Every finding on record at Gresham Post Acute Care and Rehabilitation

Based on observation, interview and record review it was determined the facility failed to assess, implement treatment and provide on-going monitoring to prevent pressure ulcers for 1 of 2 sampled residents (#30) reviewed for pressure ulcers. This failure resulted in Resident 30 developing a facility acquired Stage 2 pressure ulcer (a shallow wound involving partial skin loss). Findings include: The facility's 10/2024 Skin Management Policy and Procedure directed the following:-If new skin impairments are found, the licensed nurse will notify the resident, notify the provider, obtain treatment orders, initiate and document pertinent details in the risk management, document findings in the clinical record and place the resident on alert. -Wounds rounds and photo documentation will be completed within seven days for a pressure ulcer/injury. -If a resident refuses skin evaluation, education will be provided and documented. If the resident continues to refuse for 24 hours, staff will notify the RCM or designee who will meet with the resident and complete a managed risk agreement. Resident 30 was admitted to the facility in 11/2022 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso) and dependence on a ventilator (when a person cannot breathe adequately on their own and relies on a machine for life). Resident 30's 9/25/25 Braden Scale for Predicting Pressure Sore Risk indicated the resident was at high risk to develop pressure ulcers. Resident 30's 10/1/25 Annual MDS revealed the resident was cognitively intact, experienced upper and lower extremity impairment on both sides, was dependent upon staff assistance to complete all ADLs and was at risk of developing pressure ulcers. Resident 30's 12/2/25 Skin Impairment Care Plan revealed the following:-The resident had pressure ulcers on her/his right gluteus (buttocks), left plantar great toe (bottom of her/his big toe), left medial (inner part) ankle and right elbow. -The licensed nurse was to be notified of any new skin issues. -Weekly treatment documentation was to include measurement of each area of skin's breakdown's width, length, depth and type of tissue, exudate (fluid that leaks from blood vessels into nearby tissues, often in response to injury, infection or inflammation) and any other notable changes or observations. -Abnormalities, failure to heal, signs and symptoms of infection and maceration (skin breakdown from being too wet) were to be reported to the physician. A 12/13/25 Skin Integrity Form initiated by Staff 21 (LPN) revealed a pressure ulcer was found by Staff 21 on Resident 30's right ring finger after the resident requested the dressing on her/his right hand to be changed. The form did not indicate any additional details about the wound including staging, size, wound bed appearance, exudate (fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) or presence of signs of infection. The form did not provide any information regarding who or why a dressing was placed on the resident's right ring finger prior to it being changed on 12/13/25.A 12/13/25 Progress Note indicated Resident 30 had a pressure ulcer on her/his right ring finger, and the resident's right hand was to be elevated in order to relieve pressure on the area.On 12/15/25 at 10:12 AM, Resident 30 was observed in her/his room in bed. The back of the resident's right hand was observed to push into the mattress on her/his bed. No pillow or padding was observed in place to help reduce the pressure to the resident's pressure ulcer on her/his right hand. Resident 30 stated she/he was dependent on assistance from staff to move her/his right arm/hand and regularly requested staff to place a pillow under her/his right wrist to help reduce pressure, but staff refused. On 12/15/25 at 12:34 PM, Resident 30 was observed in her/his room in bed. The resident's right hand was pushed into the mattress without any pillow or padding in place to help alleviate pressure to the resident's pressure ulcer. Random observations of Resident 30 on 12/16/25 from 1:20 PM to 5:03 PM revealed the resident was in her/his room in bed. A pillow was placed under the resident's right wrist in such a way that the pressure ulcer on the resident's right ring finger pushed into the bed. On 12/16/25 at 5:10 PM, Staff 21 stated Resident 30 refused most care but would allow staff to prop up her/his right hand on a pillow for pressure relief. On 12/17/25 at 1:28 PM, Staff 22 (RN) observed Resident 30 in her/his room in bed with a pillow placed under the resident's right wrist. Staff 22 stated the resident's pressure ulcer on her/his right hand was directly on the bed and did not receive any pressure relief because of how the pillow was positioned. With Resident 30's permission, Staff 22 removed the dressing that covered the resident's pressure ulcer on her/his ring finger. The wound bed was bright red and blood dripped from the wound. The wound was approximately the size of a quarter in diameter. Staff 22 completed the treatment to the wound and then propped the resident's right wrist on a pillow to offload Resident 30's right hand/ring finger. On 12/17/25 at 6:58 AM, Staff 23 (CNA) stated Staff 24 (RN) informed her Resident 30's right hand was to be floated as the resident had a wound on her/his hand. Staff 23 stated she had not had the opportunity to float the resident's right hand, and she had not seen a pillow used to offload the resident's right hand when she had been in the resident's room. On 12/17/25 at 7:16 AM, Staff 25 (CNA) stated Resident 30 wanted a pillow placed under her/his right hand and did not refuse when it was offered. Staff 25 stated he last saw a pillow used to offload the resident's right hand on 12/13/25 but had not seen the resident since this time. On 12/17/25 at 9:44 AM and 12/19/25 at 8:03 AM, Staff 24 stated she observed the pressure ulcer on Resident 30's knuckle on her/his right ring finger approximately two-to-three weeks ago during wound rounds. Staff 24 stated she did not obtain measurements of the wound, assess the wound, initiate a Skin Integrity Form or obtain treatment orders. Staff 24 stated she was just waiting for orders so she was just treating it on my own. Staff 24 stated when she initially observed the wound, it was a Stage 2 pressure ulcer and was approximately the size of a pencil eraser in diameter. Staff 24 stated she completed treatments to the resident's right hand and ensured the resident's right hand was offloaded for the two days after the wound was discovered, and the resident's wound improved. Staff 24 stated the resident wound got worse again because treatments were not completed on the days she did not work at the facility. Staff 24 stated the wound was currently a Stage 2 but had increased to approximately the size of a quarter in diameter. Staff 24 stated she informed Resident 30 she/he had a pressure ulcer on her/his fourth right finger a few weeks ago as a result of her/his hand being smashed into the bed. Staff 24 stated she educated the resident on the importance of off-loading pressure on her/his right hand. Staff 24 further stated she was the nurse assigned to Resident 30's care on 12/15/25, and no staff reported to her that Resident 30 refused to elevate her/his right hand. On 12/17/25 at 3:28 PM, Staff 26 (LPN Resident Care Manager) stated she expected Resident 30's right hand to be elevated at all times to provide pressure relief, and if the resident refused her/his hand to be elevated, staff should notify the nurse. Staff 26 further stated a Skin Integrity Form should have been initiated at the time the resident's wound was initially discovered to ensure the resident received timely treatment. On 12/18/25 at 3:01 PM Staff 21 stated the wound on the resident's right hand was beefy red but did not bleed when she initially observed it on 12/13/25. Staff 21 stated she could not remember if she measured the wound on 12/13/25 and could not provide any additional details.On 12/19/25 at 8:13 AM Staff 2 (DNS) stated a Skin Integrity Form should have been initiated at the time Resident 30's right hand wound was initially discovered so a root cause analysis could have been completed, appropriate treatments put in place and a timely assessment of the resident's wound, including staging and measurement information, was obtained.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming for 2 of 3 sampled residents (#s 5 and 58) reviewed for ADLs. This placed residents at risk for poor grooming. Findings include: 1. Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain). A review of Resident 58's 12/8/25 annual comprehensive MDS revealed she/he was dependent on staff for personal hygiene tasks and did not have any rejection of care. Resident 58's care plan dated 1/23/25 revealed the resident was dependent on staff and required two staff members for ADL care and for daily shaving. Care conference notes dated 7/15/25 and 9/11/25 revealed Witness 3 (Family Member) had raised concerns of Resident 58 not receiving personal hygiene cares daily. Daily observations from 12/15/25 through 12/18/25 from the hours of 9:00 AM to 12:00 PM revealed Resident 58 to have dark hairs of varying lengths up to one half inch growing from her/his chin. On 12/16/25 at 9:22 AM Witness 3 stated Resident 58 was unable to shave independently and relied on facility staff to complete the care. Witness 3 stated she/he reported concerns to facility staff that daily hygiene cares were not being completed, and she/he purchased an electric razor to make it easier for staff to shave Resident 58. Witness 3 stated prior to the brain injury, it was important to Resident 58 to always look good and would not have wanted visible facial hair. On 12/16/25 at 3:08 PM Staff 16 (CNA) reported Resident 58 liked to be shaved after showers and sometimes refused to be shaved by shaking her/his hands. Staff 18 stated female residents were shaved after showers and male residents were shaved when they want to be shaved. On 12/17/25 at 9:29 AM Staff 17 (CNA) reported she never shaved Resident 58 because she was scared to shave her/him due to the resident swinging her/his arms during cares. Staff 17 stated she had not noticed Resident 58 had facial hair when she provided cares and stated the resident would not have wanted to have facial hair. On 12/18/25 at 9:22 AM Staff 18 (CNA) stated she and a second CNA assisted Resident 58 on 12/18/25 in the morning had not shaved the resident because the activity department shaved Resident 58. On 12/18/25 at 10:46 AM Staff 19 (LPN) reported Resident 58 was to be shaved daily and as needed. She stated it was not okay to leave Resident 58 with facial hair. On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) stated staffed were expected to shave Resident 58 daily during morning cares. Staff 20 stated staff were expected to review and implement the care plan for Resident 58. 2. Resident 5 was admitted to facility in 3/2025 with diagnoses including muscle weakness and somatoform disorder (a mental illness that causes bodily symptoms, including pain). The Quarterly MDS dated [DATE] revealed Resident 5 was cognitively intact and dependent with personal hygiene, including shaving. Resident 5's Care Plan dated 6/1/25 revealed Resident 5 required one staff person to assist with shaving. On 12/15/25 at 3:20 PM, Resident 5 was observed to have unshaven facial hair above her/his upper lip area. On 12/15/25 at 3:52 PM, Resident 5 was observed covering her/his unshaven facial hair when the resident was about it. Resident 5 stated she/he used to shave her/his facial hair every two or three weeks and did not know staff could perform the task for her/him. On 12/18/25 at 9:40 AM, Staff 17 (CNA) stated she was not comfortable asking Resident 5 if she/he would like to be shaved and did not offer the service to her/him. On 12/18/25 at 10:20 AM, Staff 20 (LPN Care Manager) stated staff were uncomfortable to ask Resident 5 if she/he would like her/his facial hair shaved. Staff 20 stated she expected staff to implement Resident 5's care plan when providing care, including performing shaving tasks. On 12/19/25 at 10:31 AM, Staff 2 (DNS) and Staff 40 (RN Regional Nurse Coordinator) acknowledged Resident 5 required one staff person assist with shaving because Staff 5 was dependent on staff for ADL care. Staff 40 stated although it was a sensitive topic, she expected staff to offer shaving services to residents who required assistance.

Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 5 sampled resident (#68) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases. Findings include:Resident 68 admitted to the facility in 10/2019 with diagnoses including congestive heart failure and dysphagia (difficulty swallowing foods or liquids).The 9/14/25 Quarterly MDS indicated Resident 68 had severe cognitive impairment.Resident 68's physician order dated 1/7/25 revealed she/he required oxygen as needed.On 12/17/25 at 8:57 AM Resident 68's oxygen cannula and tubing were observed on the floor next to her/his bed.On 12/17/25 at 9:04 AM Staff 12 (RN) was observed to provide care for Resident 68. After the provision of care, Staff 12 was observed to pick up the resident's nasal cannula and oxygen tubing from the floor. Staff 12 wiped the nasal cannula with an alcohol wipe and placed the nasal cannula and tubing on the resident's bed.On 12/17/25 at 9:12PM Staff 12 stated when Resident 68's nasal cannula and oxygen tubing were found on the floor; her process was to wipe the nasal cannula with an alcohol wipe to disinfect it before placing it back on the resident or on the resident's bed.On 12/17/25 at 12:39 PM Staff 11 (Infection Preventionist) and Staff 14 (Regional Infection Preventionist) stated oxygen tubing and nasal cannulas found on the floor were considered contaminated. Staff 14 stated the tubing and nasal cannula should not have been wiped with an alcohol wipe and reused but should have been discarded and replaced. Staff 14 further stated wiping equipment with an alcohol wipe did not meet infection prevention standards.

