infected person and inadequate infection control. Viral Hepatitis C can remain active on dry surfaces and equipment for up to six weeks, resulting in a longer period for transmission. Potential adverse outcomes of Viral Hepatitis C include cirrhosis, liver cancer and death. According to the CDC website, section titled, Recommendations for Prevention and Control for Viral Hepatitis C dated 8/7/20, included the following guidance: health-care workers should follow universal blood/body fluid precautions, wear gloves if they must touch another person's blood or open sores and avoid sharing and/or touching personal care items that might have blood on them, such as toothbrushes, razors, nail clippers, etc. Resident 52 was admitted to the facility in 6/2021 with diagnoses including moderate vascular dementia with behavioral disturbance, malignant melanoma (skin cancer), and Viral Hepatitis C. Resident 52's 9/9/22 Care Plan indicated the resident was at risk for actual skin impairment/pressure ulcer and had a sebaceous cyst (a type of liquid-filled bump that occurs on the skin) on top of her/his head. The care plan also indicated Resident 52 was resistant to treatment and ADL cares. The care plan lacked person-centered interventions related to the resident's bleeding cyst. The 10/5/22 Quarterly MDS indicated Resident 52 was severely cognitively impaired, required limited assistance with ADL care and was independent with ambulation. She/he was coded as having an open lesion other than ulcers, rashes, cuts (e.g., cancer lesion). On 1/8/23 between the hours of 11:27 AM and 4:23 PM observations were made of Resident 52. Resident 52's head had a golf-ball sized, protruding red nodule which was actively bleeding down both sides of her/his face and neck. Resident 52 was observed lying in her/his bed with bloodstained sheets and a blanket. Resident 52 walked independently throughout the facility and in communal areas, wore blood stained clothing, carried a bloodstained blanket, had an exposed bloody head wound, and touched/handled a communal chair in the dining room. Resident 52's hands were soiled with dried blood the entire time. Resident 52's hands were observed to have blood on each finger pad, on top of and under her/his nails. Interviews on 1/9/23 revealed the following: -12:35 PM Staff 19 (CNA) stated Resident 52 often picked at the exposed head wound and refused hand hygiene. Staff 19 stated Resident 52 often removed the gauze head bandage and discarded the soiled gauze bandage throughout the facility, including the communal bathroom. -12:36 PM Staff 35 (CNA) stated Resident 52 refused bandaging and treatment of her/his head wound. Staff 35 stated Resident 52 discarded the soiled gauze bandage in the dining room and communal bathroom. Staff 35 stated Resident 52 often picked at the exposed head wound and blood dripped down her/his face. Staff 35 stated Resident 52 easily became agitated and often refused hand hygiene. -12:36 PM Staff 5 (RN/IP) stated Resident 52 had a cancerous tumor on her/his head. Staff 5 stated Resident 52 refused treatment and bandaging of the head wound, walked around the facility with the exposed head wound bleeding, and stated it's an ongoing problem. Staff 5 stated Resident 52, can't keep from messing with it, there's nothing much else we can do. -12:36 PM Staff 3 (RNCM) stated Resident 52 could become belligerent and refused bandaging of the exposed head wound. Staff 3 stated Resident 52 often picked at the exposed head wound and had blood run down her/his face. Staff 3 stated it's an infection control issue because Resident 52 bled and walked around the facility. Staff 3 stated Resident 52 often refused hand hygiene and her/his hands were a mess. -12:40 PM Staff 30 (CNA) stated Resident 52 picked at the exposed head wound, removed, and discarded the soiled gauze bandage throughout the facility daily. Staff 30 stated Resident 52 often refused hand hygiene. Resident 52's 1/9/23 physician order indicated: Keep growth on top of head clean, dry, and covered with gauze at all times. To prevent infection and to contain blood. If resident refuses, reapproach in 15 minutes. On 1/9/23 at 2:24 PM Staff 1 (Administrator) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to do the following: - Failure to have a system in place to ensure Resident 52's hands and personal property were clean and free from blood. - Failure to ensure the physician orders were followed to keep growth on top of her/his head clean, dry, and covered with gauze at all times to prevent infection and to contain blood. - Failure to have a system in place to ensure staff followed appropriate infection control practices and standard precautions. - Failure to ensure residents and staff did not contract Viral Hepatitis C. On 1/9/23 at 7:28 PM the facility submitted a removal plan which was reviewed and approved. The IJ removal plan indicated the facility would implement the following actions: - Resident 52 was moved to a private room and was assigned a one-on-one caregiver 24 hours a day seven days a week as of 1/9/23 at 7:00 PM. The resident's room was stocked with uncontaminated furniture and a commode to reduce the use of the communal bathroom. Resident 52's former room was completely disinfected by housekeeping as soon as the resident moved. - The assigned one-on-one caregiver would have gloves, appropriate alcohol-based hand sanitizer, and clean rags and/or paper towels to clean the resident's hands. When the resident's hands become visibly soiled the one-on-one caregiver would take the resident to the sink and wash her/his hands with soap and water. The resident's clothing would also be changed when contaminated. If the resident refused to change clothes or wash her/his hands, she/he would be re-approached by the one-on-one caregiver or nurse every 15 minutes until the task (washing hands or changing clothes) was completed. - The one-on-one caregiver would have separate red biohazard bags and garbage bins available in the resident's room, one for any waste, another for laundry, washable linen, and clothes. The one-on-one caregiver would have virucidal disinfectant to clean the surfaces in the resident's room when she/he was contaminated with blood. Housekeeping would clean the resident's room once each day shift and evening shift. PPE supplies would be set up in three drawer infection control bins accessible to staff. The supplies would be used in the room and on the portable tote, stocked with appropriate disinfectants and used by the one-on-one caregiver when the resident was up and ambulating. - The IP, RN Educator, or Staffing Coordinator would educate each CNA prior to becoming a one-on-one caregiver. If education was needed after hours, the charge nurse would provide the education. The education would be provided verbally and with a handout for reference. A copy of this education would be kept in the three-drawer bin located in the resident's room. This education would include disinfectant wipes, contact time, standard precautions, and what to do when the resident was mobile. The education would also include the duties expected of the one-on-one caregiver. There would be a sign off sheet when the education was completed for each CNA. Housekeeping would disinfect all community high touch areas four times a day and as needed. This would be done after breakfast and lunch, before dinner, and at bedtime. - A clarification was added to the physician order on the TAR as follows: if resident refuses the dressing changes per MD order re-approach in 15 minutes (one-on-one caregiver will stay with the resident to clean anything she/he touches). - An order was obtained from the physician to start hydroxyzine (anti-itch medication) TID to reduce the resident's anxiety, itching, and picking at wounds. - Hand hygiene will be done for each resident before and after each meal in addition to morning and bedtime routine and as needed for the bathroom/sneezing/touching nose and mouth or any other contamination. A portable tote with appropriate virucidal disinfectant for the one-on-one caregiver would be supplied when the resident was up and ambulating. - A stat lab order was received and sent to the lab to confirm whether the resident had Viral Hepatitis C. If the resident's lab results showed the resident was positive there would be an order to treat if clinically appropriate. An order was received to test and treat all residents and staff for Hepatitis C, if the resident's lab results came back positive. Resident 52's Viral Hepatitis C diagnosis was from 2014. The facility would seek clarification if the Viral Hepatitis C was treated at that time. The resident was placed on alert charting for the nurse to check in with the resident and her/his one-on-one caregiver every hour to ensure the resident was free of blood on her/his clothing or body. On 1/10/23 at 10:00 AM the survey team determined all components of the IJ removal plan were in place and the immediacy was removed. Following the removal of the immediacy, noncompliance remained at isolated with no actual harm with potential for more than minimal harm that is not IJ. 41458 2. Based on observation, interview and record review it was determined the facility failed to ensure proper infection control practices were followed during meal service for 2 of 3 hallways. This placed residents at risk for infections. Findings include: a. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Resident 59's 11/18/22 Admission MDS indicated the resident was cognitively intact. On 1/13/23 at 11:47 AM Staff 3 (RNCM) and surveyor were with Resident 59 when Staff 31 (CNA) brought Resident 59's lunch into her/his room. Staff 31 removed the plastic wrap from Resident 59's plate then set the plate followed by cups of liquid on the bedside table approximately one inch from Resident 59's partially filled urinal. Staff 3 observed Staff 31 place the uncovered food and cups of liquid next to and near Resident 59's partially filled urinal and in approximately two to three minutes, Staff 3 left the room and returned with Staff 31. Staff 3 asked Staff 31 to remove the urinal from the bedside table, remove and discard the food and liquids from the bedside table, disinfect the bedside table and provide the resident with a new plate of food and liquids once the bedside table was disinfected. Staff 3 confirmed this practice was an infection control problem. On 1/17/23 at 2:13 PM Resident 59 stated staff frequently placed her/his food and liquids on the bedside table next to or near the urinal. Resident 59 stated she/he did not like staff putting her/his food and liquids next to the urinal, she/he asked staff to move the urinal but it was always a major issue to get anything done. Resident 59 stated sometimes she/he was laying in bed and staff put the nearly full urinal right by her/his plate of food then placed the bedside table over her/him so she/he could eat. Resident 59 stated her/his urinal sometimes sloshed over and spilled on her/his bedside table or bed linens and smelled. The resident stated the urinal often left a ring on the bedside table and staff put her/his silverware in the dirty area. Resident 59 stated she/he would not have pee sitting on her/his dining room table at home and did not want that done at the facility, either. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 (DNS) were provided with the findings of this investigation and acknowledged this practice was an infection control concern. 46053 b. A review of the facility's 2020 COVID-19 Infection Control Prevention policy revealed: Staff will encourage and assist residents with hand hygiene prior to and after each meal . Resident 55 was admitted to the facility in 2/2022 with diagnoses including calculus of the bile duct with acute cholecystitis without obstruction (a condition characterized by stones in the pathway connecting the liver with the small intestine). Resident 49 was admitted to the facility in 12/2022 with diagnoses including cerebral stroke. On 1/12/23 at 11:47 AM Staff 18 (CNA) was observed delivering lunch plates to Residents 55 and 49 in their shared room. Staff 18 entered the residents' room without performing hand hygiene, adjusted Resident 55's bedding and call light and then cleared and repositioned her/his tray table. Staff 18 then exited the room, collected Resident 55's plate from the cart in the hallway, returned to place it on her/his table and removed the plastic cling wrap covering the food. Without performing hand hygiene, Staff 18 approached Resident 49's bedside and cleared and adjusted her/his tray table. Staff 18 exited the room, collected Resident 49's plate from the cart in the hallway and returned to place it on her/his tray table. Without performing hand hygiene, he removed the cling wrap covering the plate. He then returned to the cart in the hallway, collected two sets of cutlery wrapped in napkins, returned to the room and placed them on the Residents' tray tables. Staff 18 did not perform hand hygiene during this process nor did he offer assistance to Residents 49 and 55 to perform hand hygiene. Staff 18 confirmed he sometimes performed hand hygiene during this process but did not do it today. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. c. On 1/8/23 at 12:04 PM Staff 30 wore gloves as she pushed a lunch cart on the east hallway. Staff 30 removed plastic wrap on the lunch plates and delivered the plates to four of four rooms with no hand hygiene or change of gloves. On 1/13/23 2:32 PM Staff 30 confirmed she did not perform hand hygiene or change gloves when she passed the lunch plates. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 3. Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 1/10/23 at 9:12 AM Staff 9 (HK/Laundry Supervisor) stated the laundry staff removed the final load of laundry from the washers and placed it in wire baskets at the end of every evening shift at approximately 10:00 PM. She reported housekeeping staff loaded wet laundry into the dryers at 6:30 AM the following morning. On 1/11/23 at 10:58 PM Staff 38 (LPN) provided access to the locked laundry facility using her key. No laundry staff were working and this part of the facility was locked for the night. Wet laundry was observed in two wire baskets covered with sheets and stationed adjacent to the two dryers. The sheets that covered the baskets were observed to be wet. Staff 38 confirmed the laundry was clean and wet and stated laundry should not be stored wet because mold and mildew could grow under these conditions. On 1/12/23 at 8:46 AM Staff 9 confirmed the wet laundry that was observed in the baskets on 1/11/23 at 10:58 PM was loaded into the dryers by laundry staff this morning without being rewashed. She stated this was how the laundry was handled every day. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information. 4. Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water borne pathogens. This placed all residents at risk for exposure to water borne pathogens. Findings include: On 1/17/23 at 2:25 PM Staff 8 (Maintenance Director) reported he did not complete a thorough analysis of the facility's water systems to identify and address the risk of water borne pathogens such as legionella. He reported his current plan to limit the risk of exposure to potentially harmful water borne bacteria involved flushing the eye wash stations regularly. He reported he did not complete regular testing of the facility's water supply nor did the facility contract with an agency to conduct a risk assessment or testing of the water supply on their behalf. Staff 8 confirmed the absence of a sustainable plan to mitigate the risks associated with the potential growth of water borne pathogens within the facility's water system. On 1/19/23 at 1:40 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 5 (RN/IP) acknowledged these findings and provided no further information.

Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of dignity, quality of care, accidents, nursing services, staffing and infection control. This placed residents at risk for adverse consequences, injury and contracting infectious diseases and resulted in a hip fracture for Resident 41 and a worsening wound for Resident 27. Findings include: The facility's 8/15/22 Quality Assurance and Performance Improvement (QAPI) Plan identified the following goal for improvement: -To improve and maintain survey compliance for the rest of 2022 and on-going. The facility's 1/19/2023 survey identified the following: 1. The facility failed to ensure residents were treated in a dignified manner. This deficient practice was also identified on the 1/2022 survey. Refer to F550. 2. The facility failed to assess, monitor and document non-pressure related wounds, provide appropriate equipment to address the positioning needs of residents and follow physician orders. These deficient practices were also identified on the 1/2022 survey. Refer to F684. 3. The facility failed to ensure adequate supervision and a safe environment for residents. This deficient practice was also identified on the 5/2022 and 8/2022 complaint surveys. Refer to F689. 4. The facility failed to provide care and services related to catheter care. This deficient practice was also identified on the 1/2022 survey. Refer to F690. 5. The facility failed to ensure RN coverage for eight consecutive hours per day, seven days per week. This deficient practice was also identified on the 1/2022 survey. Refer to F727. 6. The facility failed to ensure provision of education related to risks and benefits, informed consent and the opportunity to receive administration of pneumococcal immunizations. This deficient practice was also identified on the 1/2022 survey. Refer to F883. There was no indication the facility's QAA Committee developed and implemented action plans to correct previously identified quality deficiencies. On 1/19/23 at 2:21 PM Staff 1 (Administrator) acknowledged the repeated deficient practices. Staff 1 stated the facility's QAA team met quarterly with a smaller sub group of the team meeting at least every other week. Staff 1 stated the focus on the QAA committee was on high level survey issues, specifically abuse prevention and COVID. Staff 1 further stated the facility experienced staffing changes in the positions of the Infection Preventionist (IP) and Resident Care Manager (RNCM) which contributed to failure to correct previously identified deficiencies.

1. Based on observation, interview and record review it was determined the facility failed to comprehensively assess/measure resident wounds, monitor wounds for signs/symptoms of infection and document the effectiveness of wound treatment for 1 of 1 sampled resident (#27) reviewed for skin conditions. This failure resulted in Resident 27's worsening wound as evidenced by two emergency room trips and three antibiotic courses. Findings include: Resident 27 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease and stroke with hemiparesis (weakness to one side of the body) affecting left non-dominant side. The 10/26/22 Care Plan indicated Resident 27 was at risk for actual skin impairment/pressure ulcer. Interventions included: Encourage small, frequent position changes, pressure reduction mattress on bed and chair, turn and reposition every two hours while in bed, use pillows to separate pressure areas, weekly skin audit by the nurse and as needed. The 10/26/22 Annual MDS indicated Resident 27 was moderately cognitively impaired and at risk for pressure ulcers/injuries. The 10/26/22 CAA for Pressure Ulcer/Injury revealed Resident 27 was at risk for skin impairment, required the assistance of two people for all turning and repositioning, had a pressure reducing mattress, and was on a turn and repositioning schedule when in bed to offload any pressure points. A review of Resident 27's progress notes indicated the following; -On 11/11/22 a slight skin breakdown was found upon assessment of lump on Resident 27's upper back. -On 11/15/22 a provider visit indicated Resident 27 was seen due to staff concerns of an area of skin breakdown on her/his back. A lump was noticed on the resident's back and may be an infected cyst. Treatment orders included Keflex (an antibiotic) for seven days, obtain a skin culture, consider a surgical referral if needed and continue to monitor closely. -On 11/15/22 when staff removed the padded bandage from the area, the lump on Resident 27's back was macerated (soft, wet or soggy to the touch) underneath and the bandage was soiled. Resident 27 was started on antibiotics and put on alert monitoring. -On 11/16/22 the physician order was updated to include: Notify RCM (Resident Care Manager) if any signs of redness, swelling, drainage, odor, warmth, or any other signs of worsening or infection every two day(s) for skin breakdown on lump. -On 11/17/22 no worsening condition noted to back. -On 11/18/22 Resident 27 was sent to the emergency department (ED) at the request of Witness 9 (POA/family member) and the Witness's concern the wound looked infected. The resident returned on the same day. The ED after-visit summary indicated a diagnoses of cellulitis and an abscess on Resident 27's back. The discharge orders included a prescription for Bactrim (an antibiotic) and the Keflex was discontinued. -On 11/19/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 11/20/22 there was no swelling observed, scant bloody drainage on old dressing, darkened (red/purple) skin surrounded the open area, 5cm in diameter. Between 11/21/22- 11/28/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 11/29/22 the facility provider note indicated Resident 27's back infection had improved, continue to apply dressing until it was fully healed and monitor for any recurring infection. Antibiotic treatment was completed. Between 11/30/22 to 12/9/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 12/10/22 Resident 27 was noted to have bloody drainage from the wound on her/his back. A request was made for a change in the order to prevent damage from moisture. The new order was scheduled to start the next day. Between 12/11/22 and 12/24/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 12/25/22 wound assessment documentation indicated the wound on Resident 27's back had signs of infection. The bandage was stuck to the resident's back, worn down with no date written on it and saturated with fluid. When the bandage was removed there was draining fluid, a strong odor, redness, swelling and pain at the site. The resident was laying on her/his side and was given PRN pain medicine for the pain. The family and provider were notified. -On 12/26/22 a nurse changed the dressing on Resident 27's back wound. The bandage was saturated. The on-call provider was notified and gave orders to send the resident out to the hospital. -On 12/26/22 Resident 27 was sent to the ED and returned the same day. The ED visit note indicated Resident 27 had an upper back wound related to an abscess. A new order for antibiotics was given for a soft tissue infection. -On 12/27/22 no signs/symptoms of infection, wound was draining. -On 12/27/22 the facility provider looked at the wound on Resident 27's back after she/he returned from the ED for suspected infection. The facility provider noted the wound looked good and was healing well. The facility provider updated the order and the wound was to be kept clean, dry, and covered. Between 12/28/22-12/31/22, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. -On 1/1/23 the dressing was changed on Resident 27's back. The wound had tunneling and drainage was serosanguineous (yellowish with small amounts of blood). Resident 27 was turned side to side. Between 1/2/23-1/5/23, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation on the effectiveness of the wound treatment in Resident 27's record. -On 1/6/23 the dressing was saturated with puss and the wound dressing was changed. The packing was saturated in puss, there was a strong odor, redness, increased pain for resident and the wound had tunneled 1/4cm deeper. On 1/8/23 at 5:54 PM Witness 9 stated the facility notified her on 11/15/22 of a lump on Resident 27's back and it was being watched. Witness 9 stated she/he visited Resident 27 on 11/18/22, was shocked by how the lump looked and requested Resident 27 be sent to the hospital. Between 1/7/23-1/13/23, there was no documentation of assessments/measurements of the wound, no monitoring of the wound for signs/symptoms of infection including redness, swelling, odor and drainage, and no documentation of the effectiveness of the wound treatment in Resident 27's record. On 1/12/23 at 9:21 AM with the resident's permission, wound care was observed by an RN surveyor and a non-RN surveyor. Staff 23 (RN) provided wound care. The RN surveyor observation revealed: wound was jagged, with a linear open area, approximately 1 cm long and .5 cm wide located in the center of Resident 27's mid back, with a small amount of pink-tinged drainage observed. Staff 23 removed the dressing, cleansed the wound with wound cleanser spray and gauze, used a long Q-tip and pressed approximately five inches of gauze packing into the wound and covered the wound with a clean dressing. Staff 23 did not measure the length, width or depth of the wound. Staff 23 did not document characteristics of the wound including the location, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor and whether or not the resident experienced pain. Staff 23 stated she believed the wound was measured by the RNCM and the RNCM should document in the progress notes. On 1/12/23 at 11:03 AM Staff 16 (LPN) stated she was concerned wound care was not done daily because of the lack of documentation. On 1/13/23 at 2:17 PM Staff 3 (RNCM) stated Resident 27's wound was not measured daily and nursing staff should measure the wound weekly and document their findings in the progress notes. Staff 3 confirmed there was no documentation of weekly assessments/measurements, treatment, and effectiveness of treatment to indicate if the wound was healing or not. Staff 3 stated the wound was monitored daily and if there was no progress note, then the wound presumably was healing. Resident 27's progress notes revealed the following: -On 1/14/23 the wound dressing was changed on Resident 27's upper back. The dressing was saturated. The wound was cleaned and packed with calcium alginate per order. The wound was covered with 4x4 adhesive foam dressing. Resident 27 was on her side. Will continue to monitor. On 1/15/23 there was no documentation of the wound treatment in Resident 27's record. -On 1/16/23 wound is healing, tunneling stalled, new tissue was present, drainage has decreased and pain has decreased. -On 1/17/23 there was no documentation of the wound treatment in Resident 27's record. -On 1/18/23 the wound dressing to Resident 27's mid back was changed. The old dressing/packing was removed with yellow brownish drainage. The wound site looked a bit discolored with greyish edges near the wound opening. There was no redness to the wound site. The tunneling wound was packed with packing gauze and covered with a dressing. Resident 27 tolerated the dressing change and was turned, repositioned every 2 hours and as needed. -On 1/19/23, there was no documentation of the wound treatment in Resident 27's record. On 1/19/23 at 11:28 AM Staff 2 (DNS) stated wound assessments and documentation needed to improve. She further stated wound assessment/measurements, monitoring and documentation needed to be completed at least weekly. On 1/19/23 at 11:58 AM Staff 5 (RN/IP) stated wound care documentation was not completed as expected. The expectation was the wound should be assessed/measured, monitored, and documented at least weekly. 39632 2. Based on observation, interview and record review it was determined the facility failed to provide appropriate equipment to address the positioning needs of residents for 1 of 4 sampled residents (#35) reviewed for positioning. This placed residents at risk for discomfort. Findings include: Resident 35 was admitted to the facility in 7/2017 with diagnoses including Alzheimer's disease. The 8/12/20 Assistive Device Evaluation indicated Resident 35 used a tilt-in-space wheelchair (a reclining wheelchair which allowed the resident to tilt backwards). Observations of Resident 35 from 1/8/23 through 1/17/23 between the hours of 9:14 AM and 7:45 PM revealed the resident in a tilt-in-space wheelchair without a head rest. Resident 35 was positioned in a backwards reclined position with her/his head, neck and upper shoulders unsupported. The resident's neck was extended with the top of her/his head tilted backwards and her/his chin directed towards the ceiling. On 1/11/23 at 10:55 AM and 11:04 AM Staff 10 (CNA) and Staff 15 (CNA) observed Resident 35 in her/his tilt-in-space chair and confirmed the resident's head and neck was not supported. On 1/11/23 at 11:19 AM Staff 4 (RNCM) stated she thought Resident 35's tilt-in-space wheelchair headrest was removed a long time ago and she was unsure why it was not replaced. On 1/11/23 at 11:34 AM Staff 2 (DNS) stated she was unaware Resident 35's tilt-in-space wheelchair did not have a headrest and she expected the resident's head, neck and shoulders to be supported while in the chair. On 1/19/23 at 10:58 AM Staff 1 (Administrator) was notified of the findings of this investigation and provided no additional comments or information.