Based on observations, interviews, and record review it was determined the facility failed to ensure medications were not expired for 1 of 4 medication carts and 1 of 2 medication room. This placed residents at risk for decreased efficiency of medications. Finding include:On [DATE] at 9:56 AM, an expired bottle of vitamin B 12 was observed in the 100-hall medication cart. Staff 35 (CMA) confirmed the bottle of vitamin B 12 expired in 8/2025.On [DATE] at 1:29 PM two undated open vials of Tubersol were observed in the 200-hall medication room. Staff 3 (LPN Resident Care Manager) stated Tubersol was good for 30 days after opening. Staff 3 confirmed there was no open date on either open vial of Tubersol and stated there was no indication when the vials were open.On [DATE] at 1:41 PM, Staff 2 (DNS) stated medications must be destroyed when expired. Staff 2 stated Tubersol was good for 30 days after the vial was open and confirmed the two opened, undated vials of Tubersol had no indication of an open date and were to be destroyed.

Based on observations, interviews, and record review it was determined the facility failed to ensure the medication error rate was less than five percent for 2 of 29 attempts. This placed residents at risk for adverse side effects related to medication errors. Finding include:Resident 62 was admitted to the facility in 2/2025 with a diagnosis of heart failure.A review of physician orders revealed a 12/16/25 order for potassium chloride oral packet 20 MEQ give 2 packets twice a day and torsemide 100 mg, give 0.5 tablet twice a day.On 12/17/25 at 8:28 AM, Staff 34 (CMA) was observed to administer torsemide 100 mg and potassium chloride 20 MEQ, 1 packet.On 12/17/25 at 9:42 AM, Staff 34 confirmed Resident 34 had orders to administer torsemide 50 mg and potassium chloride 20 MEQ two packets. Staff 34 stated she was unaware the order changed and acknowledged she administered the wrong dose of torsemide and potassium chloride.On 12/19/25 at 8:45 AM, Staff 2 (DNS) stated staff are expected to administer medications per physician orders.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for adverse outcomes associated with medication administration. Findings include:Resident 3 was admitted to the facility in 11/2025 with diagnoses including Amyotrophic Lateral Sclerosis (ALS, a progressive and fatal neurological disorder that causes weakness, paralysis and respiratory failure). Resident 3's 11/10/25 Pharmacist's admission Medication Regimen Review revealed the following recommendations: -Rivaroxaban (an anticoagulant medication that reduces the blood's clotting ability and places people at increased risk of bleeding) should be administered with food to increase its efficacy.-The resident should be monitored for signs and symptoms of bleeding due to her/his use of rivaroxaban. Resident 3's 12/1/25 Pharmacist's Medication Regimen Review recommended give with evening meal be added to the resident's physician orders for the rivaroxaban and/or adjust the medication's administration time if needed. Resident 3's 12/2025 Physician Orders directed the resident to receive rivaroxaban once daily at bedtime for a clotting event. No evidence was found in Resident 3's clinical record to indicate the resident was being monitored for signs and symptoms of bleeding or follow up to the pharmacist's recommendations was implemented.On 12/19/25 at 7:44 AM, Staff 21 (LPN) stated she was unfamiliar with rivaroxaban and was unaware Resident 3 received the medication. Staff 21 stated she did not know what the medication was used for, if it required monitoring or if it was to be administered with food. On 12/19/25 at 7:49 AM, Staff 24 (RN) stated she was unfamiliar with rivaroxaban and was unable to answer any questions about the medication without first looking it up. Staff 24 stated residents who received an anticoagulant medication required monitoring and Resident 3 did not have monitoring in place for an anticoagulant. Staff 24 further stated any medication that needed to be administered with food should be notated in the resident's MAR/TAR and no such indication was noted in Resident 3's MAR/TAR for the rivaroxaban. On 12/19/25 at 8:31 AM, Staff 26 (LPN Resident Care Manager) stated Resident Care Managers followed up on recommendations from the pharmacist as quick as we can. Staff 26 stated Resident 3 was supposed to be monitored for bleeding due to her/his anticoagulant use and confirmed she/he was not. Staff 26 further stated the pharmacist's recommendation to administer rivaroxaban with food did not need to be added to the resident's clinical record as the resident received continuous nutrition via a feeding tube. On 12/19/25 at 8:37 AM, Staff 2 (DNS) stated pharmacy recommendations were to be responded to within a week of receipt. Staff 2 stated Resident 3's physician orders should be updated to include not to be given on an empty stomach for the rivaroxaban and the resident's TAR and care plan should be updated to include anticoagulant monitoring.

Based on observation, interview and record review it was determined the facility failed to conduct a safety assessment and obtain orders prior to initiating the use of bed rails for 1 of 2 sampled resident (#18) reviewed for bed rails. This placed residents at risk for potential accidents and/or injuries. Findings include: Resident 18 was admitted to the facility in 10/2025 with diagnoses including osteoporosis (condition which bones become weak and brittle) and muscle weakness.The admission MDS Assessment 10/28/25 indicated Resident 18 required substantial assistance for bed mobility and transfer out of bed.Resident 18's current Care Plan did not include the use of bed rails, and no evidence was found in the resident's clinical record an evaluation was completed for the use of bed rails. On 12/15/25 at 12:42 PM Resident 18 was observed in bed with bilateral quarter rails in the upright position.On 12/16/25 at 3:13 PM Staff 13 (CNA) stated she was aware Resident 18 had bilateral bed rails in place on her/his bed. Staff 13 was unable to locate an order or care plan supporting the use of bilateral bed rails.On 12/16/25 at 3:25 PM Staff 3 (LPN Care Manager) confirmed there was no physician order in place for Resident 18's bilateral bed rails. Staff 3 acknowledged the bed rails should not have been in place without an order and stated this was an oversight on her part. Staff 3 further stated the use of bilateral bed rails for Resident 18 was not care planned. On 12/16/25 at 3:40 PM Staff 2 (DNS) stated his expectation was that prior to the use of bed rails, the resident would have a physician order in place, an assessment completed, and the care plan updated to reflect their use. Staff 2 confirmed appropriated steps were not completed prior to Resident 18's bed rails being in place.

Based on interview and record review it was determined the facility failed to ensure resident received trauma informed care for 1 of 1 sampled residents (# 55) reviewed for behavioral and emotional care needs. This placed resident at risk for re-traumatization. Findings Include:The facility's undated Trauma Informed Care and Culturally Competent Care policy revealed the resident assessment process involved an in-depth evaluation of trauma-related symptoms and the identification of triggers. The policy revealed the facility's process involved the development of an individualized care plan to address past trauma, and to identify and decrease exposure to triggers that may re-traumatize the resident.Resident 55 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD) and sleep terrors.Resident 55's 9/11/25 Social Service History, Trauma, and Substance Use Disorder (SUD) Assessment indicated no trauma history.Resident 55's 9/16/25 admission Minimum Data Set (MDS) indicated the resident was cognitively intact and had a diagnosis of PTSD.No evidence was found in Resident 55's clinical record to indicate an assessment of the resident's trauma was completed or a care plan was developed to address the resident's potential trauma triggers.In interviews on 12/15/25 at 9:58 AM and 12/16/25 at 1:31 PM in the resident's room while she/he was in bed, Resident 55 stated she/he had a diagnosis of PTSD and experienced startle responses to loud noises that triggered increased respirations and pain levels. Resident 55 stated these symptoms were triggered when staff spoke loudly when waking the resident from sleep.On 12/17/25 at 12:07 PM Staff 7 (CNA) stated she was not aware of any trauma-related concerns for Resident 55 and was not aware of any triggers.On 12/17/25 at 12:27 PM Staff 5 (LPN) stated Resident 55 had a history of war-related trauma. Staff 5 was unaware of any issues for Resident 55 around loud noises.On 12/18/25 at 10:22 AM Staff 3 (LPN Resident Care Manager) confirmed Resident 55's care plan did not include any information related to trauma or triggers.On 12/18/25 at 10:49 AM Staff 4 (Social Services Director) stated Resident 55 denied trauma during the 9/11/25 Social Service History, Trauma, and SUD Assessment. Staff 4 stated no further investigation of Resident 55's trauma history was completed as Resident 55 answered no to the trauma question on the assessment. Staff 4 confirmed Resident 55's care plan did not include information related to Resident 55's diagnosis of PTSD, trauma history, or triggers.

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 2 of 3 sampled residents (#s 10 and 68) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include:1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. Resident 10's 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact, and the resident did not require the use of oxygen services. A review of Resident 10's health record revealed no current physician order for ongoing oxygen use unless the oxygen level dropped below 92% On 12/15/25 at 12:41 PM Resident 10 was observed with an oxygen nasal cannula (tube with two prongs that fit in the nostrils to deliver supplemental oxygen) in her/his left nostril and connected to an oxygen concentrator (medical device that provides concentrated oxygen). On 12/17/25 at 9:54 AM Staff 5 (LPN) stated residents needed a physician order for the ongoing use of oxygen and they were expected to be followed as written. Staff 5 was not aware the resident was using the oxygen ongoing. On 12/17/25 at 10:10 AM Resident 10 was observed sitting in bed with an oxygen nasal cannula in her/his nose and was connected to an oxygen concentrator. On 12/17/25 at 10:12 AM Staff 20 (Resident Care Manager/LPN) stated she completed an audit of all residents on 12/16/25, during which she discovered Resident 10 had an oxygen concentrator in the room and directed staff to remove it. Staff 20 walked to Resident 10's room, confirmed the concentrator was still present and observed the resident receiving oxygen via nasal cannula. Staff 20 stated Resident 10 had a physician order to receive oxygen only if her/his oxygen saturations dropped below 92% and her/his vital signs did not indicate the need for oxygen. 2. Resident 68 admitted to the facility in 10/2019 with diagnoses including congestive heart failure and dysphagia (difficulty swallowing foods or liquids). The 9/14/25 Quarterly MDS indicated Resident 68 had severe cognitive impairment. Resident 68's physician order dated 1/7/25 revealed she/he required oxygen as needed. On 12/15/25 at 9:55 AM the oxygen concentrator was observed to have a foam filter with a thick layer of dust. On 12/16/25 at 12:47 PM Staff 41 (CNA) stated checking and cleaning oxygen filters was the responsibility of the nurse and not an assigned duty for CNAs. On 12/16/25 at 1:02 PM Staff 15 (RN) observed Resident 68's oxygen concentrator and acknowledged the foam filter was very dirty and needed to be cleaned. On 12/16/25 at 12:28 PM Staff 2 (DNS) stated the facility did not have a cleaning schedule for Resident 68's oxygen filter and his expectation was oxygen filters would be cleaned weekly.