Based on observation, interview and record review it was determined the facility failed to ensure adequate supervision and a safe environment for 2 of 3 sampled residents (#s 41 and 58) reviewed for accidents. This failure placed residents at increased risk for injuries and resulted in Resident 41 sustaining a hip fracture from a fall. Findings include: 1. Resident 41 was admitted to the facility in 6/2018 with diagnoses including frontotemporal dementia (a type of dementia characterized by changes in emotions, behavior, personality and language). Resident 41's 8/31/22 Quarterly MDS indicated the resident's cognition was severely impaired, she/he required extensive assistance from at least two staff for transfers and was totally dependent on staff for locomotion on and off of the unit. Resident 41's 9/12/22 Morse Fall Scale revealed the resident was at high risk for falling. A review of Resident 41's 9/14/22 Care Plan revealed the resident was at risk for falls due to cognitive impairment and lack of impulse control and included the following interventions related to safety and falls: -The resident's room was to be kept free from clutter and floors free from spills; -A fall mat was to be in place; -A tab alarm was to be in place when the resident was in bed; -A seatbelt and tab alarm were to be in place when the resident was in her/his wheelchair; -The bed was to be in the lowest position when occupied; and -The resident was not to be left unattended with her/his bed in the highest position. A review of Resident 41's progress notes revealed she/he fell on [DATE] and 10/1/22 as a result of failed self transfers. A 12/1/22 FRI Form revealed Resident 41 was sent to the hospital on 11/29/22 and returned to the facility on [DATE] with a diagnosis of a left hip fracture, cause unknown. A review of the facility's 12/5/22 Incident Note completed by Staff 4 (RNCM) revealed the following: -11/28/22 Staff 36 (CNA) left the resident unattended in bed with her/his bed in the high position before leaving for a break. While Staff 36 was on her break, the resident was found on the floor in the middle of her/his room. Staff 44 (Agency LPN) determined the resident did not experience discomfort with transferring from the floor into her/his wheelchair and did not have problems standing or pivoting. Staff 44 did not inform Staff 36 the resident had fallen when she returned from her break. -11/29/22 Resident 41 was transferred to the hospital as she/he was observed to be unresponsive. -11/30/22 Resident 41 returned to the facility from the hospital with a diagnosis of left hip fracture. -12/5/22 the left hip fracture was a result of the resident attempting to self transfer and being left unattended in her/his room with her/his bed in a high position. Resident 41's care plan was not followed. A review of Resident 41's health record revealed the following related to Resident 41's fall on 11/28/22: -No evidence the resident was assessed for injury or pain; -No evidence neurological checks were completed; -No evidence the resident was put on alert charting to assess for signs of latent injury; -No evidence an investigation into the root cause of the fall was initiated; and -No evidence the DNS, RNCM, the resident's responsible party or staff working the next scheduled shift were notified the resident experienced a fall. An attempt was made to contact Staff 44 via phone and no return phone call was received. On 1/8/23 at 1:40 PM Witness 8 (Family Member) stated she received a phone call on 11/29/22 at 5:00 PM from Resident 41's attending physician at the hospital who informed her the resident had sustained a left hip fracture which appeared to be from the result of a recent fall. On 1/8/23 at 2:05 PM Staff 36 stated Resident 41 was considered at risk for falls prior to the resident's 11/28/22 fall. She stated Resident 41's care plan at the time of the 11/28/22 fall was for the resident to be supervised when in bed if the bed was in a high position. Staff 36 confirmed she was Resident 41's assigned CNA on 11/28/22. She stated she left Resident 41 in bed unattended with her/his bed in a high position as the resident was not finished drinking her/his liquids before leaving for her break. She stated she was not informed of Resident 41's fall when she returned from her break but was made aware a few days later when she was called by Staff 4 (RNCM) who was completing the fall investigation. On 1/11/23 at 11:32 AM Staff 37 (CNA) stated she worked on 11/28/22 and checked on Resident 41 after she heard a noise coming from the resident's room. She stated she entered the room and discovered the resident on the ground and the resident's bed was raised to a high position. She stated she assisted the resident off of the ground with the help of the nurse and another CNA. On 1/13/23 at 10:12 AM Staff 4 (RNCM) stated Resident 41's bed should have been at knee level for care and during meal times and the resident should have been supervised during these instances. She confirmed Staff 36 should have lowered the resident's bed prior to leaving the room on 11/28/22. Staff 4 further stated Staff 44 should have informed the DNS, RNCM, family and staff working the next shift of the resident's fall, documented her assessment of the resident, started an incident report and initiated alert monitoring. On 1/19/23 at 10:41 AM Staff 2 (DNS) was informed of the findings and no additional information was provided. 2. Resident 58 was admitted to the facility in 10/2022 with diagnoses including alcohol abuse and Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1). Resident 58's 10/19/22 Wandering Risk Scale revealed the resident to be at risk to wander. Resident 58's 10/26/22 Admission MDS revealed the resident was moderately impaired in terms of cognitive functioning, was independent for locomotion on and off the unit and wandered. Resident 58's 10/26/22 Admission MDS Behavior CAA revealed the resident eloped from the facility shortly after her/his admission due to a malfunction of the keylock pad equipment on the facility's east gate. The resident exited out the east gate and she/he was found shortly thereafter in the facility's parking lot. The resident had wandering/exit-seeking behaviors and regularly talked about returning home and drinking whiskey. Resident 58's 11/28/22 Wandering/Wants To Go Home/Elopement Risk Care Plan listed the following interventions: -Assess and provide appropriate seating in dining room; -Complete wandering assessment on admission, 72 hours post admission, one month post admission, quarterly and as needed; -Encourage socialization with other appropriate residents and provide activities; -Reinforce reasons for placement; -15 minute checks and -Assign one to one if staff were available. A 12/27/22 FRI Form revealed Resident 58 eloped from the facility from the outer east gate which was discovered to be unlocked. A review of the 15 Minute Safety Checks CNA Task completed on 12/27/22 revealed no evidence Resident 58 was checked on from 7:00 PM to 7:43 PM. A review of the 12/30/22 Incident Review/Summary completed by Staff 4 (RNCM) indicated Resident 58 walked outside every day since his admission trying to get the gates open. This Review/Summary revealed the following about the resident's 12/27/22 elopement: -15 minute checks of Resident 58 were completed by Staff 40 (CNA) until she went on break at 7:00 PM and did not resume until she returned from break at approximately 7:30 PM. Staff 40 stated the last time she saw the resident was around 7:00 PM prior to leaving for her break. -Staff 30 (CNA) along with the other CNA assisted another resident in the shower during Staff 40's break. -Staff 40 asked Staff 30 about Resident 58's whereabouts upon return from her break around 7:30 PM. Staff 30 assisted a resident in the shower at this time. -Staff 30 notified Resident 58 was missing around 7:30 PM to 7:35 PM. -It was determined the resident had eloped after the east gate was discovered to be unlocked at approximately 7:45 PM. The facility's video camera footage confirmed Resident 58 eloped through the east gate which was unlocked. Observations of Resident 58 conducted between 1/9/23 and 1/18/23 from 8:00 AM to 4:40 PM revealed the resident to be in bed either watching television, reading the newspaper or walking outside of the facility within the gated grounds. The resident was observed to frequently walk from the west to the east side of the building and push on the east gate. On 1/8/23 2:31 PM Resident 58 reported she/he independently took a trip to the city of Cornelius on TriMet (public transportation company) approximately a week prior. The resident reported falling a few times when on this outing and stated she/he was helped by strangers. On 1/11/23 at 12:05 PM Staff 37 (CNA) stated Resident 58 had a CNA regularly scheduled to provide one to one supervision but this was discontinued. Staff 37 stated when Resident 58's exit-seeking behavior was observed to be more frequent/heightened during a shift, staff reported this behavior, and if there was availability, the resident was assigned a staff person to provide one to one supervision. Staff 37 observed Resident 58's exit-seeking behavior increased in the evenings and nights and the resident usually attempted to exit out of the east gate. On 1/13/23 at 8:54 AM Staff 16 (LPN) stated staff were supposed to redirect Resident 58 when she/he was observed wandering or exit-seeking. She stated CNAs were responsible for completing 15-minute checks of the resident and they implemented one to one supervision of Resident 58 when increased exit-seeking was observed and/or if the resident was talking about wanting to leave the facility. On 1/13/23 at 10:12 AM Staff 4 (RNCM) stated Resident 58 talked about eloping since her/his admission to the facility and the resident checked the integrity of the gates daily since her/his admission. Staff 4 stated the resident eloped in 10/2022 after punching random numbers on the east gate's keypad which opened the gate. After this 10/2022 elopement, Staff 4 stated Resident 58 received daily one to one staff supervision until 12/7/22 when the gates were repaired. Staff 4 stated the 12/27/22 elopement was a result of a power outage and the magnet on the east gate malfunctioning. She stated on 12/27/22 the facility experienced three power glitches when the electricity in the building flickered but did not fully go out. She further stated staff had checked on the integrity of the gates until approximately 5:00 PM and they were locked. Staff 4 stated the gates had a 45-90 minute back up should the power completely go out. In the event of a power outage, a staff person was to chain the gates to prevent any potential resident elopements. Staff 4 stated Staff 39 (Staffing Coordinator) was assigned to train staff what to do in the event of a power outage. On 1/13/23 at 11:00 AM Staff 39 (Staffing Coordinator) stated she did not provide staff with any orientation specific to resident elopements or power outages, including what to do about the facility gates in the case of a power outage. On 1/13/23 at 2:33 PM Staff 40 (CNA) stated she was Resident 58's assigned CNA on the evening of 12/27/22. She stated she observed the resident to have increased wandering that evening as the resident was observed walking outside and around the building approximately every 30 minutes since the start of her shift at 2:00 PM. She further stated Resident 58 was not assigned one to one supervision despite her/his increased behaviors. She stated she took her break from 7:00 PM to 7:30 PM and informed the other two CNAs working in the east wing of the building. She then stated the CNAs were assisting another resident with a shower at the time she left for her break. At approximately 7:35 PM after returning from her break she went to check on Resident 58 and discovered the resident was missing. On 1/13/23 at 3:13 PM Staff 41 (Agency LPN) stated she was the nurse scheduled on the west wing on the evening of 12/27/22. She stated she observed Resident 58 to have increased wandering and exit-seeking behaviors on this evening of 12/27/22, but no one to one supervision was provided. She further stated she was not made aware of the resident's 10/2022 elopement until after her/his elopement on 12/27/22. Staff 41 was not aware of any elopement precautions, including the CNAs completing 15-minute checks on Resident 58. On 1/18/23 at 8:30 AM Staff 15 (CNA) stated Resident 58 gave various reasons where she/he was going when exit-seeking, including going to the bar. Staff 15 stated the resident told her she/he pushed on the gate every day to see if it was locked. On 1/18/23 at 9:34 AM Staff 8 (Maintenance Director) stated he checked the east and west gates on a daily basis to make sure they were locked since Resident 58's 10/2022 elopement. On 12/27/22, Staff 8 stated he and his assistant checked on the east and west gates approximately three times to make sure they remained locked due to the storms and power flickering that occurred on that day. He further stated he checked on the gates around 5:00 PM before leaving for the day and thought all staff were aware of the gate being a potential problem. Before leaving for the day, he spoke to Staff 42 (LPN) because he was worried about the possibility of the gates malfunctioning. He stated he informed Staff 42 of Resident 58's previous elopement and of the gates' previous malfunction. He confirmed there was no system in place for monitoring the gates to make sure they remained locked after he left the facility. On 1/18/23 at 12:44 PM Staff 42 stated Staff 8 did not provide with any warning about the possibility of the gates malfunctioning. She stated she was not made aware of Resident 58's prior elopement in 10/2022 until after her/his 12/27/22 elopement. On 1/19/23 at 10:41 AM Staff 2 (DNS) was informed of the findings of this investigation and provided no additional information.

Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 2 of 3 sampled residents (#s15 and 59) reviewed for therapy. This failure resulted in Resident 59 displaying signs of distress, depressed mood, a decline from former social patterns and repeatedly verbalizing feelings of frustration. Findings include: The Stroke Foundation, What to Expect From a Stroke, dated 2023, explained that stroke rehabilitation (PT, OT and SLP) is the therapy and activities that drive recovery by helping to re-learn ways of doing things affected by a stroke. It aims to stimulate the brain to change and adapt. By creating new pathways a person can learn to use other parts of the brain to recover function of those parts affected by the stroke. Improvement after a stroke can continue for years but for many people it's quickest in the first six months. 1. Resident 59 was admitted to the facility in 11/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed Resident 59 had left-sided hemiparesis with no functional movement of her/his left arm or hand and limited movement of her/his left leg. At times the resident was observed laying on her/his left arm/hand. Resident 59 was typically in bed with a hospital gown on. No PT or OT therapy was observed. The 11/11/22 Hospital Discharge Orders indicated the reason Resident 59 discharged to nursing home care was to receive PT and OT services. Written orders for PT and OT to assess and treat were provided. Resident 59's 11/18/22 Admission MDS indicated the resident had intact cognition and upper and lower extremity impairment on one side. Resident 59 required limited assistance with one person physical assist for bed mobility, total dependence with two plus persons physical assist for transferring, extensive assistance with one person physical assist for dressing, toilet use and personal hygiene and walking did not occur. The functional rehabilitation section revealed Resident 59 and direct care staff believed the resident was capable of increased independence. The special treatements section indicated there were no therapy minutes documented. There was no evidence in Resident 59's clinical record to show she/he received PT and OT assessments or treatment. On 1/8/23 at 1:02 PM, 1/11/23 at 7:56 AM and 1/12/23 at 8:35 AM and 12:31 PM and 1/18/23 at 8:27 AM Resident 59 stated when she/he was in the hospital, she/he had PT and OT services. Resident 59 stated she/he was told she/he would have rehab services at the facility but had no rehab therapy services. Resident 59 stated she/he was pissed because these people don't even care about us. Why did they even take me when they knew they couldn't give me the rehab I needed. I haven't had shit. I am just sitting in this bed rotting. Resident 59 stated she/he spoke to Staff 3 (RNCM) many times regarding rehab services and went up the chain of command but nothing happened. Resident 59 stated she/he used to be very active; rode her/his bike and walked all of the time. Resident 59 stated up until her/his stroke she/he worked full-time. Resident 59 stated she/he was the goofy grandparent but did not want her/his grandkids to come to visit because Resident 59 did not want them to see her/him this way. Resident 59 stated she/he just wanted to get better so she/he could see her/his grandkids and go home. Resident 59 frequently spoke in an elevated voice, was teary at times and repeatedly verbalized frustration with not having therapy services. On 1/11/23 at 11:16 PM Staff 24 (CNA) stated Resident 59 was uncomfortable with her/his condition and has not learned to live with it. Staff 24 stated Resident 59 needed PT and then she/he would feel more comfortable sitting in her/his wheelchair in the common areas, around others. Staff 24 stated Resident 59 just wanted to work with PT so she/he could get better and then Resident 59 would be so much happier. Staff 24 stated they told Staff 2 (DNS) and Staff 3 (RNCM) many times that Resident 59 needed PT but nothing was done. On 1/13/23 at 11:24 Staff 3 confirmed Resident 59's PT and OT services were not scheduled. Staff 3 stated she was not aware Resident 59 had PT and OT orders when she/he first admitted to the facility and there was a breakdown in communication. Staff 3 stated she learned Resident 59 had PT and OT orders sometime later and notified Staff 7 (SSD) because Staff 7 was responsible for scheduling therapy services. Staff 3 stated she spoke with Resident 59 a couple of times about her/his PT and OT and communicated with Staff 7 but the resident still did not have services. Staff 3 stated it sometimes took a week or two for therapy to be scheduled but services should have been ordered by now. Staff 3 acknowledged Resident 59 was upset and frustrated because of the lack of PT and OT services. On 1/13/23 at 11:47 AM Resident 59 was observed speaking to Staff 3 about her/his frustrations with PT and OT services not being scheduled. Resident 59 verbalized to Staff 3 that she/he did not want to be shitting or pissing in her/his bed. The resident stated she/he should not even be at the facility and her/his goal was to be as independent as possible. Resident 59 stated the whole ball got dropped because nobody cares about me. Resident 59 spoke in an elevated voice and verbalized feelings of frustration. Staff 3 told Resident 59 once therapy started she/he would be able to do better and be more independent. On 1/13/23 at 1:15 PM Staff 2 (DNS) stated Staff 7 scheduled all therapies. Staff 2 stated therapy should be scheduled pretty quickly but sometimes it took up to two weeks but should not take over two months to get therapy services scheduled. She stated the facility did not typically have residents who were at the facility for therapy because therapy was not the focus of the facility so that was probably why Resident 59's therapy orders were missed. Multiple attempts were made by the facility administration and surveyor to contact Staff 7 via email, text and phone and Staff 7 indicated she was not available to be interviewed until her anticipated return on 1/23/23 or 1/26/23. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 were informed of the findings of this investigation. Staff 1 and Staff 2 acknowledged Resident 59 was upset and frustrated over the lack of PT and OT services. No additional information was provided. 2. Resident 15 was admitted to the facility in 2/2022 with diagnoses including stroke and hemiplegia/hemiparesis (the loss of ability to move part or most of the body) of the non-dominant side. Multiple random observations from 1/8/23 through 1/17/23 between the hours of 8:00 AM and 11:50 PM revealed Resident 15 had left-sided hemiparesis with some movement of her/his left side. Resident 15 was always in bed with a hospital gown on. No PT or OT therapy was observed. Resident 15's 12/3/22 Progress Notes indicated the resident was sent to the hospital on an emergency basis and was admitted for care and treatment. Resident 15 was readmitted to the facility on [DATE]. Resident 15's 12/7/22 Hospital Discharge Orders indicated the resident had signed physician orders for PT and OT services. There was no evidence in Resident 59's clinical record to show she/he received PT or OT assessments or treatment. On 1/8/23 at 2:06 PM Resident 15 stated she/he needed PT to help her/him sit up in a chair. On 1/13/23 at 10:46 AM Staff 3 (RNCM) stated she did not realize Resident 15 had orders for PT and OT but Staff 7 (SSD) should have received a copy of the therapy orders because she was responsible for scheduling therapy services. Staff 3 confirmed Resident 15 was readmitted on [DATE] with orders for PT and OT services and no therapy services were scheduled or completed. On 1/17/23 at 10:23 AM Staff 2 (DNS) stated she was not aware Resident 15 had PT and OT orders. She stated Staff 7 scheduled therapy services but she did not know if Staff 7 scheduled Resident 15's PT and OT therapy. Multiple attempts were made by the facility administration and surveyor to contact Staff 7 via email, text and phone and Staff 7 indicated she was not available to be interviewed until her anticipated return on 1/23/23 or 1/26/23. On 1/18/23 at 11:19 AM Staff 1 (Administrator) and Staff 2 were informed of the findings of this investigation. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure Staff 11 (CNA) followed professional standards of practice regarding the dietary needs for 1 of 3 sampled residents (#500) reviewed for accidents. This resulted in Resident 500 eating solid food and she/he choked, which resulted in her/his death in the facility. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional care plan training with instructions to follow the resident's care plan for all staff who provided care. This incident was identified as meeting the criteria for past noncompliance. Findings include: Oregon Board of Nursing Rule [DATE] Authorized Duties and Standards for Certified Nursing Assistant 1 (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse Oregon Board of Nursing Rule [DATE] Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: 2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established. Resident 500 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 500's MDS Quarterly dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. The dietary assessment dated [DATE] revealed Resident 500 was prescribed a mechanically altered diet which consisted of pureed foods and thickened liquids. She/he was edentulous (no teeth) and was dependent on staff for eating and supervision. A document titled Gracelen Terrace CNA/NA Standards of Care detailed expectations for resident care and safety, including to follow resident care plans. The document was signed by Staff 11 on [DATE]. An [DATE] at 9:45 AM progress note by Staff 5 (RN) revealed on [DATE] around 8:55 PM she overheard other staff say call the nurse, stood up and observed Resident 500 in her/his wheelchair choking. Staff 5 was informed the resident choked on a regular textured sandwich given to her/him by Staff 11. Staff 5 immediately began abdominal thrusts and instructed staff to call 911. 911 was called on [DATE] at 8:57 PM. A CNA assisted Staff 5 with back blows to Resident 500 and continued with abdominal thrusts. Resident 500 was unresponsive, placed on the floor and her/his airway was cleared. CPR was initiated and food particles came out of the resident's mouth. Emergency personnel on the phone continued to give instructions and CPR was continued until EMTs (Emergency Medical Technicians) arrived at 9:08 PM but Resident 500 did not regain a pulse. EMT's called the resident's time of death at 9:11 PM. The facility's [DATE] investigation summary and revealed the root cause of Resident 500's death was the care plan was not followed by Staff 11. Staff 11 made sandwiches for several residents and did not review food textures for Resident 500 or other residents prior to handing out the sandwiches. Resident 500 was given a sandwich by Staff 11, who left the resident unsupervised. Staff 11 was immediately counseled and placed on administrative leave following the incident. A statement written and signed by Staff 6 (Staffing Coordinator) on [DATE] revealed on Monday, [DATE] she met with Staff 11 at the facility to do orientation which included a review of CNA/NA standards of care, Kardex (plan of care), the one page care plan location and the master copy of the diet textures location. On [DATE] at 12:22 PM Staff 6 stated she was responsible for hiring and scheduling CNAs. Newly hired and agency staff were given orientation by Staff 6. Staff 6 revealed Staff 11 was agency staff from another state (Texas) and reported to the facility on [DATE]. He filled out paperwork, was given access to the electronic medical record, given CNA standards of care, shown how to access the Kardex and other basic information. Staff 6 revealed Staff 11 read and signed the standards of care form. On [DATE] at 10:42 AM Staff 11 stated he met with Staff 6 on [DATE]. He revealed Staff 6 gave him the paperwork with CNA duties, asked him if he knew how to access Kardex and the electronic medical records which he confirmed he knew. Staff 11 confirmed he made sandwiches on [DATE] and gave a sandwich to Resident 500. He went to another hall and upon return observed Resident 500 on the floor and observed staff performing CPR on Resident 500. Staff 11 confirmed he did not check anyone's care plan that night for diet textures, including Resident 500. On [DATE] at 1:15 PM, Staff 1 (Administrator) confirmed it was an expectation that facility staff reviewed resident care plans. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance for F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey [DATE] and before the date of this survey [DATE]. 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F689 as evidenced by: - No deficient practice was found at F689 with additional sampled residents. - Evidence the deficient practice was identified by the facility; the facility took immediate action to immediately suspend, counsel the staff responsible, trained all staff for care plan implementation and diet texture. The Diet Textures training material was signed by 38 staff and indicated the training was completed by [DATE]. - Staff 1 confirmed Staff 11 will never be allowed to work in the facility and had not worked in facility since immediately following the [DATE] incident. Refer to F689

Based on interview and record review it was determined the facility failed to ensure physician orders and care planned interventions were followed for 1 of 3 sampled residents (#500) reviewed for dietary services. As a result of facility staff not following the care planned interventions related to diet textures, Resident 500 choked which resulted in her/his death. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional care plan training with instructions to follow the resident's care plan for all staff who provided care. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 500 admitted to the facility in 2013 with diagnoses including dementia and dysphasia (difficult speech). A [DATE] physician order directed Resident 500 to be given a regular diet, pureed texture with liquid consistency at mildly thick nectar. The [DATE] Dietary Assessment by Staff 13 (RD) indicated Resident 500 needed a puree diet texture. Resident 500 did not have any reports she/he choked, pocketed food (held in mouth) or any reported swallowing difficulty. The [DATE] Quarterly MDS identified Resident 500 BIMS score of 3 (severe cognitive impairment), required a mechanically altered diet and was totally dependent for eating with one person assistance. Resident 500's [DATE] care plan identified her/him as an aspiration risk (food or liquid may enter airway) and directed staff to provide pureed texture for food. An [DATE] at 9:45 AM progress note by Staff 5 (RN) revealed on [DATE] around 8:55 PM she overheard people in the hall say call the nurse call the nurse. She immediately stood up and saw Resident 500 in the hall in her/his wheelchair choking. Staff 5 was informed the resident choked on a regular textured sandwich given to her/him by Staff 11 (CNA). Staff 5 immediately began abdominal thrusts and yelled to call 911. 911 was called on [DATE] at 8:57 PM. A CNA assisted her, and five back blows were given and abdominal thrusts continued. Resident 500 was unresponsive and was placed on the floor, the airway was cleared, CPR was initiated, food particles came out of the resident's mouth, emergency personnel on the phone gave instructions and CPR continued. No pulse was able to be attained on Resident 500, the crash cart was brought by a LPN with the connected defibrillator (provides electric thrust to restart the heart), instructions were given from the defibrillator to continue CPR shock to be given at that time. Staff 5 continued CPR, then Staff 7 (CNA) took over and continued CPR until EMS (Emergency Medical Services) arrived at 9:08 PM. EMS stopped the CPR for Resident 500. Resident 500 had no heart rate and the time of death was called on [DATE] at 9:11 PM. An [DATE] Incident Review/Summary progress note by Staff 3 (RNCM) summarized her investigation for the root cause of Resident 500's death was the care plan was not followed and Resident 500 was given a regular textured meat sandwich when she/he was to only have pureed texture. Resident 500 choked on the sandwich and was unable to cough, speak or call out for help due to the sandwich texture which prevented air to pass in the throat. Staff tried to intervene but were unable to dislodge the food. Staff 3, MD (Doctor of Medicine), and ARNP (Advanced Registered Nurse Practitioner) discussed Resident 500's comorbidities on [DATE] and [DATE]. The MD and ARNP agreed Resident 500's death would be documented as Accidental. On [DATE] at 12:22 PM Staff 6 (Staffing Coordinator) stated she was responsible for hiring and scheduling CNAs. New hires or agency staff were given orientation to the facility by Staff 6. Staff 6 revealed Staff 11 was an agency staff and started work at the facility on [DATE]. He completed paperwork, was given access to the electronic medical record, given CNA standards of care, shown how to access the Kardex (care plan) and other basic information. Staff 6 revealed Staff 11 read and signed the standards of care form and was given a tour of the facility. On [DATE] at 1:00 PM Staff 5 confirmed the accuracy of her progress note written on [DATE]. On [DATE] at 3:27 PM Staff 7 (CNA) stated he was working the evening of [DATE]. He was outside a resident's room and heard another staff say his name loudly, observed Resident 500 in her/his wheelchair and a staff member giving her/him the [MEDICATION(S)] Maneuver (abdominal thrusts). Staff 7 picked Resident 500 up and began the [MEDICATION(S)] Maneuver. Staff 7 said to get the nurse and Staff 5 came over, told the staff to lie Resident 500 on the floor and started CPR. Staff 7 and Staff 5 rolled the resident over and swept out her/his mouth and observed pieces of the sandwich in her/his mouth. Staff 7 revealed the CPR was stopped when paramedics arrived and the time of death was called by EMTs. Staff 7 recalled Staff 11 gave out sandwiches to residents earlier in the night. Staff 7 observed a paper plate with a sandwich with bites missing from the sandwich located next to Resident 500. Staff 7 revealed resident care plans were kept at the nurse's station and on the tablets located in resident hallways. On [DATE] at 5:17 PM Staff 10 (Housekeeping) stated he was working in the hall where Resident 500 was seated in her/his wheelchair. The first time Resident 500 was observed, she/he did not have a sandwich. When Staff 10 returned a few minutes later, he observed Resident 500 to eat the regular textured sandwich with a couple of bites taken out of it. Staff 10 gave the resident a napkin, turned around and a couple of seconds later heard Resident 500 cough. Another housekeeping staff said the resident might be choking and Staff 10 revealed Resident 500 looked as if she/he were trying to spit the food out. One of the agency CNAs said to get the nurse, and Staff 10 stated he did at that time. Staff 10 revealed he was unaware of Resident 500's dietary needs as he worked in housekeeping. On [DATE] at 10:42 AM Staff 11 stated he worked the evening shift on [DATE]. Staff 11 revealed a resident wanted a sandwich and he made sandwiches for everyone. Staff 11 confirmed he gave a regular textured sandwich to Resident 500. He went to another hall and upon return he observed Resident 500 on the floor and staff performing CPR. He ran down the hall and asked what was going on. Another staff said someone gave her/him a sandwich and Staff 11 told them he gave Resident 500 the sandwich. Staff 11 revealed he saw Resident 500 with a sandwich before at least twice and other staff said they also saw the resident with sandwiches before [DATE]. Staff 11 revealed he was assigned the room where the resident resided but did not have Resident 500 on his roster. Staff 11 confirmed he did not check anyone's care plan that night, including Resident 500's. On [DATE] at 12:32 PM Staff 12 (CNA) stated she worked the evening shift on [DATE]. She revealed after she saw Resident 500 on the floor, she asked Staff 11 what happened and he told her he gave Resident 500 a sandwich. Staff 12 asked Staff 11 why he gave a sandwich to Resident 500 because she/he was on a pureed diet. Staff 11 told her he didn't know that and nobody told him. Staff 12 revealed she never observed Resident 500 to eat sandwiches prior to [DATE] and nobody else who was present during the incident told her they observed Resident 500 eat regular textured sandwiches prior to [DATE]. On [DATE] at 1:15 PM Staff 3 (RNCM) stated Resident 500 required extensive assist with dressing, transfers and needed supervision to eat to ensure Resident 500 would eat. She confirmed Resident 500 had been requiring eating assistance for several years. Staff 3 revealed she did not heard from staff Resident 500 was given solid food prior to [DATE]. On [DATE] at 1:15 PM Staff 2 (DNS) stated new or agency CNAs were always given orientation to meet resident needs. She confirmed Staff 11 was given orientation when he started working at the facility, and it was an expectation staff would review and follow the resident care plans. On [DATE] at 1:15 PM Staff 1 (Administrator) confirmed it was an expectation facility staff reviewed and followed the resident care plans. On [DATE] at 1:15 PM Staff 3 confirmed Staff 11 did not follow Resident 500's care plan on [DATE]. Staff 3 revealed the facility immediately took steps to counsel and suspend Staff 11. In addition, all staff attended a training on care plans and diet texture, which was completed on [DATE]. On [DATE] and [DATE] Staff 3, Staff 4 (RNCM), Staff 5, Staff 7, Staff 8, Staff 9, and Staff 12 were interviewed and all expressed the standard of care was to review the care plan before they provided care, which included diet textures, for the residents. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance for F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey [DATE] and before the date of this survey [DATE]. 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F689 as evidenced by: - No deficient practice was found at F689 with additional sampled residents. - Evidence the deficient practice was identified by the facility; the facility took immediate action to immediately suspend, counsel the staff responsible, trained all staff for care plan implementation and diet texture. The Diet Textures training material was signed by 38 staff and indicated the training was completed by [DATE]. - New forms were developed and/or revised for communication of diet textures, new signage was posted for resident diets and a training at the CNA meeting for diet textures and instruction to follow the care plan was completed. - DNS, RNCM, and CNA interviews indicated knowledge and awareness of diet textures and expectations to follow residents care plans.