Based on interview and record review it was determined the facility failed to follow the nutritional orders and care plan for 1 of 1 sampled resident (#58) reviewed for assisted nutrition and hydration. This placed residents at risk for inadequate nutrition and dehydration. Findings include:Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain), persistent vegetative state, and dysphagia (difficulty swallowing).The care plan dated 1/23/25 revealed the following interventions regarding tube feeding:*Tube Feed: Continuous 24 hours. Isosource 1.5 total amount: 1440mls Flow Rate 60ml/hr. Flush Rate: 50ml/hr. *Two licensed nurses are required to verify the correct tube feed and formula when placing a new bag.*Labeling system (All TF [Tube feeding] bags labeled with 2 LN signatures and date/time hung).A physician's order dated 11/10/25 indicated the resident's tube feeding was to run continuously for 24 hours at a rate of 60ml per hour for a total of 1440 ml per day. On 12/15/25 at 11:42 AM Resident 58 was observed in bed. The resident's tube feeding was connected but the pump used to administer the feeding was turned off. Two bags were attached to the pump. One was labeled Isosource and dated/timed 12/14/25 6:30 AM. The other unlabeled bag contained clear liquid. The bag was not observed changed until 12/15/25 at 2:45 PM.Staff 5 (LPN) confirmed on 12/16/25 at 2:24 PM Resident 58's tube feed should have run continuously for 24 hours. She stated the bag was changed when it ran out and the only time the pump was turned off was for showers and bed baths or if Resident 58 was full or vomiting.On 12/16/25 at 3:08 PM Staff 16 (CNA) stated she would make sure the pump was always running and would notify the nurse if there were issues. She stated the nurses would disconnect the pump when it became blocked and during showers.On 12/17/25 at 10:29 AM the tube feeding was observed to be disconnected from Resident 58 when she/he was assisted to the dining room for an activity. On 12/17/25 at 3:32 PM Resident 58 was returned to her/his room by two CNAs with the pump connected and running. At 3:58 PM the pump was observed to be beeping with the alarm on the screen showing the pump had been idle for ten minutes. The nurse was not observed to respond to the alarm until 4:26 PM.On 12/18/25 at 8:57 AM Resident 58 was observed on a stretcher without her/his tube feeding attached. The resident was being transported to a medical appointment and returned to the facility within 2 hours. In an interview with Staff 18 (CNA) on 12/18/25 at 9:22 AM she reported the pump was always running and the pump would not be turned off except when the resident went out to appointments. She stated the pump was supposed to go with the resident when she/he went to the dining room. On 12/18/25 at 4:01 PM Staff 28 (LPN) confirmed she had worked with Resident 58 on 12/15/25 for the 6:00 AM to 6:00 PM shift but had not observed the pump not running until she changed the bag. She stated the last time she recalled seeing the pump running before she changed the bag was between 8:00 AM and 9:00 AM on 12/15/25 when she had given Resident 58 her/his medications. Staff 20 (Resident Care Manager/LPN) confirmed on 12/18/25 at 1:15 PM Resident 58's tube feed should run for 24 hours and there were no orders to stop the feeding or administer a bolus feeding, so the resident would not have made up missing fluid and nutrients when the pump was stopped for extended periods of time. Staff 20 stated she unaware there were time periods Resident 58 was not receiving tube feeding and confirmed the nurse should have noticed the pump was off for at least three hours on 12/15/25.

Based on observations, interviews and record review it was determined the facility failed to reassess resident's ability to swallow medications for 1 of 6 sampled residents (#12) reviewed for medications, failed to complete neurological checks for 1 of 1 sampled resident (#6) reviewed for accidents and obtain a physician order for 1 of 1 sampled resident (#8) reviewed for suction devices. This placed residents at risk for side effects related to missed medications, unassessed injuries and medical complications. Findings include:1. Resident 6 was admitted to the facility in 2/2025 with a diagnosis of cerebellar ataxia (a neurological condition causing poor muscle control (ataxia) due to damage or disease in the cerebellum, leading to issues with balance, walking (unsteady gait), speech (slurring), swallowing, and fine motor skills like writing, often described as appearing drunk). A review of progress notes revealed Resident 6 had the following falls: -On 9/20/25 an unwitnessed fall and hit her/his head -On 10/15/25 an unwitnessed fall -On 10/18/25 an unwitnessed fall -On 10/20/25 a witnessed fall and hit her/his face -On 10/25/25 an unwitnessed fall and hit her/his forehead -On 11/3/25 an unwitnessed fall A review of the Neurological Assessment Flow Sheets revealed incomplete neurological assessments with missing assessments on the following dates: -9/20/25 -10/15/25 -10/18/25 -10/20/25 -10/25/25 -11/3/25 On 12/18/25 at 9:42 AM Staff 3 (LPN Resident Care Manager) stated neurological assessments were to be completed after unwitnessed falls and after witnessed falls if the resident hit their head. On 12/18/25 at 10:13 AM, Staff 3 stated neurological assessments were to be completed every 15 minutes for one hour, every 30 minutes for an hour, every hour for four hours, and every four hours for 24 hours. On 12/18/25 at 10:33 AM, Staff 3 acknowledged the neurological assessments on 9/20/25, 10/15/25, 10/18/25, 10/20/25, 10/25/25, and 11/3/25 were incomplete. On 12/19/25 at 8:35 AM, Staff 2 (DNS) stated neurological assessments were to be completed per the above schedule, so issues were identified and acted on promptly. Staff 2 acknowledged the neurological assessments on 9/20/25, 10/15/25, 10/18/25, 10/20/25, 10/25/25, and 11/3/25 were not completed per the schedule and were missing assessments. 2. Resident 12 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and Bell's Palsy (a sudden, temporary weakness or paralysis of the muscles on one side of the face). A review of physician orders revealed a 12/4/25 order for speech therapy to evaluate and treat Resident 12. A review of the 12/5/25 speech therapy notes evaluation indicated Resident 12's plan of treatment was to be seen three times a week for treatment of swallowing dysfunction. A review of the speech therapy progress notes revealed the following: -On 12/8/25 resident was unable to be seen due to a scheduling conflict. -On 12/10/25 resident was in bed asleep, not alert enough for safe oral intake trial or to participate in swallow exercises. -On 12/12/25 resident was in bed asleep, not alert enough for safe oral intake trial or to participate in swallow exercises. -On 12/15/25 resident was unable to be seen due to a scheduling conflict. -On 12/17/25 resident refused treatment, was in bed, not alert enough for safe oral intake trial or to participate in swallow exercises. A review of physician orders revealed a 12/12/25 order to hold all of Resident 12's medication from 12/12/25 until 12/15/25. A review of the meal monitor task revealed Resident 12 consumed the following meals: -On 12/12/25 76-100% dinner. -On 12/13/25 51-75% breakfast and lunch. -On 12/14/25 76-100% breakfast and 51-75% dinner. A review of Resident 12's medical record showed no documentation of increased swallowing difficulty on 12/12/25 and no evidence of any reassessment of swallowing ability. On 12/15/25 at 10:41 AM, Witness 4 (Family Member) stated the facility put a hold on Resident 12's medications over the weekend due to her/his inability to swallow. Witness 4 stated the facility was giving Resident 12 her/his medications crushed in pudding, and they tried to get her/him to take the medication in one big bite, which was too much for Resident 12 to swallow. On 12/17/25 at 10:58 AM, Staff 32 (CNA) stated Resident 12 was having a hard time swallowing last week but was eating and swallowing better this week. On 12/17/25 at 11:51 AM, Staff 3 (LPN Resident Care Manager) stated she placed Resident 12's medications on hold on 12/12/25 because Resident 12 was having a hard time swallowing anything and everyone was scared, she/he would aspirate. Staff 3 stated she was unsure if Resident 12 had speech therapy since admission. On 12/18/25 Staff 31 (Speech Therapist) stated Resident 12 was overall very weak and had delayed swallowing. Staff 31 stated she had not seen Resident 12 since the evaluation on 12/5/25 due to days where Resident 12 was too sleepy to participate or there were scheduling conflicts. Staff 31 stated she was the only speech therapist in the facility and attempted to see residents as often as she was able. Staff 31 stated she was not informed about Resident 12's inability to swallow on 12/12/25 and was not informed Resident 12's medications were held over the weekend. On 12/19/25 at 8:32 AM Staff 2 (DNS) acknowledged Resident 12's speech therapy plan of care was to be seen three times a week for dysphagia. Staff 2 stated he expected Resident 12 to be seen per the plan of care and acknowledged Resident 12 was not seen three days a week per the plan of care. Staff 2 stated Resident 12 was eating over the weekend per the documentation, and he expected Resident 12's swallowing to be reassessed for her/his ability to swallow medications as she/he was able to swallow food. Staff 2 acknowledged there was no evidence Resident 12's swallowing ability was assessed or reassessed from 12/12/25 through 12/15/25. 3.Resident 8 admitted to the facility in 2016 with diagnoses including a stroke. Resident 8's 10/22/25 Annual MDS Assessment indicated she/he was cognitively intact and used no suction machine (a medical device that creates a vacuum to remove fluids for a person's airway). On 12/15/25 at 12:44 PM Resident 8 stated she/he used the suction machine at her/his bedside. A suction machine was observed on the left side of her/his bedside table. Record review of Resident 8's health record on 12/16/25 revealed there was no physician order for the use of a suction machine and no plan of care was found for the use of a suction machine. On 12/17/25 at 11:16 AM Staff 20 (Resident Care Manager/LPN) stated Resident 8 had previously used a suction machine and acknowledged the suction machine was on Resident 8's bedside table. Staff 20 stated the resident did not have a physician order for the use of the suction machine and stated the ongoing use of a suction machine required a physician order. She stated Resident 8 did not have any health indication or assessment in her/his health record which indicated the need for the use of a suction machine.

Based on observation, interview, and record review it was determined the facility failed to follow up on resident's request for new hearing aids for 1 of 2 sampled resident (#6) reviewed for hearing. This placed resident at risk for unmet needs. Findings include:Resident 6 was admitted to the facility in 2/2025 with a diagnosis of bilateral hearing loss.An 8/29/25 care plan indicated Resident 6 had a hearing deficit and to assist her/him with putting the hearing aids in every morning.An 8/29/25 care conference indicated Resident 6 had hearing aids but requested a new pair.On 12/15/25 at 11:43 AM, Resident 6 stated she/he was eligible for new hearing aids and requested assistance with getting them. Resident 6 stated she/he was eligible in 7/2025. Resident 6 stated her/his old pair of hearing aids were lost during one of the room moves. On 12/17/25 at 11:34 AM, Staff 33 (Social Service Director) stated she was unaware of Resident 6's hearing aids missing. Staff 33 stated Resident 6 requested a new pair during the care conference in 8/2025. Staff 33 acknowledged she had not followed up on this request.On 12/17/25 at 11:38 AM, Staff 32 (CNA) stated Resident 6 was hard of hearing but did not have hearing aids.On 12/17/25 at 11:57 AM, Staff 3 (LPN Resident Care Manager) stated she was unaware of if Resident 6 had hearing aids, but she/he was care planned for hearing aids. On 12/17/25 at 12:35 AM, Staff 4 (Social Service Director) stated she was unaware Resident 6's hearing aids were missing. Staff 4 stated when a resident request new hearing aids, it was expected staff complete as soon as possible. Staff 4 stated Resident 6 requested new hearing aids on 8/29/25 and there was no follow up. On 12/19/25 at 8:42 AM, Staff 2 (DNS) stated when residents requested new hearing aids the request should be followed up immediately including if they are eligible for new hearing aids. Staff 2 stated Resident 6 requested new hearing aids on 8/29/25 and acknowledged there was no follow regarding the request.