Based on observation, interview and record review it was determined the facility failed to implement infection control practices to prevent the spread of the COVID-19 virus from 7/16/20 through 7/21/20 for 3 of 3 hallways and 2 of 2 dining/activity rooms reviewed for infection control. This failure, determined to be an immediate jeopardy situation, resulted from lack of social distancing in communal dining and group activities, multiple staff not performing hand hygiene appropriately, not disinfecting items between residents and not offering residents cloth face coverings which exposed residents to the risk of contracting the highly communicable COVID-19 virus. Findings include: The CDC (Centers for Disease Control and Prevention), Coronavirus 2019 (COVID-19), last revised 6/19/20, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal Protective Equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. CDC, Coronavirus 2019 (COVID-19), page last updated 6/25/20, refers the facility to implement Social Distancing Measures which depend on the stages described in the CMS (Centers for Medicare & Medicaid Services) Reopening Guidance or the direction of state and local officials. CDC directs nursing facilities to implement aggressive social distancing measures (remaining at least six feet apart from others): cancel communal dining and group activities, such as internal and external activities; remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene; remind HCP (Health Care Provider) to practice social distancing and wear a facemask (for source control) when in break rooms or common areas. The Oregon Health Authority (OHA), Provisional Guidance: Clinical Care and Health Care Infection Prevention and Control for COVID-19, last revised 6/29/20, stated Universal Source Control strategies do not eliminate the need for physical distancing among Healthcare Providers in the workplace. CDC, Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19, page last updated 7/9/20, refers to the facility to implement Resident Groups: CMS is waiving the requirements . to allow for residents to have the right to participate in-person in resident groups. This waiver would only permit the facility to restrict having in-person meetings during the national emergency given the recommendations of social distancing and limiting gatherings of more than ten people. Refraining from in-person gatherings will help prevent the spread of COVID-19. The CDC, Coronavirus Disease 2019 (COVID-19), last revised 7/15/20, stated healthcare facilities should implement Universal Source Control which indicated patients and visitors should, ideally, wear their own cloth face covering upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering. Patients may remove their face covering when in their rooms but should put back on when around others or leaving their rooms. On 7/20/20 at 12:01 AM, the Oregon Health Authority reported Multnomah County had a total of 3,486 positive COVID-19 cases and 75 deaths. On 7/19/20 Multnomah County reported 123 new COVID-19 cases. This was the highest number of daily cases reported. The facility is located in Multnomah County. The facility had one positive COVID-19 staff person out of facility and two staff pending COVID-19 test results. 1. On 7/16/20 the following observations were made in the East and West dining rooms: -At 11:06 AM, 23 residents in the East dining room were seated at six tables, four residents per table. Multiple staff were plating food, passing trays and assisting residents with eating which did not allow for social distancing between residents or staff; -At 11:53 AM, 14 residents were in the West dining room with four residents seated at a table. Multiple staff were plating food, passing trays and assisting residents with eating which did not allow for social distancing between residents or staff. On 7/20/20 the following observations were made in the East dining room: -At 10:56 AM, staff were observed to set up tables and bring residents into the dining room for lunch service. Residents were in the dining room waiting with out social distancing and no masks. One resident was observed to pull her/his self along two other resident wheelchairs to assist with self propelling out of the dining room. This resident had no face mask. No staff intervention was observed to prevent the resident from touching other residents; -At 11:07 AM, there were 25 residents and 4 staff in the East dining room. There were six small tables and four residents per small square tables. No social distancing between residents or staff was observed; -At 11:18 AM, a resident, who was not socially distanced and had no face mask, was seated at the dining room table and was observed to reach over and start to pull on the back of another resident's wheelchair, then pull the resident's hair. No staff intervention to separate the residents was observed; -At 12:01 PM, the back right tables of the East dining room were observed with eight residents and four staff sitting around the small tables. The East dining room had 24 residents and seven staff in the room. The room was crowded and the staff were turning sideways to get in-between residents and lifting plates up over residents heads to get around the room. No residents had face masks on. On 7/20/20 at 11:18 AM, observations were made in the West dining room of ten residents seated awaiting lunch. By 11:30 AM, 12 residents were seated in the area with multiple staff plating food, passing trays and assisting residents with eating without being able to socially distance or wearing face masks. In an interview on 7/16/20 at 10:00 AM, Staff 2 (Infection Control Preventionist/LPN) stated the facility performed congregated dining and were not able to maintain social distancing requirements secondary to limited space. On 7/16/20 at 1:45 PM, Staff 1 (Administrator), Staff 2 (Infection Control Preventionist/LPN) and Staff 3 (CEO) acknowledged concerns with infection control practices, including communal dining and lack of social distancing of residents and staff. No additional information was provided. In an interview on 7/20/20 at 1:10 PM, Staff 15 (CNA) stated staff were unable to socially distance in the dining room and the dining rooms were very crowded during mealtime. In an interview on 7/20/20 at 2:16 PM, Staff 16 (CNA) stated the facility made no changes to dining, continued to congregate residents for dining and staff and residents were unable to maintain social distancing because of the limited space in the dining areas. Staff 16 stated staff were constantly bumping into one another. On 7/21/20 at 12:02 PM, Staff 1, Staff 2, Staff 23 (RNCM/Acting DNS) acknowledged the communal dining and lack of social distancing in the facility. 2. On 7/21/20 a record review of the facility's 5/2020, 6/2020 and 7/2020 Group Activity Calendar revealed the facility had scheduled group activities daily. The activities averaged six groups per day. These groups were identified as held on the East and West dining/activity rooms in the facility. On 7/16/20 at 10:09 AM, seven residents were seated in the East dining/activity area for a music and coffee activity; not all residents were six feet apart. Several residents lined-up in the East hallway near the East dining/activity area and were not socially distanced. By 10:35 AM, eight residents were in the music activity and were not adequately socially distanced. No residents wore masks. On 7/16/20 at 1:45 PM, Staff 1 (Administrator), Staff 2 (Infection Control Preventionist/LPN) and Staff 3 (CEO) acknowledged concerns with lack of social distancing of residents and staff. No additional information was provided. On 7/20/20 at 9:54 AM, seven residents and five staff were observed in the West dining/activity room not socially distanced and residents were not wearing masks. Residents faced the TV and five of the eight residents were sleeping. On 7/20/20 at 10:00 AM, ten residents were observed in the East dining/activity room not socially distanced and not wearing masks. Residents were facing the TV which was playing music on a dark screen with some writing. At 10:02 AM, Staff 10 (Activities Assistant) was observed to turn off the TV and announced the start of a trivia group. Twelve residents and two staff were observed in the room not socially distanced and residents not wearing masks. Ten of the 12 residents were sleeping with only one Resident answering the trivia questions. At 10:39 AM, the trivia group was observed with nine of the 11 residents sleeping. The trivia group continued at 10:46 AM with residents not socially distanced and not wearing masks. On 7/20/20 at 2:42 PM, a Bingo group was observed with ten residents and three staff in the East dining/activity room. No residents were wearing masks and not all were socially distanced. On 7/20/20 at 11:39 AM, Staff 2 (Infection Control Preventionist/LPN) stated the groups were held daily and she would expect residents socially distanced but that was often difficult as some residents wander around the room and in and out of the group space. In an interview on 7/21/20 at 8:00 AM, Witness 1 (Confidential Witness) stated there had been no changes to congregated activities with the exception that no outside visitors were allowed to enter the facility. In an interview on 7/21/20 at 9:53 AM, Staff 24 (LPN) stated activities occurred daily and social distancing was difficult due to space limitations. Staff 24 stated there had been no changes to the activity or dining program since the start of COVID-19. On 7/21/20 at 10:01 AM, Staff 10 (Activity Assistant) confirmed the facility held group activities on an ongoing basis. She reported the staff tried to keep the groups to ten residents, but that was difficult. Staff 10 confirmed residents did not wear masks in facility. On 7/21/20 at 12:02 PM, Staff 1 (Administrator), Staff 2, Staff 23 (RNCM/Acting DNS) acknowledged the lack of social distancing in the facility. 3. The Facility Policy Gracelen Terrace: Hand Hygiene Protocol/Procedure, undated, instructed all Health Care Workers (HCW) to follow hand washing/hand hygiene protocol/procedure to help prevent the spread of infection to other staff, residents and visitors. The policy determined staff were required to use alcohol hand sanitizer as follows: -After removing gloves and before donning new gloves; -Every time you remove your gloves; -Before/after direct contact with a resident. Multiple observations of staff not completing hand hygiene per CDC guidelines and/or facility policy were made from 7/16/20 through 7/20/20 between the hours of 8:00 AM and 4:00 PM. Examples of observations include: On 7/16/20 from 11:29 AM to 11:53 AM, 23 residents in the East dining room were seated at six tables with staff positioned between two residents who required assistance. Staff alternated between each resident and often touched one resident or adjusted clothing covers without hand hygiene between residents. On 7/16/20 at 11:33 AM, Staff 22 (CNA) passed trays to three resident rooms without using hand hygiene after exiting a room and/or before entering the next room. On 7/16/20 from 11:46 AM to 11:59 AM, staff in the West dining area pushed residents in wheelchairs to tables and touched residents without completing hand hygiene between residents. On 7/20/20 at 10:58 AM, Staff 12 (CNA) touched a resident wheelchair, bent over to talk to another resident and put his hands on the knees of his pants. Staff 12 proceeded to walk down the east hall and push another resident's wheelchair with no hand hygiene performed between residents. On 7/20/20 at 11:01 AM, Staff 8 (CNA) touched a resident wheelchair, then went into another resident's room and came out to the hall and touched another resident's wheelchair without hand hygiene performed between residents. On 7/20/20 at 11:03 AM, Staff 12 pushed a resident wheelchair, stood at the nurse's station and touched the countertop with no hand hygiene proir to touching counter. On 7/20/20 at 11:24 AM, Staff 16 (CNA) took a dirty cup, emptied contents into a gray bin in the West Dining hallway, doffed dirty gloves and returned to the West Dining area without completing hand hygiene before passing food to residents. On 7/20/20 at 11:28 AM, Staff 13 (CNA) wore gloves and did not change or complete hand hygiene between several residents when she touched several residents heads to put a shirt saver on the residents. On 7/20/20 at 11:29 AM, Staff 9 (CNA) tapped a resident on the chest to wake. Staff 9 proceeded to rub another resident's chest with no hand hygiene between residents. Staff 9 then went to the beverage cart, put on a pair of gloves with no hand hygiene prior to donning gloves and serving beverages. On 7/20/20 at 11:32 AM, Staff 16 donned clean gloves without completing hand hygiene then doffed gloves and donned new gloves without completing hand hygiene and at 12:12 PM, Staff 16 completed feeding assistance with a resident then initiated feeding assistance with a second resident without completing hand hygiene between residents; On 7/20/20 at 1:06 PM, Staff 15 (CNA) exited room [ROOM NUMBER] without completing hand hygiene, entered room [ROOM NUMBER] without hand hygiene and exited the room without hand hygiene. On 7/16/20 at 12:36 PM, Staff 2 (Infection Preventionist/LPN) stated she would expect staff to use hand sanitizer or wash hands between touching residents or items in residents environment. On 7/20/20 at 11:44 AM and 11:48 AM, Staff 8 and Staff 13 stated staff were expected to wash or sanitize their hands after every time they touched a resident or resident item. On 7/20/20 at 1:10 PM, Staff 15 stated hand hygiene should be performed every time a resident was touched, before putting on and after taking off gloves and between each resident when passing trays. On 7/20/20 at 2:16 PM, Staff 16 stated hand hygiene should be performed after touching a resident, before entering and after exiting a room, after feeding assistance with one resident and before starting feeding assistance with another resident and after taking off gloves. Staff 16 stated staff got very busy and sometimes forgot proper hand hygiene. On 7/21/20 at 8:00 AM, Witness 1 (Confidential Witness) stated staff do not complete hand hygiene before or after taking off gloves; that staff routinely remove gloves, put on new gloves and don't complete hand hygiene. On 7/21/20 at 12:02 PM, Staff 1 (Administrator), Staff 2 and Staff 24 (RNCM/Acting DNS) were informed of observed concerns with hand hygiene. Staff 2 stated she discussed hand hygiene with staff on multiple occasions, including hand hygiene protocol when wearing gloves and expected staff to be performing hand hygiene per protocols. 4. The CDC, Coronavirus Disease 2019 (COVID-19), last revised 7/15/20, instructed facilities to develop a schedule for regular cleaning and disinfection of shared equipment frequently touched surfaces in resident rooms and common areas. Facilities were directed to ensure EPA(United States Environmental Protection Agency)-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment . and to ensure Health Care Providers are appropriately trained in use of disinfectants. On 7/21/20 the Activity Department policy and procedures were requested. The facility was unable to provide. On 7/20/20 11:05 AM, there was observation at East nurse station of a nurse picking up the phone and giving the receiver to a resident to talk. This resident was not wearing a mask and had the receiver to her/his ear and mouth. At 11:15 AM, the resident appeared finished talking and she/he put the receiver on the counter, then picked the reciever back up. A staff came to assist resident and hung up the phone for the resident. At 11:32 AM, another resident, without a mask, was escorted to the same phone. A staff with a mask, put the phone receiver to her ear and mouth and talked, then gave to resident who put the receiver to her/his ear and mouth. At 11:34 AM, the resident hung up the phone. No disinfection of the phone prior to or after use was observed. On 7/20 at 1:02 PM, Staff 11 (Activity Assistant) was observed to exit room [ROOM NUMBER] with an old appearing stuffed animal cat. Staff 11 put the stuffed animal on the nurse's counter where other staff and residents had been observed touching the surface prior. One staff member stood over the stuffed animal while waiting to wash his hands and touched the counter. Staff 11 washed her hands, then picked up the stuffed animal off the counter, carried it close to her while touching her clothing and walked over to the West wing activity office. She then took the stuffed animal and went to East wing and gave the stuffed animal to resident in room [ROOM NUMBER] and left the stuffed animal with a resident. No sanitization of activity supply was observed. On 7/20/20 at 11:44 AM and 11:52 AM, Staff 8 (CNA) and Staff 12 (CNA) reported the phone the residents used at the nurse station was cleaned once a day. Staff 8 had no knowledge of the resident phone cleaned more than daily. On 7/21/20 at 8:19 AM, Staff 2 (Infection Control Preventionist/LPN) stated items taken room to room, items such as stuffed animals should be disinfected between residents. Staff 2 stated the resident telephone should be disinfected prior to and after resident or staff use. On 7/21/20, Staff 11 was not available for activity supplies interview due to community exposure to COVID-19 and she was pending test results before returning to facility. On 7/21/20 at 10:01 AM, Staff 10 (Activity Assistant) stated items should not be shared between residents and items should be disinfected prior to giving items to a resident. Staff 10 stated the residents play group Bingo at least two times per week and during Bingo the residents use plastic chips. The chips were brought to the activity office one time per week to wipe each one with a bleach wipe. On 7/21/20 at 12:02 PM, Staff 1 (Administrator), Staff 2 (Infection Control Preventionist/LPN) and Staff 23 (RNCM/Acting DNS) acknowledged the need for disinfecting items and implementing infection control practices when taking items in and out of resident rooms and shared items such as the telephone and activity supplies. 5. During all observations from 7/16/20 through 7/20/20 between the hours of 8:00 AM and 4:00 PM, no residents were observed wearing masks in any of the three halls including a new admit placed on 14-day monitoring precautions. In an interview on 7/16/20 at 12:36 PM, Staff 2 (Infection Control Preventionist/LPN) stated the facility did not ask residents, on any of the three halls, to wear masks when in or out of their rooms, including residents placed on 14-day monitoring precautions. On 7/21/20 at 12:02 PM, Staff 1, Staff 2, Staff 23 (RNCM/Acting DNS) acknowledged the facility had not offered face masks or face coverings to residents and no residents wore masks in the facility. Staff 1 reported several residents had asked for face masks. On 7/21/20 at 12:02 PM, the facility was informed of the immediate jeopardy situation for failure to implement infection control practices to prevent the spread of the highly communicable COVID-19 virus from 7/16/20 through 7/21/20. A plan to abate the immediate jeopardy situation was requested. On 7/21/20 at 3:38 PM, the abatement plan for the immediate jeopardy was approved. The plan included the following: -Meal services changed to ensure social distancing. -All communal activities in each dining room were discontinue immediately; -Any activity item used with a resident will be disinfected. -Education and training of staff regarding the following: -Staff to redirect residents away from each other to maintain social distancing; -All residents will be offered masks to wear, provide cues and encouragement; -Resident phones will be disinfected before and after use; -Staff in-serviced on hand hygiene; -Ongoing audits to ensure compliance conducted. On 7/21/20 at 4:25 PM the immediate jeopardy removal plan was verified based on observation conducted which showed facility staff observed had performed hand hygiene as required, meal service had changed to allow social distancing. Staff were interviewed and confirmed education was provided regarding hand hygiene, change in meal service, social distancing, disinfecting resident phone and items shared room to room offering residents mask to wear. On 7/21/20 at 4:30 PM the immediate jeopardy was abated.

Based on interview and record review it was determined the facility failed to ensure all resident specific fall interventions were in place prior to falls for 4 of 5 sampled residents (#s 1, 2, 3 and 4) reviewed for falls. Resident 1 sustained a laceration and required sutures and Resident 2 sustained injuries including a fractured finger. Findings include: 1. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 3/9/16 MDS associated CAAs indicated the resident had dementia with long term memory impairment. The assessment indicated the resident was not able to understand conversation and was not able to speak. The resident had a history of [REDACTED]. The goal was to prevent injury if the resident fell . The Care Plan revised on 6/21/16 indicated the resident was at high risk for falls related to confusion, balance problems and poor safety awareness. Interventions to prevent falls with injury included the call light was to be kept within reach, the resident was to wear non-skid footwear and the resident was to not use a chair, recliner or any type of seating in the room. The resident was a FALL RISK with the use of chairs. The 12/22/16 Quarterly Nursing Assessment indicated Resident 1 had poor safety awareness and lacked insight. The resident was assessed to be unsteady and leaned forward when the resident walked. The 2/15/17 Incident Note indicated Resident 1 fell at approximately 7:35 pm. The resident was found on the floor on her/his stomach with her/his right arm underneath the resident. The resident's right side of the face was on the floor and blood was present. The resident was transferred to bed and was observed to have a large hematoma (collection of blood outside of a blood vessel) to the right eye region. The resident was also observed with blood coming from her/his mouth. The resident had gross disfiguration of the right ring finger. The resident was transferred to a local hospital at 7:45 pm. The note indicated the resident had a club chair next to the bed and the resident's care plan directed staff not to have a chair in the resident's room. The 2/17/17 Review/Summary indicated Resident 1 was assisted to her/his room after dinner by Staff 8 (CNA). Resident 1 was assisted to sit in the chair located in the resident's room. Staff 8 left the room to answer another resident's call light. Resident 1 was found on the floor in front of the doorway inside of the resident's room. The resident showed signs of extreme pain. The resident was observed to have blood from the mouth and the resident's right ring finger appeared to be mal-aligned. The resident was transported to the local hospital for evaluation. On 2/27/17 Staff 8 (CNA) indicated he was assigned to Resident 1 on 2/15/17. After dinner Resident 1 was assisted back to her/his room and the resident sat in the chair located in the resident's room. Staff 8 indicated he was not sure if he assisted the resident to the room or if another staff assisted the resident. Resident 1 was later found on the floor by another CNA. On 2/27/17 at 11:20 am Staff 2 (DNS) indicated at the time of the facility investigation, Staff 8 (CNA) confirmed after dinner on 2/15/17 he assisted Resident 1 to the chair located in the resident's room. The 2/20/17 physician progress notes [REDACTED]. The resident fell at the facility and sustained a right forth finger dislocation, fifth finger fracture and a right eye laceration/hematoma. The note indicated the resident continued to be high risk for falls because the resident was not able to walk but still tried to stand. On 2/24/17 at 1:00 pm Staff 9 (RNCM) indicated Staff 8 (CNA) did not frequently work with Resident 1. Resident 1's family wanted the resident to have a chair in her/his room but no matter what kind of chair was used Resident 1 attempted to stand without staff assistance and fell . The care plan directed staff not to have a chair in Resident 1's room due to the resident's attempts to self transfer. Resident 1's roommate had a chair in the room and Staff 8 assisted the resident to the chair, left the room and Resident 1 fell . After dinner the resident should not have been placed in the chair but directly into bed. 2. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 9/12/16 Restraint-Physical evaluation indicated Resident 2 had frequent falls out of the wheelchair. The resident leaned forward to reach for items and fell out of the wheelchair. The resident had many falls with injury to due to the behavior of leaning forward. Interventions tried before a safety belt included the resident was not to be left alone in the resident's room. The 12/21/16 MDS and associated CAAs indicated Resident 2 had a stroke with right side weakness and dementia. The resident was assessed to have a decline in cognitive abilities including speech. The resident required a mechanical lift for transfers and used a reclining wheelchair and safety belt. The resident was not to be left alone when in the wheelchair. The resident was a high risk for falls due to dementia, confusion and impaired mobility. The Care Plan initiated on 10/5/16 indicated the resident was a high risk for falls related to dementia and poor safety awareness. The interventions identified to prevent falls include the call light was to be within reach, the resident was to be in a reclining wheelchair and a seat belt was to be used when in the wheelchair. On 2/24/17 at 9:45 am Staff 5 (CNA) indicated if Resident 2 sat in an upright position the resident leaned forward and often fell . The staff were to keep their hands on the resident or position themselves in front of the resident to prevent the resident from falling forward. On 2/24/17 at 1:30 pm Staff 7 (CNA) indicated the resident 2 attempted to stand if left unattended. The resident had a reclining wheelchair to prevent the resident from falling forward. The 12/28/16 Incident Review/Summary indicated Resident 2 was not aware she/he was not able to walk or bear weight and had a history of [REDACTED]. The summary indicated on 12/27/16 at 3:00 pm the resident fell in the shower room. A CNA assisted the resident with a shower and during the shower another resident entered the shower room. The CNA turned from the resident to redirect the other resident out of the shower room. Resident 2 fell forward and hit her/his head on the floor. The resident sustained [REDACTED]. On 2/27/17 at 10:57 am Staff 4 (CNA) indicated Resident 2 had a history of [REDACTED]. The resident used a reclining wheelchair and a safety belt in order to prevent falls. On 12/27/16 Staff 4 indicated she assisted Resident 2 with a shower. The resident was in a shower chair and the shower chair did not recline. During the shower another resident entered the shower room. Staff 4 left Resident 2's side and was approximately three feet from the resident. The resident fell forward to the floor. On 2/24/17 Staff 6 (RNCM) indicated staff were not to leave the resident's side when the resident was not reclined. On 12/27/16 Staff 4 (CNA) did not keep the resident within her reach and the resident fell forward. On 2/24/17 at 1:40 pm Staff 2 (DNS) indicated staff were to keep their eyes and hands on Resident 2 at all times. 3. Resident 3 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 1/25/16 MDS associated CAAs indicated Resident 3 was cognitively intact but at times was confused. The resident did not walk but was able to pivot transfer. The resident was assessed to be at low risk for falls. The 10/20/16 Care Plan indicated the resident was at risk for falls and interventions included the resident was to wear non-skid foot wear, the call light was to be within reach and the resident was to be encouraged to ask for staff assistance for transfers. The 11/2/16 Fall assessment indicated the resident was at high risk for falls due to a history of falls, impaired gait and the use of furniture for support. The 11/20/16 Progress Note indicated the resident had a failed self transfer and was found on the floor. The care plan was updated to include a fall mat was to be placed at the resident's bed side. The 12/4/16 Incident Review/Summary note indicated the resident had a failed self transfer and was found on the ground. A tab alarm was added to the resident care plan to alert staff if Resident 3 attempted to self transfer. The 12/18/16 Progress Note indicated the resident fell the previous night and had an extensive hematoma to the left eye region. The 12/18/16 Hospital Emergency Department report indicated the resident fell . The resident had pain and bruising. The resident did not have a loss of consciousness. The resident was alert and was in no acute distress. Imaging studies were performed of the resident's head, neck and pelvis and injuries were not identified. The resident was discharged back to the facility. The undated Resident Occurrence Report and associated Incident Review Summary indicated Resident 3 fell on [DATE] at 12:10 am. Staff 11 (CNA) was the resident's assigned CNA. The summary indicated the resident's alarm sounded, staff entered the room and Resident 3 was found on the floor next to the bed. The resident's call light was noted to be on but it was unclear how long the light was on before staff entered the room. The resident indicated she/he reached for something and fell . The resident had an egg sized hematoma on the left forehead region and the area was purple. The summary indicated the resident was sent to the emergency department for evaluation. The resident was found to not have head trauma and/or fractures. The summary also indicated Resident 3 was care planned to have a fall mat at the bedside, bolsters (foam to help identify edge of bed) and a tab alarm when the resident was in bed. The summary indicated the resident did not have a fall mat at the side of the bed and bolsters were not in place at the time of the fall. On 2/27/17 at 9:40 am and on 2/28/17 at 9:36 am a telephone call was placed to Staff 11 (CNA). A return call was not received. On 2/24/17 at 10:35 am Staff 2 (DNS) indicated bolsters were used to help residents identify the edge of the bed. Staff 2 acknowledged on 12/18/16 the fall mat and the bolsters were not in place when Resident 3 fell . 4. Resident 4 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 8/8/16 Admission MDS and associated CAAs indicated Resident 4 was cognitively impaired and required staff assist with all ADLs. The resident had a history of [REDACTED]. The Care Plan initiated on 8/1/16 indicated the resident was at risk for falls. The interventions to prevent falls and injury included the resident's bed was to be in the lowest position, the resident was not to be left unattended in the bathroom, a fall mat was to be at the bedside, bolsters (foam pillows) were to be used for positioning to help the resident recognize the edge of the bed, the resident was to have non-skid socks on and the resident was to have an alarm in bed and in the wheelchair. The 2/2/17 Progress Note indicated the resident was found on the floor. The resident was in front of her/his wheelchair. The note indicated the tab alarm was not in place. The resident was assessed to not have injuries. On 2/24/17 at 12:00 pm Staff 10 (CNA) indicated she worked with the resident on 2/2/17. She assisted the resident to the wheelchair and took the resident to the dining room. Staff 10 indicated she forgot to place the alarm on the resident when she assisted the resident to the wheelchair. After Resident 4 finished breakfast, the resident propelled her/his wheelchair back to the room and the resident was found on the floor approximately 15 minutes after breakfast. On 2/24/17 at 11:15 am Staff 2 (DNS) acknowledged Resident 4 fell and the tab alarm was not on the resident as directed by the care plan.