Based on observation, interview, and record review it was determined the facility failed to assess bowel and bladder continence for 1 of 1 sampled resident (#12) reviewed for bladder and bowel incontinence. This placed residents at risk for incontinence. Finding include:Resident 12 was admitted to the facility on [DATE] with diagnoses including dementia and mixed incontinence (when a person experiences symptoms of both stress incontinence and urge incontinence at the same time).On 12/15/25 at 10:32 AM, Witness 4 (Family Member) stated Resident 12 was continent of bowel and bladder at home. Witness 4 stated Resident 12 had been in the facility for two weeks, and they did not take Resident 12 to the bathroom, they just let her/him be incontinent.A review of Resident 12's care plan revealed a 12/5/25 care plan indicating Resident 12 needed one-person extensive assist for toileting and was at risk for incontinence with a goal to always remain continent but no evidence of interventions to assist Resident 12 with remaining continent. On 12/15/25 at 10:44 AM, Resident 12 stated the staff waited until she/he was incontinent and then changed her/him instead of taking her/him to the bathroom.On 12/17/25 at 10:58 AM, Staff 32 (CNA) stated she thought Resident 12 was incontinent and Resident 12 did not ask to use the bathroom.On 12/17/25 at 11:51 AM, Staff 3 (LPN Resident Care Manager) stated Resident 12 requested and got up to the bathroom on 12/16/25,On 12/17/25 at 12:03 PM, Staff 3 stated when a resident admitted to the facility and were continent, the care plan indicated staff were to ask the resident every time they were in the room and if the resident needed to use the bathroom. Staff 3 stated there were no interventions on Resident 12's care plan to assist her/him to remain continent. On 12/18/25 at 11:35 PM, Staff 29 (LPN Resident Care Manager/MDS Coordinator) stated she assessed Resident 12's continent status by reviewing CNA charting. Staff 29 stated the facility does not initiate toileting programs to assist residents in remaining continent.On 12/18/25 at 12:11 PM, Witness 5 (Family Member) stated at home Resident 12 was continent of bowel and bladder.On 12/18/25 at 12:23 PM, Staff 3 stated residents should be assessed for continence upon admission to the facility. Staff 3 stated Resident 12 was not assessed for continence when she/he admitted to the facility.On 12/19/25 at 8:32 AM, Staff 2 (DNS) stated residents should be assessed for continence upon admission and residents should have a care plan based on the completed assessment. Staff 2 stated a record review of CNA charting was not sufficient for an assessment and acknowledged Resident 12 was not assessed for continence upon admission.

Based on interview and record review it was determined the facility failed to provide the risk and benefits for the use of a psychotropic medication to a resident prior to administration for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 2 admitted to the facility in 6/2025 with diagnoses of bipolar disorder, ADHD (Attention Deficit Hyperactive Disorder), and depression. Review of Resident 2's physician orders revealed a new psychotropic medication for bupropion (an antidepressant) 75 mg was added on 12/9/25 and included an indication a consent was required before administering the medication.The 12/2025 MAR revealed bupropion 75mg was administered to Resident 2 starting 12/11/25.Review of Resident 2's medical record found no consent was obtained prior to administering the medication.On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) confirmed nurses were expected to obtain consent for psychotropic medications prior to administering psychotropic medication. Staff 20 acknowledged a consent was not obtained prior to Resident 2 starting bupropion 75mg.

Based on observation, interview and record review it was determined the facility failed to ensure call devices and overbed lights were accessible for 2 of 5 sampled residents (#s 5 and 30) reviewed for accommodation of needs. This placed residents at risk for delayed assistance and unmet needs. Findings include: 1. The facility's 9/2022 Answering the Call Light Policy directed staff to ensure the call light was accessible to the resident when in bed. Resident 30 was admitted to the facility in 11/2022 with diagnoses including quadriplegia (paralysis affecting all four limbs and the torso) and dependence on a ventilator (when a person cannot breathe adequately on their own and relies on a machine for life). Resident 30's 10/1/25 Annual MDS revealed the resident was cognitively intact, experienced upper and lower extremity impairment on both sides and was dependent upon staff assistance to complete all ADLs. Resident 30's 10/3/25 Care Plan indicated the resident utilized a soft touch call light (an assistance device, often a lightweight button or pad, designed for individuals with poor dexterity or limited movement) with her/his left hand to make her/his needs known. On 12/15/25 at 10:04 AM, Resident 30 was observed in her/his room in bed. The resident's call light was positioned on the left side of the bed near the resident's head. The resident demonstrated she/he was unable to independently access the call light as it was positioned too high on her/his bed. The resident stated her/his call light was placed out of reach on a daily basis, and as a result, she/he had to yell out to get staff's attention. On 12/16/25 at 1:20 PM, Resident 30 was observed in her/his room in bed. The resident's call light was positioned near the resident's left shoulder. The resident demonstrated she/he was unable to independently access the call light as it was positioned too high on her/his bed. The resident stated an unidentified staff person just assisted her/him in bed, left her/his room and did not ensure she/he could reach her/his call light before they left. On 12/16/25 at 5:03 PM, Resident 30 was observed in her/his room in bed. The resident attempted to reach her/his call light but was unable to do so. The state surveyor activated the resident's call light at the request of the resident, and it was answered at 5:05 PM by Staff 42 (CNA). Staff 42 assisted the resident and exited the room without ensuring the resident was able to reach her/his call light. Staff 42 stated the positioning of Resident 30's call light was dependent upon the resident's strength for the day. Staff 42 stated staff usually did a call light test with the resident to ensure the resident could reach her/his call light before they left the room. On 12/17/25 at 6:19 AM, Resident 30 was observed in her/his room in bed. The resident's call light was placed by her/his left hip, and the resident independently activated her/his call light. At 6:27 AM Staff 43 (CNA) answered the resident's call. Staff 43 raised the head of the bed to assist the resident with a drink of water and then lowered it after the resident was finished. Staff 43 did not confirm with the resident if she/he could reach her/his call light and exited the room. The resident demonstrated at this time she/he could no longer reach her/his call light. On 12/17/25 6:34 AM, Staff 43 stated Resident 30's call light was to be placed on her/his left side and staff were supposed to ensure the resident was able to reach it before leaving her/his room. On 12/17/25 at 1:28 PM, Resident 30 was observed in her/his room in bed. Staff 22 (RN) and Staff 25 (CNA) observed Resident 30 was unable to reach her/his call light. Staff 25 stated the placement of the resident's call light needed to be frequently adjusted due to her/his level of strength and after care was completed. On 12/17/25 at 3:28 PM, Staff 26 (LPN Resident Care Manager) stated she expected Resident 30's call light to be placed on her/his left side and in a place where she/he could reach it. Staff 26 further stated staff were to do a return demonstration if they moved the resident's call light. On 12/18/25 at 10:23 AM, Staff 2 (DNS) stated Resident 30's mobility was so limited that he expected staff to ensure the resident was able to reach it before exiting the resident's room. 2. Resident 5 was admitted to facility in 3/2025 with diagnoses including muscle weakness and somatoform disorder (a mental illness that causes bodily symptoms, including pain). Observations on 12/15/25 at 3:54 PM revealed two overbed lights in Resident 5's room were missing their cords. Resident 5 was sitting up in bed and stated she/he had to use the call light for staff assistance to turn the light on and off because the only working light was controlled by a switch located at the entrance of her/his room. The Quarterly MDS dated [DATE] revealed Resident 5 required extensive assistance with all ADLs. On 12/17/25 at 11:50 AM, Staff 36 (CNA) stated if something was broken in a resident's room, she would inform maintenance by inputting the issue into the computer. She stated maintenance would notice it right away and fix it. On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated if the lights needed to be fixed in a resident's room, the issues were reported to maintenance by inputting the concerns into a computer system. On 12/17/25 at 3:14 PM, Staff 15 (Maintenance Director) confirmed there were no cords for two of Resident 5's overbed lights. He stated residents shouldn't have to call staff to turn off and on their overbed lights. On 12/19/25 at 10:45 AM, Staff 1 (Administrator) acknowledged the broken cords in Resident 5's room and stated all overhead lights should be available for residents to use.

Based on observation and interview it was determined the facility failed to ensure personal fans were clean for 2 of 2 sampled residents (#s 44 and 67) reviewed for personal fans and 1 of 1 sampled resident (#10) reviewed for privacy curtains. This placed residents at risk for not having a clean hygienic and comfortable homelike environment. Findings include:1.Resident 10 admitted to the facility in 9/2025 with diagnoses including diabetes. Resident 10's 12/2/25 Significant Change MDS assessment indicated she/he was cognitively intact. On 12/15/25 at 12:41 PM and 12/17/25 at 11:37 AM Resident 10's privacy curtain was observed with multiple small stains on the lower half of the curtain and a large brownish stain in the bottom right corner of the curtain. Resident 10 stated the curtain was dirty for many weeks and had asked multiple staff to have dirty curtain washed. Resident 10 stated she/he did not like to look at the dirty curtain. On 12/17/25 at 12:10 PM Staff 17 (Housekeeping) stated her department was responsible to ensure the resident's privacy curtains were washed and clean in resident rooms. On 12/17/25 at 3:32 PM Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 10's privacy curtain was not clean and needed to be changed. Staff 2 stated he expected all residents to have clean privacy curtains. 2. Resident 44 was admitted to the facility in 2023 with diagnoses including a stroke. On 12/17/25 at 11:38 AM Resident 44's room door was observed with a black box fan positioned in front of it. The fan was coated with a layer of dust and dirty, dust layered coated with visible strings of dust were blowing from the fan. On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) stated they were not responsible for cleaning residents' personal fans. Staff 38 stated she had not cleaned the personal fans for approximately the past six months. On 12/17/25 at 3:26 PM, Staff 2 (DNS) and Staff 14 (Regional Corporate Nurse) confirmed Resident 44 had a dirty personal box fan in her/his room. They stated staff were expected to keep the fan clean and free from dust. 3. Resident 67 was admitted to facility in 11/2023 with diagnoses including anoxic brain damage (lack of oxygen to the brain leading to severe cognitive, physical and emotional issues) and spastic quadriplegic cerebral palsy (severe stiffness in limbs and severe mobility limitations). The Annual MDS with an ARD of 12/1/25 revealed Resident 67 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The resident was in a persistent vegetative state with no discernible consciousness. On 12/15/25 at 2:55 PM, Resident 67's bedside table was observed to have a fan covered in a thick layer of dust and cobwebs. The fan was off and pointed towards Resident 67's face. On 12/16/25 at 2:13 PM and on 12/17/25 at 9:04 AM, Resident 67's fan was observed to have a thick layer of dust, was turned on and pointed towards her/his face. Resident 67's mouth was observed to be open on both occasions. On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated nursing staff only cleaned bodily fluids in a resident's room. On 12/17/25 at 12:11 PM, Staff 37 (Housekeeping) stated she and housekeeping staff were not responsible for cleaning the personal fans of residents. On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) both entered Resident 67's room acknowledged the thick layer of dust on Resident 67's fan. Staff 38 and Staff 15 both stated they were not responsible for cleaning the personal fans in resident's rooms. On 12/17/25 at 3:26 PM, Staff 2 (DNS) entered Resident 67's room and acknowledged her/his fan was on, dirty and pointed towards Resident 67's face.