Based on observation, interview and record review it was determined facility staff failed to follow professional standards regarding medication administration for 4 of 4 sampled residents (#s 1, 2, 3, & 4) reviewed for medication errors. As a result, Resident 1 became unresponsive and required hospitalization and Resident #s 2, 3 and 4 were at risk for adverse side effects from the medication errors. Findings include: Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides 851-063-0070 Authorized Duties and Standards for Certified Medication Aides (1) Under supervision by a licensed nurse, CMAs may administer: (a) Oral, sublingual and [MEDICATION NAME] medications; (2) Administration of PRN Medications. CMAs may administer PRN medications (including controlled substances) to stable clients according to physician's or nurse practitioner's orders in the following circumstances: (a) In response to specific client requests: (A) Client request must be reported to licensed nurse; and (B) Client response must be reported to licensed nurse. (b) At the direction of the licensed nurse, when: (3) CMAs may: (a) Administer regularly scheduled controlled substances; (b) Jointly witness wasted controlled substances with a licensed nurse; (9) Standards of Care for Certified Medication Assistants. In the process of client care the CMA shall consistently apply standards set for CNAs and: (a) Establish competency as a CMA; (b) Maintain competency as a CMA; (c) Perform within Authorized Duties; (d) Follow written instructions of a licensed health care professional authorized to independently diagnose and treat as transcribed in the Medication Administration Record (MAR); and (e) Accurately record on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] administered, medications withheld or refused and the reason why a medication was withheld or refused. 1. Resident 1 was admitted to the facility in 1996 with [DIAGNOSES REDACTED]. According to Resident 1's 3/2012 MAR, Resident 1 was scheduled to receive medications at 8:00 pm, including [MEDICATION NAME] 50 mg (an anti-hypertensive medication), [MEDICATION NAME] 20 mg (a cholesterol medication), [MEDICATION NAME] 5-500 (a narcotic medication) and [MEDICATION NAME] inhaler (an asthma medication). According to a 3/22/12 Medication Error Incident Report, Resident 1 was given his/her roommate's 8:00 pm medications, including Calcium 500 mg, Klonopin 1 mg (a benzodiazepine), [MEDICATION NAME] mg (a narcotic medication) and [MEDICATION NAME] 400 mg (an antipsychotic medication). Staff 7, CMA, documented on Resident 1's roommate's Narcotic Records for [MEDICATION NAME] that those medications had been "wasted" due to falling to the floor. The facility's investigation revealed at 7:30 pm, Staff 7, CMA, went into Resident 1's room to provide medications to his/her roommate. Resident 1 waved Staff 7 over and Staff 7 engaged in conversation with Resident 1. While talking with the resident, Staff 7 gave Resident 1 the medications she was holding in her hands. Staff 7 reportedly realized her mistake as Resident 1 was swallowing the medications and informed the resident she had provided him/her with the wrong medications. Staff 7 left the room and proceeded with her medication pass, preparing and administering Resident 1's routine medications. Resident 1 put the call light on and informed Staff 2, CNA, that Staff 7 had given him/her the wrong medications. According to Staff 7's, CMA, documented witness statement, she was taking medications in for Resident 1's roommate and ending up talking with Resident 1. Staff 7 documented she did not realize they were the wrong medications until it was too late. According to Staff 2's, CNA, documented witness statement, Resident 1 had informed her of the medication error. Staff 2 left the room and asked Staff 7, CMA, about the resident's report. Staff 7 stated she had given the wrong medications to Resident 1. Staff 2 told Staff 7 to inform the nurse. According to Staff 3's, CMA, documented witness statement, she was on the east side of the building when Staff 2, CNA, informed her about the medication error. Staff 3 documented "I made it clear that if they didn't say anything I would." According to Staff 4's, LPN, documented witness statement, Staff 7, CMA, notified her at 7:55 pm Resident 1 was given his/her roommate's medications. Additionally, Resident 1 was given his/her regular medications after the incident, however, Staff 7 had not consulted with Staff 4 prior to administering those medications. Staff 7 reported to Staff 4 the medications were given at 7:30 pm, then later stated she had reported the incident as soon as she was aware of the error. A 3/22/12 IDT (Interdisciplinary Team) Progress Note disclosed the physician was contacted, who stated with the large [MEDICATION NAME] dose, the resident would most likely be somnolent. The physician ordered for staff to assess Resident 1's oxygen saturation and vital signs every two hours. It was further noted Staff 6, DNS, directed staff to do neurological checks for the resident's responsiveness every hour. At the time of the medication error and at 9:30 pm, the resident's vital signs and oxygen saturation levels were stable and he/she was responsive. A 3/23/12 IDT Progress Note revealed at hourly checks from 10:00 pm to 2:00 am, Resident 1's vital signs and oxygen saturation levels were within normal limits. At 3:00 am, Resident 1 was found unresponsive and 911 was called. Resident 1 was sent to the hospital. A 3/23/12 IDT Progress Note disclosed the resident was still at the hospital, remained somnolent, but arousable. The resident continued on cardiac and respiratory monitoring and received IV hydration to maintain hydration and flush excess medications from his/her system. The resident re-admitted to the facility on [DATE]. The 3/23/12 Hospital History and Physical described Resident 1 was "quite somnolent." The resident received [MEDICATION NAME] (an antidote) twice, with no significant documented improvement immediately following the [MEDICATION NAME]. Resident 1 was diagnosed with [REDACTED]. On 5/21/12 at 11:00 am, Resident 1 was observed to be cognitively impaired, sitting in the dining room. In interview on 5/21/12 at 8:30 am, Staff 1, RNCM, stated Resident 1 could remember things if asked within a "short window." However, if the resident had taken a nap, he/she would not remember information. Staff 1 stated after the 3/22/12 incident, Staff 7, CMA, was pulled off the floor and no longer worked in the facility. In interview on 5/21/12 at 10:15 am, Staff 2, CNA, stated Resident 1 had the call light on around 7:30 pm. Staff 2 stated she went into the resident's room and thought it was about getting his/her nightly soda as that was when the resident usually got a soda. Resident 1 told her "she gave me the wrong medicine." Staff 2 stated she left the resident's room and asked Staff 7, CMA, if the resident had been given the wrong medications. Staff 7 confirmed the medication error, however, had not reported it to the nurse. In interview on 5/21/12 at 10:23 am, Staff 3, CMA, stated while passing medications on the east side of the building, Staff 2, CNA, had informed her Resident 1 reported being given the wrong medications. Staff 3 stated she spoke with Staff 2 and Staff 7, informing them if they did not report it to the nurse, she would. Staff 7 had stated to her she had not reported the medication error due to not finding the nurse. Staff 3 stated when she found the nurse herself, Staff 7 was talking with the nurse. Staff 3 stated there was at least 30 to 45 minutes from the time of the incident until it was reported to the nurse. In interviews on 5/21/12 at 11:35 am and 11:48 am, Staff 6, DNS, stated Resident 1 was cognitively impaired and would not remember the incident. When asked how the facility monitored for possible medication errors, Staff 6 stated staff watched for medication errors, their pharmacist performed audits and narcotic records were audited. Staff 6 stated she had worked with Staff 7, CMA, for several years and she had been "steady as a rock", but then staff began reporting Staff 7 for medication errors. Staff 6 stated she talked with Staff 7, who reported having personal problems. Staff 6 stated she reminded Staff 7 to be focused with her medications and to report if she was feeling "stressed out." In interview on 5/21/12 at 2:33 pm, Staff 4, LPN, stated she was coming out from break and Staff 7, CMA, reported giving Resident 1 the wrong medications. Staff 4 stated Staff 7 denied telling Resident 1 about giving him/her the wrong medications. Staff 4 stated Staff 7's statements changed over the evening and when asked why it took her so long to report the incident, Staff 7 stated she had informed Staff 4 as soon as it had occurred. Per Staff 4, Staff 7 did not report it timely, but rather, there was a 30 to 45 minute delay. Staff 7 stated "it appeared she was not going to tell anyone" as Staff 4 had documented on the narcotic records the medications were wasted due to falling on the floor. In interview on 5/22/12 at 12:50 pm, Staff 5, LPN, stated she had completed neurological checks on Resident 1 throughout the night. Staff 5 stated the resident was responsive and at his/her baseline. Staff 5 stated when Resident 1 exhibited a change, he/she was sent out to the hospital. After many unsuccessful attempts, Staff 7, CMA, was unable to be contacted. The facility's investigation found multiple areas of concern regarding Staff 7's actions: Staff 7 failed to notify the LPN of the event immediately, but rather waited 25 minutes after the occurrence; Staff 7 provided Resident 1 with additional medications without advice or directives from the LPN or physician after completing the medication error; Staff 7 required the encouragement/directives of two other staff members to report the incident; and Staff 7 documented on the roommate's records the medications were dropped on the floor, then wasted. Staff 7's signature was the only one confirming that action and was there was no co-signature of the LPN. 2. Resident 2 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. Resident 2's 12/2011 physician's orders [REDACTED]. According to the 1/2012 MAR, Staff 7, CMA, documented administering Klonopin to Resident 1 on 1/8/12 at 8:00 pm. A 1/9/12 IDT (Interdisciplinary Team) Progress Note disclosed Resident 2 inadvertently missed the 1/8/12 8:00 pm Klonopin dose. No behaviors or [MEDICAL CONDITION] activity was noted from the missed dose. According to the 1/8/12 Medication Error Incident Report, Resident 1's Klonopin ran out, Staff 7, CMA, failed to notify the LN (licensed nurse) and the resident missed the dose. It was noted Staff 7 stated she did not notify the West Hall LN because she was gone and had no response as to why she did not notify the East Hall LN. In interviews on 5/21/12 at 11:35 am and 11:48 am and on 5/22/12 at 12:00 pm, Staff 6, DNS, stated she had worked with Staff 7, CMA, for several years and she had been "steady as a rock", but then staff began reporting Staff 7 for medication errors. Staff 6 stated she talked with Staff 7, who reported having personal problems. Staff 6 stated she reminded Staff 7 to be focused with her medications and to report if she was feeling "stressed out." Staff 6 stated she reviewed Resident 2's narcotic records and determined the 1/8/12 8:00 pm dose had not been given. Staff 6 stated Staff 7 falsely documented administering the medication to the resident. After many unsuccessful attempts, Staff 7, CMA, was unable to be contacted. 3. Resident 3 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Resident 3's 2/2012 physician's orders [REDACTED]. A 2/8/12 IDT (Interdisciplinary Team) Progress Note revealed Resident 3 complained of generalized body pain at 5:20 pm and was given PRN [MEDICATION NAME]. According to the 2/2012 MAR, on 2/8/12, Resident 3 received the routine [MEDICATION NAME] 5 mg at 7:00 am, 2:00 pm and 8:00 pm. At 5:20 pm, Staff 7, CMA, documented Resident 3 received a PRN 2.5 mg dose of [MEDICATION NAME]. According to Resident 3's routine [MEDICATION NAME] 5 mg Narcotic Record, the resident was administered four doses on 2/8/12, including one dose that was identified as a PRN. A 2/9/12 IDT Progress Note revealed when the CMA was instructed to provide the resident with the PRN [MEDICATION NAME], rather than giving 2.5 mg per orders, the CMA gave 5 mg. After receiving the medication, the resident was up and self ambulatory, per his/her baseline. According to the Medication Error Incident Report, Resident 3 had no noted immediate adverse effects from the medication error. Staff 7 was educated on proper PRN dosage and was informed to ensure looking at MARs for proper medication administration. In interviews on 5/21/12 at 11:35 am and 11:48 am and on 5/22/12 at 12:00 pm, Staff 6, DNS, stated she had worked with Staff 7, CMA, for several years and she had been "steady as a rock", but then staff began reporting Staff 7 for medication errors. Staff 6 stated she talked with Staff 7, who reported having personal problems. Staff 6 stated she reminded Staff 7 to be focused with her medications and to report if she was feeling "stressed out." In interview on 5/21/12 at 2:33 pm, Staff 4, LPN, stated she recalled the incident occurring, but could not recall specific details. After many unsuccessful attempts, Staff 7, CMA, was unable to be contacted. 4. Resident 4 admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Resident 4 had 2/23/12 physician's orders [REDACTED]. According to the 3/2012 MAR, Staff 7, CMA, documented administering [MEDICATION NAME] to Resident 4 on 3/2/12 and 3/3/12 at 8:00 pm. According to a Medication Error Incident Report, Resident 4 missed the scheduled doses of [MEDICATION NAME] at 8:00 pm on 3/2/12 and 3/3/12. The resident's medication card was still in the medication room on 3/4/12, unused and there were no missing doses from the day medication card. No immediate adverse effects were noted as of 3/5/12. In interviews on 5/21/12 at 11:35 am and 11:48 am and on 5/22/12 at 12:00 pm, Staff 6, DNS, stated she had worked with Staff 7, CMA, for several years and she had been "steady as a rock", but then staff began reporting Staff 7 for medication errors. Staff 6 stated she talked with Staff 7, who reported having personal problems. Staff 6 stated she reminded Staff 7 to be focused with her medications and to report if she was feeling "stressed out." Staff 6 stated Staff 7 had falsely documented administering those medications to Resident 4. After many unsuccessful attempts, Staff 7, CMA, was unable to be contacted.