Based on interview and record review it was determined the facility failed to accurately reassess for ongoing restraint use for 1 of 1 sampled resident (#58) reviewed for restraints. This placed residents at risk for unnecessary restraint use and reduced communication. Findings include:Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain).A review of progress notes from Resident 58's date of admission through 12/18/25 revealed Resident 58 had a mitten hand restraint on her/his left hand since 11/3/23. Review of physician orders for Resident 58 revealed the resident had a weighted mitten hand restraint in use on her/his left hand since 3/14/24, which demonstrated the facility utilized the restraint prior to obtaining a physician's order. The current order dated 2/20/25 directed staff to use the restraint mitten on the resident's left hand; remove every two hours to assess skin and to wash the mitten every shift. Review of the SNF Managed Risk Agreement dated 4/16/24 revealed Witness 1 (Family Member) requested a mitten be used on Resident 58's left hand, a weighted elbow sleeve used on the resident's left elbow, and, as a last resort, soft wrist restraints to keep the resident safe. The reason for the restraints was because the resident frequently pulled out her/his tracheostomy tube, injured self, and pulled out her/his g-tube (tube inserted into the abdomen for feeding). A 1/13/25 revised care plan indicated Resident 58's physical restraint use interventions were initiated on 12/13/23. The care plan directed staff to monitor/document/report PRN any changes regarding effectiveness of the restraint, less restrictive devices attempted, and, if appropriate any negative or adverse effects noted.Review of care conference notes dated 7/15/25 and 9/11/25 revealed the question for 'Assistive/Restrictive device(s) continue to be appropriate' was marked as yes. There were no details documented of what was reviewed including, alternate options to restraint use, any monitoring or reassessment of the restraint need, or any risks associated with the restraint use. Review of the 11/2025 and 12/2025 MAR/TAR and task logs revealed the resident had no documented targeted behavior of restlessness or fidgeting, pulling or grabbing at equipment or staff, or erratic movements. The 11/2025 and 12/2025 MAR/TAR revealed the restraint was used daily.An Annual MDS dated [DATE] assessed Resident 58 with no physical restraints in place, no behaviors that posed a risk to self or others, and cognitive function was not assessed due to the resident being in a persistent vegetative stated. There was no evidence found in Resident 58's clinical record to indicate the resident's mitten was re-assessed for continued need or if less-restrictive alternate options were explored. Random observations between 12/15/25 through 12/19/25 between 8:00 AM to 4:30 PM each day revealed Resident 58 had the mitten on her/his left hand. No observations were made of the resident as restless or attempting to pull on her/his g-tube. On 12/17/25 at 3:32 PM, Resident 58 was observed without the mitten during an activity. The resident did not attempt to remove her/his g-tube, be combative, or attempt self-inflicted harm. During interviews on 12/16/25 at 2:24 with Staff 5 (LPN), and at 3:08 PM with Staff 16 (CNA), 12/17/25 at 9:29 AM with Staff 17 (CNA), and 12/18/25 at 9:22 AM with Staff18 (CNA) all staff stated the reason for continued use of the mitten was Resident 58 was combative with cares and in the past tried to pull out tubes.On 12/18/25 at 1:15 PM Staff 20 (Resident Care Manager/LPN) confirmed a reassessment of the restraint was not completed and a discussion with the family regarding the appropriateness of continued use or alternative options were needed. On 12/19/25 at 8:07 AM Staff 27 (CNA/Restorative Aide) stated Resident 58 was more active with her left hand and used her/his left hand to communicate with others. She stated Resident 58 could not see or speak, so the resident used a left thumbs up signal or raised her/his left hand to respond yes to questions, would lower her/his thumb to answer no to questions, would reach out to touch Staff 27, and would stick up her/his middle finger to express frustration.

Based on observation, interview and record review it was determined the facility failed to accurately identify restraint use in the comprehensive assessment for 1 of 1 sampled resident (#58) reviewed for restraints. This placed residents at risk for injuries and unidentified care needs. Findings include:Resident 58 was admitted to the facility in 11/2023 with diagnoses including diffuse traumatic brain injury (widespread damage to the brain).Review of progress notes revealed Resident 58 had a mitten hand restraint in use on her/his left hand since 11/3/23.Review of physician orders for Resident 58 revealed the resident had a weighted mitten hand restraint in use on her/his left hand since 3/14/24. Review of the 11/2025 and 12/2025 MAR/TAR revealed documentation demonstrating the restraint was used on every Day and NOC shift. The Annual MDS dated [DATE] indicated Resident 58 had no physical restraints in place.Random observations from 12/15/25 through 12/19/25 between the hours of 8:00 AM to 4:30 PM each day revealed Resident 58 had the mitten on her/his left hand.On 12/19/25 at 10:55 AM Staff 29 (MDS Coordinator/LPN) confirmed she completed the comprehensive MDS on 12/8/25 and the restraint section was inaccurately coded.

Based on interview and record review it was determined the facility failed to administer anti-seizure medication according to physician orders for 1 of 3 sampled residents (# 1) reviewed for medications. This placed residents at risk for adverse medication side effects and increased episodes of seizures. Findings include:Resident 1 admitted to the facility on 9/2025, with diagnoses including seizures and respiratory failure. A 9/22/25 Physician Order noted felbamate (an anti-seizure medication) was to be administered twice a day for seizures. A 9/24/25 Progress Note noted staff were working on obtaining Resident 1's anti-seizure medication and that there were complications with receiving the medication, which as not delivered until 9/25/25. Resident 1's 9/2025 MAR indicated the resident's felbamate medication was not administered until 9/25/25 (three days, and five doses after the order date of 9/22/25). On 10/22/25 at 8:56 AM, Staff 3 (Resident Care Manager) stated orders were not reviewed and staff missed the nurses struggle to obtain the medication from the pharmacy. Staff 3 also stated the pharmacy did not have the medication felbamate on hand and struggled to obtain the medication as well. On 10/22/25 at 10:22 AM, Staff 5 (Director of Respiratory therapy) stated they were not a nurse and does not review newly admitted residents' medications. Staff 5 stated when Staff 3 was not available, a nurse or the DNS would review medications for new admits. Staff 5 confirmed this did not occur. On 10/22/25 at 10:41 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1's medication was not administered timely and there continue to be pharmacy difficulties that still needed to be addressed.

Based on interview and record review it was determined the facility failed to ensure residents received treatment and services necessary to prevent constipation for 1 of 3 sampled residents (#100) reviewed for bowel care. This failure resulted in the resident experiencing no bowel movements for seven days, which led to the need for emergency department evaluation and treatment due to a fecal impaction (a severe form of constipation where a large, hard mass of stool becomes lodged in the colon or rectum, preventing normal bowel movements). The facility's Bowel Management policy dated 4/2025 indicated the following: -Resident's bowel movements were recorded daily and reviewed by the licensed nurse. -If a resident had no bowel movement for six 12 hour shifts (three days) or nine eight hour shifts (three days) or within their routine bowel pattern, the facility bowel program would be initiated and the resident would be placed on the laxative list. -If the facility bowel program was not effective within 24 to 32 hours of the resident being placed on the bowel list, the licensed nurse would notify the resident's physician and request further orders. Resident 100 was admitted to the facility on [DATE] with diagnoses including central cord syndrome (an incomplete spinal cord injury which the spinal cord's ability to transmit messages to or from the brain is damaged) and toxic encephalopathy (a neurological disorder characterized by altered mental status, cognitive impairments, memory loss, personality and behavioral changes). Resident 100's 5/23/25 admission MDS indicated the resident had severe cognitive impairments, was incontinent of bowel and required substantial to maximal assistance for toileting. Resident 100's 5/19/25 through 5/31/25 Oral Intake monitor indicated the resident ate between zero to 75% of meals until 5/26/25 when her/his intakes declined consistently to zero to 25%. Resident 100's 5/19/25 through 5/31/25 MAR indicated the resident was prescribed polyethylene glycol (laxative) one time in the morning for constipation and sennosides (stimulant laxative) one time in the morning and at bedtime for constipation. According to Resident 100's MAR, the resident accepted the prescribed polyethylene glycol on 12 out of 12 administration attempts and the sennosides on 18 out of 24 administration attempts. Resident 100's 5/19/25 through 5/31/25 Bowel Records indicated the resident had no bowel movements on the following days. -5/25/25; -5/26/25; -5/27/25; -5/28/25; -5/29/25; -5/30/25 and -5/31/25. A review of Resident 100's electronic health record indicated no evidence the resident's medical provider was notified of Resident 100's lack of bowel movements and no new orders for bowel care interventions were prescribed prior to 5/31/25. A 5/31/25 progress note written at 2:29 PM, indicated Resident 100 had not had a bowel movement since 5/24/25 [seven days] and continued to refuse to eat and drink so the resident's on-call provider was contacted and orders were obtained to send Resident 100 to the emergency department for evaluation and treatment. A 5/31/25 progress note written at 11:29 PM, indicated Resident 100 returned to the facility with new prescriptions for a UTI (an infection affecting the urinary system) and constipation. Resident 100's 5/31/25 CT Scan (a diagnostic imaging procedure) of the abdomen and pelvis revealed a large/copious amount of stool seen throughout the colon and rectum with significant rectal distention due to fecal impaction. Resident 100's Emergency Department's After Visit Summary indicated the resident was diagnosed and treated for slow transit constipation, dehydration and a UTI. On 6/16/25 at 9:04 AM, Staff 18 (LPN) reported a resident should not go more than two or three days without a bowel movement. Staff 18 stated three days with no bowel movement was the maximum and after three days the bowel protocol would be initiated. Staff 18 stated if there was no bowel movement after administering the bowel protocol (PRN medication or enema depending on the physician orders) then the medical provider should be contacted for additional instructions and orders. Staff 18 stated the facility was very strict on following the bowel protocol and if a resident did not have a bowel movement for seven days, that would be a very serious issue. On 6/16/25 at 11:15 AM, Staff 16 (LPN) stated each morning she checked the daily bowel list to determine which residents had not had a bowel movement for three days. Staff 16 stated the resident would be assessed by the nurse and a PRN bowel medication (in addition to the resident's routine bowel medications) would be administered to the resident. Staff 16 stated if there was still no bowel movement, she would contact the medical provider for further direction and interventions. On 6/16/25 at 1:43 PM and 6/17/25 at 2:53 PM, Staff 3 (RNCM) stated on 5/28/25, Resident 100 triggered on the daily bowel list. She reported the resident did not consistently eat or drink and refused her/his bowel medications at times. Staff 3 reported when a resident did not have a bowel movement for three full days, there would be a go to bowel medication depending on the resident's physician order and if the resident still did not have a bowel movement, the medical provider would be called for further orders. Staff 3 stated Resident 100 had no bowel movements since 5/24/25. Staff 3 reviewed Resident 100's bowel records and stated staff should have contacted the resident's medical provider on 5/28/25, 5/29/25 and 5/30/25 since the resident had not had a bowel movement for several days. Staff 3 stated on 5/31/25, Resident 100 was sent to the emergency department for evaluation and treatment. On 6/17/25 at 12:04 PM, Staff 9 (LPN) stated when residents did not have a bowel movement for three days, she would notify the medical provider to get further instructions. Staff 9 stated she cared for Resident 100 on 5/28/25 but was unable to recall if she contacted the resident's medical provider to notify them the resident did not have a bowel movement for four days. On 6/17/25 at 12:25 PM, Staff 8 (LPN) reviewed Resident 100's bowel records and reported on 5/28/25, Resident 100 should have been given a PRN bowel medication and the resident's medical provider should have been notified. Staff 8 stated she had been the assigned day nurse for Resident 100 on 5/29/25 and 5/30/25. She stated the resident's medical provider should have been notified of the resident's lack of bowel movements for the previous five and six days, respectively. However, she was unable to recall whether she had contacted the provider, and there was no documentation in the electronic health record indicating the provider was contacted. On 6/17/25 at 9:58 AM, Staff 4 (Nurse Practitioner) stated he was the primary medical provider for managing Resident 100's medical care. Staff 4 stated he had not been involved much with the resident but she/he had significant cognitive deficits and was sundowning. Staff 4 stated he was also aware Resident 100 was not eating or drinking and refused medications. Staff 4 stated he was unaware Resident 100 had no bowel movements from 5/25/25 through 5/31/25 (seven days). Staff 4 stated nursing staff usually communicated with him via an SBAR (a communication tool which stands for Situation, Background, Assessment and Recommendations) but he was unaware of any communications related to Resident 100's constipation prior to 5/31/25. Staff 4 stated Resident 100 was not eating or drinking much thus he would not have expected the resident to have bowel movements so there would have been no interventions needed. On 6/17/25 at 2:53 PM, Staff 2 (Interim DNS) confirmed Resident 100 had no bowel movements from 5/25/25 through 5/31/25. Staff 2 stated nursing staff should have contacted the resident's medical provider on 5/28/25 to notify them of the resident's bowel status and obtained orders for a PRN bowel medication. She confirmed nursing did not contact the medical provider on 5/28/25. Staff 2 reported nursing should have contacted the medical provider on 5/29/25 and 5/30/25, as the resident had gone several days without a bowel movement. She confirmed Resident 100's medical provider was not contacted regarding the resident's lack of bowel movements. Staff 2 further stated on 5/31/25, Resident 100 required emergency evaluation and treatment for a fecal impaction.