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was free from significant medication errors. As a result, Resident 1 became unresponsive and required hospitalization . Findings include: Resident 1 was admitted to the facility in 1996 with [DIAGNOSES REDACTED]. According to Resident 1's 3/2012 MAR, Resident 1 was scheduled to receive medications at 8:00 pm, including [MEDICATION NAME] 50 mg (an anti-hypertensive medication), [MEDICATION NAME] 20 mg (a cholesterol medication), [MEDICATION NAME] 5-500 (a narcotic medication) and [MEDICATION NAME] inhaler (an asthma medication). According to a 3/22/12 Medication Error Incident Report, Resident 1 was given his/her roommate's 8:00 pm medications, including Calcium 500 mg, Klonopin 1 mg (a benzodiazepine), [MEDICATION NAME] mg (a narcotic medication) and [MEDICATION NAME] 400 mg (an antipsychotic medication). The facility's investigation revealed at 7:30 pm, Staff 7, CMA, went into Resident 1's room to provide medications to his/her roommate. Resident 1 waved Staff 7 over and Staff 7 engaged in conversation with Resident 1. While talking with the resident, Staff 7 gave Resident 1 the medications she was holding in her hands. Staff 7 reportedly realized her mistake as Resident 1 was swallowing the medications and informed the resident she had provided him/her with the wrong medications. Staff 7 left the room and proceeded with her medication pass, preparing and administering Resident 1's routine medications. Resident 1 put the call light on and informed Staff 2, CNA, that Staff 7 had given him/her the wrong medications. According to Staff 7's, CMA, documented witness statement, she was taking medications in for Resident 1's roommate and ending up talking with Resident 1. Staff 7 documented she did not realize they were the wrong medications until it was too late. According to Staff 2's, CNA, documented witness statement, Resident 1 had informed her of the medication error. Staff 2 left the room and asked Staff 7, CMA, about the resident's report. Staff 7 stated she had given the wrong medications to Resident 1. Staff 2 told Staff 7 to inform the nurse. According to Staff 3's, CMA, documented witness statement, she was on the east side of the building when Staff 2, CNA, informed her about the medication error. Staff 3 documented "I made it clear that if they didn't say anything I would." According to Staff 4's, LPN, documented witness statement, Staff 7, CMA, notified her at 7:55 pm Resident 1 was given his/her roommate's medications. Additionally, Resident 1 was given his/her regular medications after the incident, however, Staff 7 had not consulted with Staff 4 prior to administering those medications. Staff 7 reported to Staff 4 the medications were given at 7:30 pm, then later stated she had reported the incident as soon as she was aware of the error. A 3/22/12 IDT (Interdisciplinary Team) Progress Note disclosed the physician was contacted, who stated with the large [MEDICATION NAME] dose, the resident would most likely be somnolent. The physician ordered for staff to assess Resident 1's oxygen saturation and vital signs every two hours. It was further noted Staff 6, DNS, directed staff to do neurological checks for the resident's responsiveness every hour. At the time of the medication error and at 9:30 pm, the resident's vital signs and oxygen saturation levels were stable and he/she was responsive. A 3/23/12 IDT Progress Note revealed at hourly checks from 10:00 pm to 2:00 am, Resident 1's vital signs and oxygen saturation levels were within normal limits. At 3:00 am, Resident 1 was found unresponsive and 911 was called. Resident 1 was sent to the hospital. A 3/23/12 IDT Progress Note disclosed the resident was still at the hospital, remained somnolent, but arousable. The resident continued on cardiac and respiratory monitoring and received IV hydration to maintain hydration and flush excess medications from his/her system. The resident re-admitted to the facility on [DATE]. The 3/23/12 Hospital History and Physical described Resident 1 was "quite somnolent." The resident received [MEDICATION NAME] (an antidote) twice, with no significant documented improvement immediately following the [MEDICATION NAME]. Resident 1 was diagnosed with [REDACTED]. On 5/21/12 at 11:00 am, Resident 1 was observed to be cognitively impaired, sitting in the dining room. In interview on 5/21/12 at 8:30 am, Staff 1, RNCM, stated Resident 1 could remember things if asked within a "short window." However, if the resident had taken a nap, he/she would not remember information. Staff 1 stated after the 3/22/12 incident, Staff 7, CMA, was pulled off the floor and no longer worked in the facility. In interview on 5/21/12 at 10:15 am, Staff 2, CNA, stated Resident 1 had the call light on around 7:30 pm. Staff 2 stated she went into the resident's room and thought it was about getting his/her nightly soda as that was when the resident usually got a soda. Resident 1 told her "she gave me the wrong medicine." Staff 2 stated she left the resident's room and asked Staff 7, CMA, if the resident had been given the wrong medications. Staff 7 confirmed the medication error, however, had not reported it to the nurse. In interview on 5/21/12 at 10:23 am, Staff 3, CMA, stated while passing medications on the east side of the building, Staff 2, CNA, had informed her Resident 1 reported being given the wrong medications. Staff 3 stated she spoke with Staff 2 and Staff 7, informing them if they did not report it to the nurse, she would. Staff 7 had stated to her she had not reported the medication error due to not finding the nurse. Staff 3 stated when she found the nurse herself, Staff 7 was talking with the nurse. Staff 3 stated there was at least 30 to 45 minutes from the time of the incident until it was reported to the nurse. In interviews on 5/21/12 at 11:35 am and 11:48 am, Staff 6, DNS, stated Resident 1 was cognitively impaired and would not remember the incident. When asked how the facility monitored for possible medication errors, Staff 6 stated staff watched for medication errors, their pharmacist performed audits and narcotic records were audited. Staff 6 stated she had worked with Staff 7, CMA, for several years and she had been "steady as a rock", but then staff began reporting Staff 7 for medication errors. Staff 6 stated she talked with Staff 7, who reported having personal problems. Staff 6 stated she reminded Staff 7 to be focused with her medications and to report if she was feeling "stressed out." In interview on 5/21/12 at 2:33 pm, Staff 4, LPN, stated she was coming out from break and Staff 7, CMA, reported giving Resident 1 the wrong medications. Staff 4 stated Staff 7 denied telling Resident 1 about giving him/her the wrong medications. Staff 4 stated Staff 7's statements changed over the evening and when asked why it took her so long to report the incident, Staff 7 stated she had informed Staff 4 as soon as it had occurred. Per Staff 4, Staff 7 did not report it timely, but rather, there was a 30 to 45 minute delay. In interview on 5/22/12 at 12:50 pm, Staff 5, LPN, stated she had completed neurological checks on Resident 1 throughout the night. Staff 5 stated the resident was responsive and at his/her baseline. Staff 5 stated when Resident 1 exhibited a change, he/she was sent out to the hospital. After many unsuccessful attempts, Staff 7, CMA, was unable to be contacted.

Based on interview and record review it was determined that the facility failed to provide the necessary care and services for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 fell and sustained a skull fracture and laceration which required sutures. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/20/10 Quarterly MDS indicated the resident had short term and long term memory problems and moderately impaired decision making skills. He required extensive assistance with transfers, ambulation and ADLs. The RAP summary revealed foot rests were not used on his wheelchair as it put his legs in a position of discomfort due to his arthritis. The resident was assessed at high risk for falls related to a history of falls, lack of safety awareness, decreased strength, potential for his feet to be caught under the wheelchair when mobile and the use of a diuretic and antipsychotic. Care planned interventions included to cue the resident to "walk with his feet" when transporting him in the wheelchair, to be aware of the placement of his feet to prevent his feet from being caught under his wheelchair, a low bed, fall mat at the bedside and non-skid foot wear. On 7/25/10 an IR (Incident Report) revealed the resident sustained [REDACTED]. Reportedly he put his feet down and fell forward from the wheelchair. The care plan was revised at that time to "cue" the resident and to be aware of the placement of his feet when propelling him in his wheelchair. An IR revealed on 8/26/10, at approximately 7:30 am the resident fell face forward from his wheelchair landing on the floor in the doorway of his room. The emergency medical system was activated and the resident was transported to the hospital. Hospital records revealed a CT scan was performed and concluded the resident sustained [REDACTED]. The IR indicated a CNA (Staff 4) was in the process of taking the resident to the dining room in his wheelchair prior to the fall. "Care planned to cue resident to pedal with foot, make sure he is lifting feet so they don't get pushed under the chair as it goes forward." The Witness Statement completed by Staff 4 revealed, "I got him up and as I was pushing him out of his room he was too weak to hold himself up and ended up falling and cutting his face. He was sitting in the wheelchair when he fell forward." She repeated in the witness statement she was pushing him in his wheelchair at the time of the fall. In interview on 9/9/10 at 9:15 am, Staff 1, DNS, stated she was concerned regarding conflicting statements provided related to the fall. "I interviewed the RN charge nurse (Staff 3) and the CNA (Staff 4) together. When I spoke to the CNA I asked her if she knew where his feet were supposed to be. She could not provide the information. I asked her why she did not attempt to stop his fall and she reported it happened too fast and she was looking to the side. She reported the resident was too sick to get out of bed and the charge nurse told her to get him up. The charge nurse reported that the resident was at baseline." In interview on 9/9/10 at 11:10 am, Staff 4 stated, "When I saw the resident the day of the fall he did not look good. I went and told the charge nurse he looked bad. She saw the resident and told me to get him up. I was with another CNA (Staff 5) and she helped transfer him to the wheelchair. She said, 'He looks like he is dying.' He was leaning forward in the wheelchair and I pulled him back. We were going to the hallway and another resident was blocking the doorway. I moved the resident in the doorway and came back to the resident's wheelchair. I did not push the chair, I just touched it. He fell forward to the floor. I had not yet moved the chair." She could not describe the position of the resident's feet prior to the fall. She did not report if she cued the resident to walk with his feet. In interview on 9/9/10 at 11:40 am, Staff 3 stated she was the charge nurse the day the resident fell on [DATE]. "I saw the resident approximately 10 minutes prior to the fall. He had gurgling sounds at the back of his throat and I performed oral suctioning. He occasionally requires suctioning, not unusual. I don't recall the CNA asking if she should get the resident up or not. When I was with the resident he was coherent, answering questions appropriately. He did not look awful. He has his ups and downs....His mannerisms were at his baseline. I was called to the room when he fell . He was on the floor in the doorway of his room. I called 911 as another nurse had entered the room." In interview on 9/9/10 at 12:30 pm, Staff 2, RNCM, stated she had not seen the resident on 8/26/10 until the fall occurred. "He has been progressing with his dementia. He has been running a low grade fever. The physician did not want to perform extensive testing due to his comorbidities and prognosis. When I saw the resident on the floor he was partially in his room and into the hallway." In interview on 9/9/10 at 1:00 pm, Staff 5 stated she was asked by Staff 4 to assist her with the resident transfer from his bed to his wheelchair on the day of the fall. Staff 5 was asked by the surveyor to describe the resident prior to the transfer. "He looked tired but not sick. He looked like himself." She was asked if she stated to Staff 4 that the resident looked like he was dying. She reported to the surveyor that she did not make that statement. In interview on 9/9/10 at 2:10 pm, Staff 6, RNCM, stated she had counseled Staff 4 previously related to her not following the care plan related to fall prevention. "When I spoke with her she did not appear to know what was on the care plan. Those were long standing safety interventions." Staff 4's Witness Statement and interview with the DNS confirmed she pushed the resident's wheelchair and he fell forward. She could not describe the position of his feet or that she had cued the resident before moving him in the chair. She described the resident as "looking bad" and that was the reason he fell . Two witnesses who saw the resident prior to the fall stated he was at baseline. She reported to the DNS she could not attempt to stop the fall as it happened too quickly and she was looking to the side. Therefore she could not know the position of the resident's feet. She reported to the surveyor she had not pushed the chair and that she only touched the chair. Prior to the fall she stated the resident leaned forward in his wheelchair and she pulled him back. The fact that he was leaning forward prior to the fall indicated he required closer supervision. The accident was reasonably foreseeable. The resident returned to the facility on [DATE] on hospice care. He could not provide any information related to the fall. .