Based on observation, interview and record review it was determined the facility failed to initiate treatment for a pressure injury present upon admission for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. The wound progressed from a DTI (deep tissue injury) to unstageable and required medical intervention for debridement. Findings include: Resident 173 was admitted to the facility on [DATE] with diagnoses including recent onset of paralysis of the lower extremities, diabetes, obesity, and a documented history of pressure injury to the sacrum that occurred during hospitalization . A Hospital History and Physical dated 8/16/24 indicated Resident 173 had a new pressure injury to sacrum (area above the tailbone) found on 8/14/24. The wound was described as an intact, discolored DTI (deep tissue injury). Treatment included protective ointment, a foam dressing, frequent repositioning and pressure reduction. The admission orders to the facility did not include orders for wound care. The facility Clinical Admission form dated 8/21/24 did not identify the presence of the wound to the resident's sacral area. A Braden Scale (standard form used to determine level of risk for developing pressure ulcers) dated 8/21/24 identified the resident to have no sensory perception impairment although resident had a spinal cord injury with paralysis from the waist down. The form indicated the resident had slightly limited mobility and a potential problem with friction and shearing. Resident 173's Care Plan was revised on 8/22/24 to indicate the need for the extensive assistance of two persons for bed mobility, bathing and toileting. The resident had an indwelling urinary catheter and was incontinent of bowel. The care plan was updated on 8/26/24 to include a focus area for potential skin impairment related to immobility. On 8/26/24 a therapy note indicated OT and PT collaborated with nursing staff regarding [the resident's] sacral wound. On 8/27/24 at 10:53 AM Staff 4 (LPN) confirmed she completed the resident's Clinical Admission form but was unable to visualize the resident's sacrum at that time. Staff 4 stated she received information regarding the wound in a report received from the hospital. She visualized the pressure injury on 8/26/24 and described it as crusted over and greenish and with an adjacent superficial open area. Resident 173 was scheduled to be seen by the facility wound nurse, who would recommend treatment. Staff 4 confirmed there were no current orders for treatment. On 8/27/24 the facility's certified wound specialist, Staff 6 (LPN) assessed the wound and initiated treatment. There was no documented evidence in the resident's record to indicate treatment was initiated prior to 8/27/24. On 8/27/24 at 10:57 AM Staff 6 stated Resident 173 had two wounds, one to her/his sacrum and another adjacent wound near the coccyx (tailbone). The pressure ulcers were unstageable ( full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) and covered with slough (non-viable yellow, tan, gray, green or brown tissue). Treatment was to include initiation of an air mattress and Santyl ointment to remove the slough through enzymatic debridement. On 8/28/24 at 12:11 PM Staff 3 (LPN, Resident Care Manager) stated if a resident was admitted with no wound care orders, the nurse was to enter a generic order to clean and cover then contact the provider for a more specific order. The expectation was for the generic order be entered right away and more specific orders entered by the second day. On 8/28/24 at 12:20 PM Resident 173 who was alert and oriented, confirmed the pressure wound started at the hospital. The area was not painful due to a general lack of sensation below the waist. On 8/28/24 at 3:54 PM Staff 2 (DNS) and Staff 3 (LPN, Resident Care Manager) stated the resident may have had a sacral dressing at the time of admission and refused a full assessment. The refusal was not documented and the next shifts did not follow up. They confirmed the Braden Scale completed at the time of admission was inaccurate and the resident did not receive wound care until 8/27/24, six days after admission.

Based on interview and record review it was determined the facility failed to provide eating assistance and to monitor for aspiration for 1 of 2 sampled residents (#168) reviewed for nutrition. The facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's [DATE] hospitalization for aspiration pneumonia and a subsequent death on [DATE]. Findings include: Resident 168 admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. The [DATE] Admission Orders included an order for oxygen three liters via nasal cannula during the day. The [DATE] Physician Order revealed Resident 168 was to be alert and to sit up at 90 degrees for all meals. Staff were to monitor for coughing and choking throughout the meal. The [DATE] Nutrition Care Plan revealed Resident 168 was to have one person assistance with meals and staff were to monitor, document and report as needed any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in (the) mouth, several attempts at swallowing, refusing to eat or appeared concerned during the meal. Resident 168 was to be alert and sit up for all meals. The CNA Point of Care documentation revealed on [DATE] and [DATE] Resident 168 ate independently after set up for breakfast. The Narcotic Log Book revealed Resident 168 was administered Morphine (narcotic medication which may suppress respiratory effort) at 1:16 PM by Staff 20 (CNA/CMA). [There was no evidence in the resident's medical record or facility records that any other staff member observed the resident after this medication administration.] The facility call light logs revealed Resident 168's call light was activated at 1:49 PM and not reset until 4:31 PM. The [DATE] at 1:53 PM Progress Note revealed Resident 168 had trouble swallowing and informed staff food got stuck in her/his throat. The [DATE] at 5:45 PM Progress Note revealed Resident 168's family arrived at 4:30 PM to visit and requested Resident 168 be transferred to the hospital because she/he had a gurgling voice and was very sleepy. The nurse assessed Resident 168 to be lethargic, have an upper airway gurgle and clammy skin. The nurse contacted the physician who gave a verbal order to transfer Resident 168 to the hospital. The paramedics arrived and took the resident to the hospital at 5:30 PM. The [DATE] Hospital Records revealed upon EMS (Emergency Medical Service) arrival Resident 168 oxygen saturation (O2 sat) was in the 70's while on two liters per minute of oxygen and was somnolent. [Normal oxygen saturation is 95 - 100%. Oxygen order was for three liters.] The resident's O2 sat improved to the 90's on a non-rebreather mask. A physical exam was conducted in the Emergency Department and found the resident alert and oriented on oxygen at six liters via nasal cannula. The resident reported she/he choked on food at the facility. The resident had a vomit stain on the chest of her/his clothing. The [DATE] Hospital Discharge Summary revealed Resident 168 died on [DATE] due to acute on chronic hypoxemic (low blood oxygen) and hypercapnic (higher than normal carbon dioxide level in the blood) respiratory failure due to recurrent aspiration pneumonia, approximate interval five days. On [DATE] at 7:59 AM Staff 31 (Agency CNA) verified she intermittently assisted Resident 168 with the breakfast meal on [DATE]. Staff 31 stated Resident 168 was tired, did not really want to eat and was in bed with the head of the bed up 40 to 50 degrees. Staff 31 stated she did not read Resident 168's care plan, she was not aware Resident 168 required assistance with eating and returned to Resident 168's room sporadically to offer the resident something to eat. The resident had difficulty with eating, coughed, cleared her/his throat and choked a lot. The resident continued to cough when she/he was laid down for incontinence care. Staff 31 said on [DATE], the day was ridiculous. She checked on the resident after lunch but was unable to recall what time, was unaware Resident 168 activated her/his call light at 1:49 PM and further stated no staff replaced her at the change of shift (2:00 PM) so she stayed at the facility assisting in the care of other residents but did not observe Resident 168 again. On [DATE] at 11:05 AM Staff 30 (CNA) stated he assisted Resident 168 with the lunch meal on [DATE]. Resident 168 was exhausted and experienced difficulty swallowing so he reported the swallowing difficulty to the nurse. On [DATE] at 11:08 AM Staff 32 (RN) stated the CNA reported Resident 168 had issues with swallowing, she assessed Resident 168 and she/he was fine. She downgraded the resident's diet and notified both Resident 168's family and physician. Staff 32 further stated after the family arrived, they called me to the room and requested to send the resident to the hospital. Resident 168 was gurgling and her/his voice was gargling. The family reported the resident's sleepiness was different. Staff 32 stated she called the physician and then sent the resident to the hospital. Staff 32 stated the last time she checked on Resident 168 was when she assessed Resident 168 at lunch time. On [DATE] at 11:49 AM and [DATE] at 9:00 AM Staff 3 (RNCM) stated staff are expected to review care plans daily and should be aware of any care plan revisions. Staff 3 verified Resident 168's [DATE] Nutrition Care Plan indicated Resident 168 was to be alert and to sit up for all meals and to monitor, document and report any signs or symptoms of dysphagia. Staff 3 further verified the [DATE] Physician Order indicated the resident was to be alert and sit up at 90 degrees for all meals. Staff 3 verified the CNA documentation on [DATE] and [DATE] for the breakfast meal revealed the resident ate independently with set-up assistance and the CNAs did not follow Resident 168's care plan to provide one person assistance or to monitor, document and report signs or symptoms of dysphagia including coughing or choking. Staff 3 stated Resident 168 had a big sign above [her/his] bed saying [she/he] had to sit up at 90 degrees. On [DATE] at 12:30 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On [DATE] at 2:41 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Resident 168 was no longer a resident in the facility. *Other residents in the facility had the potential risk for aspiration, transfer to the hospital or death if the facility did not provide adequate supervision. Other residents who required assistance or supervision with meals would be reassessed for needs. Care plans would be revised as indicated. *The DNS or designee would educate the facility staff on Care Plan interventions and Kardex (CNA specific care plan) location and to know high risk items for each resident. An education binder would be created for agency staff to be educated on aspiration risk, monitoring, and education and would add Kardex locations and the need to be familiar with high-risk conditions of the residents they were assigned. Education was started and would be on-going as each staff and agency staff arrived on duty. Agency staff would sign into the Agency Education binder and sign the Kardex for their assigned residents. *The DNS or designee would audit two meals per day to ensure adequate supervision and proper interventions were in place for residents who have aspiration risks identified. Two meals per day for four weeks, then five meals per week for eight weeks. Meal observations would start with dinner on [DATE]. *The findings would be brought to QAPI (Quality Assurance and Performance Improvement) monthly until resolved. One to one remediation would be done for any negative findings. On [DATE] at 10:50 AM it was determined through observations, staff interviews and review of the facility documentation all aspects of the plan of correction were implemented and completed. 43691

1. Based on interview and record review it was determined the facility failed to respond to a residents call lights timely for 4 of 12 sampled residents (#s 32, 39, 41 and 168) reviewed for staffing. This facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's in delay of care, transfer to the hospital, subsequent death and placed all residents at risk for untimely and unmet care needs. Findings include: 1. Resident 168 admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. a. The Direct Care Staff Daily Report revealed the facility had eight CNAs on duty for day shift on [DATE] which was the State minimum requirement. The facility's daily assignment sheet revealed Staff 24 (CNA) was assigned to Resident 168's care for the [DATE] evening shift. The [DATE] Admission Orders included an order for oxygen three liters via nasal cannula during the day. The [DATE] Physician Order revealed Resident 168 was to be alert and to sit up at 90 degrees for all meals. Staff were to monitor for coughing and choking throughout the meal. The [DATE] Nutrition Care Plan revealed Resident 168 was to have one person assistance with meals and staff were to monitor, document and report as needed any signs or symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat or if she/he appeared concerned during the meal. Resident 168 was to be alert and sit up for all meals. The CNA Point of Care documentation revealed on [DATE] and [DATE] Resident 168 ate independently after set up for breakfast. The Narcotic Log Book revealed Resident 168 was administered Morphine (narcotic medication which could suppress respiratory effort) at 1:16 PM. [There was no evidence in the resident's medical record or facility records any staff member observed the resident after the medication administration.] The facility call light logs revealed Resident 168's call light was activated at 1:49 PM and not reset until 4:31 PM. The [DATE] at 1:53 PM Progress Note revealed Resident 168 had trouble swallowing and informed staff food got stuck in her/his throat. The [DATE] at 5:45 PM Progress Note revealed Resident 168's family arrived at 4:30 PM to visit with the resident and requested Resident 168 be transferred to the hospital because she/he had a gurgling voice and was very sleepy. The nurse assessed Resident 168 to be lethargic, have an upper airway gurgle and clammy skin. The nurse contacted the physician who gave a verbal order to transfer Resident 168 to the hospital. The paramedics arrived and took the resident to the hospital at 5:30 PM. There was no evidence in Resident 168's medical record a full respiratory assessment was completed. The [DATE] Hospital Records revealed on EMS (Emergency Medical Service) arrival Resident 168 oxygen saturation (O2 sat) was in the 70's while on two liters per minute of oxygen and was somnolent. [Normal oxygen saturation is 95 - 100%. Oxygen order was for three liters.] The resident's O2 sat improved to the 90's on a non-rebreather mask. A physical exam was conducted in the Emergency Department found the resident alert and oriented on oxygen at six liters via nasal cannula. The resident reported she/he choked on food at the facility. The resident had a vomit stain on the chest of her/his clothing. The [DATE] Hospital Discharge Summary revealed Resident 168 died on [DATE] due to acute on chronic hypoxemic (low blood oxygen) and hypercapnic (high carbon dioxide level in the blood) respiratory failure due to recurrent aspiration pneumonia, approximate interval five days. On [DATE] at 7:59 AM Staff 31 (Agency CNA) verified she assisted Resident 168 with the breakfast meal on [DATE]. Staff 31 stated Resident 168 was tired, did not really want to eat and was in bed with the head of the bed up 40 to 50 degrees. Staff 31 stated she had not read Resident 168's care plan, she was not aware Resident 168 required assistance with eating and returned to Resident 168's room sporadically to offer the resident something to eat. The resident had difficulty with eating, coughed, cleared her/his throat and choked a lot. The resident continued to cough when she/he was laid down for incontinence care. Staff 31 said on [DATE], the day was ridiculous, she checked on the resident after lunch but was unable to recall what time, was unaware Resident 168 activated her/his call light at 1:49 PM and further stated no staff replaced her at the change of shift (2:00 PM) so she stayed at the facility assisting in the care of other residents but did not observe Resident 168 again. On [DATE] at 11:08 AM Staff 32 (RN) stated a CNA reported Resident 168 had issues with swallowing, she assessed Resident 168 and she/he was fine. She downgraded the resident's diet and notified both Resident 168's family and physician. Staff 32 further stated after the family arrived, they called her to the room and requested to send the resident to the hospital. Resident 168 was gurgling and her/his voice was gargling. The family reported the resident's sleepiness was different. Staff 32 stated she called the physician and then sent the resident to the hospital. Staff 32 stated the last time she checked on Resident 168 was when she assessed Resident 168 at lunch time. On [DATE] at 11:49 AM and [DATE] at 9:00 AM Staff 3 (RNCM) stated staff were expected to review care plans daily and be aware of any care plan revisions. Staff 3 verified Resident 168's [DATE] Nutrition Care Plan indicated Resident 168 was to be alert and to sit up for all meals and to monitor, document and report and signs or symptoms of dysphagia. Staff 3 further verified the [DATE] Physician Order indicated the resident was to be alert and sit up at 90 degrees for all meals. Staff 3 verified the CNA documentation on [DATE] and [DATE] for the breakfast meal revealed the resident ate independently with set-up assistance and the CNAs did not follow Resident 168's care plan to provide one person assistance or to monitor, document and report signs or symptoms of dysphagia including coughing or choking. Staff 3 verified Resident 168's call light went unanswered for two hours and 42 minutes between 1:49 PM and 4:31 PM on [DATE]. On [DATE] at 4:05 PM Staff 24 (CNA) stated she only worked night shifts and did not work the [DATE] evening shift. On the morning of [DATE] Staff 1 (Administrator) stated Staff 24 was assigned to care for Resident 168 on evening shift on [DATE], she talked to Staff 24 who did not remember working that shift. She asked Staff 24 to come in to figure out if Staff 24 worked as scheduled or not. No additional information was provided. On [DATE] at 12:30 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On [DATE] at 2:41 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: * Resident 168 was no longer a resident in the facility. * Other residents requiring assistance had the risk of unmet care needs and negative outcomes if adequate staff were not provided or call lights were not answered timely. See on-going audits. * The Administrator and DNS would provide education to staff and agency staff on the call light system, the volume would be turned on and up on all monitors and kiosks for call lights to be heard. The assigned charge nurse would monitor the call light board and triage the call lights between assigned staff and available resources of the IDT (interdisciplinary team) and float staff. Charge Nurses would be educated on the call light responsibilities of their duty to ensure all care needs were met on their shift. Education had started and would continue as staff and agency staff came on shift. The Administrator, DNS and RNCMs would meet on Monday, Wednesday and Friday after stand-up to review the acuity needs and adjust staffing levels accordingly to ensure all care needs could be met with toileting, turning, repositioning and ADL needs. * The Administrator or DNS would pull the call light report every eight hours, prior to the end of each shift for the next seven days. The would review any call light over 20 minutes and speak with the nurse about assessments and ensuring that the care needs were met for the residents. After seven days, if the call light times were below 20 minutes, the audits would go to daily for 11 weeks. * All findings would be brought through QAPI (Quality Assurance and Performance Improvement) until resolved. One to one remediation would be done for any negative findings. On [DATE] at 10:50 AM it was determined through observations, staff interviews and review of the facility documentation all aspects of the plan of correction were implemented and completed. b. Review of Resident 168's call light logs revealed the following:: * [DATE] at 9:51 PM; 40 minutes and 26 seconds * [DATE] at 12:31 AM: 28 minutes and 17 seconds * [DATE] at 6:15 AM; 25 minutes and 40 seconds * [DATE] 4:31 PM: 2 hours, 42 minutes and 53 seconds On [DATE] at 9:00 AM Staff 3 (RNCM) acknowledged the long call light wait times on [DATE], [DATE] and [DATE]. 32543 2. Resident 32 was admitted to the facility in 2021 with diagnoses including paralysis. On [DATE] at 10:32 AM Resident 32 stated the facility did not have enough staff to answer her/his calls for assistance timely. The resident stated it took staff 30 to 45 minutes to answer her/his call light. Resident 32's call light record from [DATE] through [DATE] revealed 12 times when the resident's call light was on for more than 20 minutes. On five occasions the call light was on for more than one hour with the longest at three hours and eleven minutes. On [DATE] at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since ,d+[DATE] and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. 3. Resident 39 was admitted to the facility in 2021 with diagnoses including paralysis of the lower body. On [DATE] at 9:59 AM Resident 39 stated she/he had to wait up to three hours for staff to respond to her/his call for assistance, and wait times are often more than 20 minutes. Resident 39's call light record from [DATE] through [DATE] revealed six times when the resident's call light was on for more than 20 minutes. The longest was one hour and forty five minutes. On [DATE] at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since ,d+[DATE] and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. 4. Resident 41 was admitted to the facility in 2021 with diagnoses including irregular heart rhythm. On [DATE] at 9:59 AM Resident 41 stated she/he waited up to one and a half hours for staff to answer her/his calls for assistance four times in the last week. Resident 41's call light record from [DATE] through [DATE] revealed 27 times when the resident's call light was on for more than 20 minutes. On four occasions the call light was on for more than one hour with the longest at one hour and twenty minutes. On [DATE] at 3:07 PM Staff 1 (Administrator) stated the expectation was for resident call lights to be answered within 20 minutes. Staff 1 stated the facility's QAPI (Quality Assurance and Performance Improvement) committee had been working on call light response times since ,d+[DATE] and all department heads had a call light monitoring system in their offices. Staff 1 was unable to explain why the issue was not resolved. Staff 29 (Regional RN) stated the facility was having technical issues with the electronic call light system and residents received care but the call lights were not getting turned off after the care was provided. Staff 29 acknowledged administrative staff were not out on the halls observing to verify the long call light issue was actually the lights not being reset and residents had received timely care. 41458 2. Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On [DATE] the facility provided a list of residents who: -Required one or two person assistance with bathing: 25; -Were fully dependent for bathing: 43; -Required one or two person assistance for eating: 35; -Were fully dependent on staff for eating: 15; -Required one or two person assistance for toileting: 42; -Were fully dependent on staff for toileting: 24; -Required one or two person assistance with transfers: 37; -Were fully dependent on staff for transfers: 28; -Required one or two person assistance with dressing: 56; -Were fully dependent on staff for dressing: 12; -Had behavioral healthcare needs: 26; -Required suctioning: 17; -Required tube feedings: 15; -Required tracheostomy care: 16. A review of the facility Direct Care Staff Daily Reports from [DATE] through [DATE] revealed the facility had insufficient CNA staff based on state minimum staffing ratios for one or more shifts on the following dates: Skilled/Long-Term Care Units: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE]. Ventilator Assisted Unit: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE]. Random observations revealed the following: [DATE]: -2:17 PM A strong urine smell was noted in the hallway around rooms [ROOM NUMBERS]; -2:24 PM Three CNAs out of six were present for the evening shift (Shift change occurred at 2:00 PM); -2:30 PM Two day shift agency CNAs were waiting for evening shift CNAs to arrive so they could leave for the day; -2:37 PM The call light in room [ROOM NUMBER] was activated for 25 minutes; -2:40 PM There was a resident in the 200 hallway yelling for help. [DATE]: -2:37 PM The call light in room [ROOM NUMBER] was activated for 46 minutes; [DATE]: -8:23 AM The call light in room [ROOM NUMBER] was activated for 18 minutes; -8:35 AM The call light in room [ROOM NUMBER] was activated for 25 minutes and the call light in room [ROOM NUMBER] was activated for 22 minutes; -10:38 AM The call light in room [ROOM NUMBER] was activated for 46 minutes and the call light in room [ROOM NUMBER] was activated for 21 minutes; -12:37 PM The call light in room [ROOM NUMBER] was activated for 32 minutes; -1:11 PM The call light in room [ROOM NUMBER] was activated for 35 minutes. [DATE]: -8:52 AM The call light in room [ROOM NUMBER] was activated for 47 minutes, the call light in room [ROOM NUMBER] was activated for 42 minutes, the call light in room [ROOM NUMBER] was activated for 37 minutes and the call light in room [ROOM NUMBER] was activated for 25 minutes; -9:29 AM The call light in room [ROOM NUMBER] was activated for 30 minutes; -11:56 AM A resident on the 200 hallway was yelling for help due to her/his hip hurting. At 12:00 PM a dietary staff member entered the room to assist the resident and was unable to provide assistance due to the resident requiring CNA help. Interviews with staff revealed the following concerns: -On [DATE] at 12:24 PM Staff 8 (Therapy Director) stated the rehab department was currently understaffed with OT staff so he had to prioritize residents' therapy services and reduce the amount of time spent with residents. -On [DATE] at 8:29 AM Staff 11 (CNA) stated CNA staff were unable to keep up with residents' turning schedules and could not meet time requirements for getting residents up and put back down. Staff 11 stated she previously spoke with management regarding staffing concerns and was told the facility was only allowed to staff to the State minimum staffing ratios. She stated it was impossible to take all of her breaks. -On [DATE] at 9:31 AM and [DATE] at 12:55 PM Staff 6 (CNA) stated all of the residents on her unit required two person assistance which made it difficult to get everything done. She stated residents' were supposed to be turned every two hours but that was a dream. She stated there were two behavioral residents who got angry, cussed and exhibited behaviors if they had to wait too long for care. She stated there was no way for CNA staff to take all of their breaks and she often provided extra care to the residents on her own time. -On [DATE] at 10:08 AM Staff 26 (CNA) reported the facility was short staffed for the past two months. Staff 26 stated the facility utilized one to five agency CNAs per shift and the agency CNAs did not receive adequate orientation and were sent out on the floor without knowing the residents. Staff 26 also reported they were unable to give shift change reports because they were too busy, which impacted resident care. -On [DATE] at 10:58 AM Staff 16 (Staffing Coordinator) stated she staffed to the State minimum staffing ratios for CNA and licensed nursing and not to the acuity needs of the residents. Staff 16 stated any staffing needs outside of the minimum staffing ratios were determined by Staff 1 (Administrator) or Staff 2 (DNS). -On [DATE] at 2:30 PM Staff 1 stated in the past two months the facility utilized a lot of agency CNA and nursing staff. Staff 1 reported the facility did not check agency staff's competency to work in the nursing home setting and assumed they were competent since they were licensed. Staff 1 stated the facility staffed according to the State minimum staffing ratios. -On [DATE] at 8:20 AM Staff 18 (CNA) stated she was unable to adhere to the required two hour turning schedule for residents. She stated there were days when she arrived for the start of day shift (at 6:00 AM) and she was the only CNA for the entire unit until 7:30 AM, when the second CNA arrived. She stated on certain days the unit was not fully staffed with CNAs until 10:00 AM when the third CNA was scheduled to start her shift. Staff 18 stated she never got all of her breaks and often could not take her full lunch. She stated she previously told administration her concerns with staffing but nothing changed. Staff 18 stated when she asked for additional help she was told there was no help to offer. -On [DATE] at 12:41 PM Staff 7 (CNA) stated the unit was often short staffed and there were times she was unable to complete bathing care. She stated there was a resident who frequently asked for showers but they only provided a bed bath because the resident took a long time to shower and they did not have adequate staff. Staff 7 stated CNAs were unable to turn residents every two hours as required and if they could turn the residents more often it would help with the residents' bed sores. Staff 7 stated she had to pick and choose who got up because they did not have adequate staffing to get all of the residents up who wanted to get up. Staff 7 stated CNA staff were unable to do any stretching or exercises with residents and, due to the facility not having a restorative program, it would be helpful to the residents if the CNAs provided this service. On [DATE] at 1:51 PM Staff 38 (Director of Operations) was informed of staffing concerns within the facility and acknowledged the current staffing issues were not acceptable and he would present a staffing model based on acuity in the morning. This is a repeat citation previously cited on [DATE], [DATE] and [DATE]. 43691

Based on interview and record review it was determined the facility failed to address QAPI (Quality Assurance and Performance Improvement) identified concerns regarding sufficient staff for 1 of 1 QA (Quality Assurance) committees reviewed for QAPI. This resulted in the failure to provide timely care and assistance to residents. Findings include: The 4/19/22 Annual Survey identified nurse staffing as an area requiring correction in order to provide adequate care to residents. A 2/12/23 complaint investigation identified nurse staffing as an area requiring continued correction with deficient practice identified from 8/2022 through 12/2022. Review of QAPI Meeting Minutes from 1/2023 identified nurse staffing as an area to address and review in future QAPI meetings. Review of QAPI Meeting Minutes from 2/2023, 3/2023 and 4/2023 included minimal information regarding an approach and attempt to resolve the ongoing identified area of nurse staffing. During the current 5/15/23 to 5/23/23 Annual Survey staffing was reviewed and identified as a continued deficient practice which impacted quality of care for residents. On 5/23/23 at 10:34 AM Staff 1 (Administrator) was informed nurse staffing and call light response timeliness were previously identified as an area of deficient practice and has continued to occur. Staff 1 confirmed nurse staffing was an on-going issue which had not been resolved by QAPI since it was identified as an issue in 4/2022. See F725.

Based on interview and record review it was determined the facility staff failed to ensure Physician's orders were transcribed and implemented properly for 1 of 3 sampled residents (#1). Resident 1 received [MEDICATION NAME] (a blood thinning medication) after the Physician ordered it held and lab work obtained; as a result the resident was hospitalized with a change of condition. Findings include: According to Nursing Standards of Practice [PHONE NUMBER] Scope of Practice Standards for Registered Nurses: (2)(d)(A) Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Registered Nurse shall: Implement the plan of care by: Implementing treatment and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/12/14 a Telephone Order, signed by the Physician, ordered the facility to hold the resident's [MEDICATION NAME] and recheck the resident's INR (international normalizing ratio, a test used to determine how fast the blood clots) on 5/15/14. The resident's May 2014 MAR indicated [REDACTED]. The facility's written investigation into the medication error for Resident 1 identified Staff 5, RN, was responsible for transcribing the Physician's orders on 5/12/14. The investigation revealed no [MEDICATION NAME] hold order was initiated in their electronic medication management system on 5/12/14 and no PT/INR lab slip could be found for 5/15/14. On 5/23/14 at 9:55 am a nursing note identified the resident was sent out to the hospital after she/he became confused and unable to vocalize anything but garbled sounds. On 5/23/14 a hospital's Discharge Summary identified the resident had [DIAGNOSES REDACTED]. In interview on 8/12/14 at 12:35 am Staff 5, RN, reported on 5/12/14 she put the Physician's order to hold the [MEDICATION NAME] in the electronic medication management system but did not print a copy of the order. Staff 5 reported she placed the Physician's order in the RNCM's box and the night nurse (Staff 4) and RNCM (Staff 3) should have double checked the orders. Staff 5 stated she "wasn't sure" if she created a lab slip for the ordered PT/INR. In interview on 8/14/14 at 10:18 am Staff 4, RN, reported on 5/12/14 Staff 5 left no Physician orders to follow up on and there were no orders in the RNCM's box to check on that night. In interview on 8/18/14 at 11:33 am Staff 3, RNCM, reported there were no printed [MEDICATION NAME] orders, dated 5/12/14, for Resident 1 in her box. In interview on 8/18/14 at 2:06 pm Staff 2, DNS, confirmed the 5/12/14 Physician's orders to hold Resident 1's [MEDICATION NAME] and recheck her/his PT/INR were not transcribed or initiated by Staff 5. Refer to 309.

Based on interview and record review the facility failed to follow Physician's orders for administering anticoagulant medications and obtaining a laboratory test for 1 of 3 (#1) sampled residents who were on [MEDICATION NAME]. As a result the resident had a change of condition and was hospitalized . Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/9/14 a PT/INR ([MEDICATION NAME]/international normalizing ratio) laboratory test results, used to determine clotting tendency and to measure [MEDICATION NAME] dosage, identified the resident's INR was critically high and measured 6.22 with a reference range of 2.00-3.00. On 5/9/14 the Physician ordered the facility to hold the resident's [MEDICATION NAME] for three days, from 5/9/14 at 3:49 pm through 5/11/14 at midnight, and to recheck the resident's PT/INR on 5/12/14. The resident's May 2014 MAR indicated [REDACTED]. On 5/12/14 a PT/INR laboratory test results indicated the resident's INR was critically high and measured 4.65 with a reference range of 2:00-3:00. A note on the bottom of the results sheet, written by Staff 5, RN, indicated the facility should "hold [MEDICATION NAME] until 5/15/14 next PT/INR." On 5/12/14 a Telephone Order, signed by the Physician, ordered the facility to hold the resident's [MEDICATION NAME] and recheck the resident's INR on 5/15/14. There was no evidence in the resident's record the facility entered the Physician's order to hold the [MEDICATION NAME] or to recheck the resident's PT/INR into their electronic medication management system. The resident's May 2014 MAR indicated [REDACTED]. There was no evidence the facility followed the Physician's order to obtain a PT/INR on 5/15/14 or the resident had a PT/INR conducted after 5/12/14 through 5/22/14. On 5/23/14 at 9:55 am a nursing note identified the resident was sent out to the hospital after she/he became confused and unable to vocalize anything but garbled sounds. The facility's written investigation into the medication error for Resident 1 identified there was no [MEDICATION NAME] hold order initiated in their electronic medication management system on 5/12/14 and no PT/INR lab slip could be found for 5/15/14. The investigation indicated the resident was admitted to the hospital on [DATE] for an elevated PT/INR. On 5/23/14 a hospital History and Physical identified the resident was admitted to the hospital with [REDACTED].> 10." The hospital's Discharge Summary indicated the Resident had [DIAGNOSES REDACTED]. In interview on 8/12/14 at 9:30 am Staff 2, DNS, reported facility staff continued to give Resident 1 [MEDICATION NAME] after the hold date on 5/12/14 because there wasn't an order in the electronic medication management system ordering them not to. In interview on 8/12/14 at 12:25 pm Witness 1, Medical Assistant, confirmed the Physician ordered Resident 1's [MEDICATION NAME] to be held 5/9/14 through 5/11/14 at midnight and ordered the resident's [MEDICATION NAME] held on 5/12/14 until after her/his PT/INR was rechecked on 5/15/14. In interview on 8/12/14 at 12:35 am Staff 5, RN, reported on 5/12/14 she put the Physician's order to hold the [MEDICATION NAME] in the electronic medication management system but did not print a copy of the order. Staff 5 reported she placed the Physician's order in the RNCM's box and the night nurse (Staff 4) and RNCM (Staff 3) should have double checked the orders. Staff 5 stated she "wasn't sure" if she created a lab slip for the PT/INR order because she thought the resident had a standing every three days order for PT/INR labs. In interview on 8/14/14 at 10:18 am Staff 4, RN, reported on 5/12/14 Staff 5 left no Physician orders to follow up on and there were no orders in the RNCM's box to check on that night. In interview on 8/18/14 at 11:33 am Staff 3, RNCM, reported charge nurses took Physician's orders for [MEDICATION NAME] and lab rechecks, input them in the electronic medication management system, printed off a copy of the order from the system, and if there were changes to the previous order, they were supposed to place a printed copy of the order in the RNCM's box for review. Staff 3 stated there were no printed [MEDICATION NAME] orders, dated 5/12/14, for Resident 1 in her box. In interview on 8/18/14 at 2:06 pm Staff 2, DNS, confirmed the facility administered [MEDICATION NAME] on 5/11/14 in error. She reported Physician's orders, dated 5/12/14, to hold Resident 1's [MEDICATION NAME] and recheck PT/INR were not followed.

Based on interview and record review it was determined the facility failed to monitor CBGs and provide insulin per physician orders [REDACTED].#1) reviewed for insulin administration. Resident 1's CBGs were not checked and the resident required hospitalization . Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's 2/24/14 hospital Orders for Discharge to SNF (Skilled Nursing Facility) included the resident's CBG was to be checked before meals and at bedtime. The resident was to be administered insulin based on the resident's CBG level. The Resident's February 2014 MAR and DAR (Diabetic Administration Record) revealed the resident's CBG was checked six of nine opportunities from 2/24/14 through 2/26/14. The MAR and DAR revealed insulin was documented and given per physician orders [REDACTED]. Two of the six times the resident's CBGs were checked there was no documentation to indicate how much insulin was administered to the resident. On 5/1/14 at 10:37 am, 5/5/14 at 9:00 am and 5/12/14 at 10:41 am a request for documentation, for the two days the amount of insulin provided to the resident was not documented, was requested from Staff 2 (RNCM), Staff 4 (DNS) and Staff 3 (Administrator). No additional information was provided. Resident 1's Progress Notes written by Staff 1 (RN) on 2/27/14 at 2:25 am revealed on 2/26/14 the resident's bedtime CBG was "hi"(facility CBG monitor reading of "hi"indicates CBG greater than 599). The note indicated the resident was at her/his baseline confused mental state. The note indicated the resident was administered insulin according to the physician orders [REDACTED]. The note indicated the physician ordered the resident's CBG to be rechecked in 45 minutes from the time the insulin was administered. Resident 1's CBG was rechecked and the level was documented as "hi". The note indicated the resident's physician was re-paged and the physician recommended the resident be transferred to the local emergency department to "safely" bring down the resident's CBGs. Resident 1's 2/26/14 hospital History and Physical revealed the resident had a history of [REDACTED]. The resident was described as "essentially unresponsive" and had acute (sudden onset) kidney injury. The resident's sodium was also noted to be low and was "likely" from the high glucose levels. The resident was admitted to the Intensive Care Unit. The resident's 3/6/14 hospital Discharge Summary revealed the resident was admitted with Diabetic Ketoacidosis (elevated acid level in the blood due to uncontrolled glucose levels) and was initially placed on a continuous intravenous infusion of insulin (insulin administered directly into a vein). The resident was stabilized and was transitioned to routine insulin injections. The summary also indicated the resident initially presented to the emergency room with "acute kidney injury" but the injury resolved with with intravenous fluids. On 4/30/14 Staff 1 (RN) stated she worked the 12 hour night shift. The shift hours were from 6:00 pm to 6:00 am. Staff 1 stated the resident was admitted to the facility with orders for CBGs to be checked before meals and at bedtime. The resident was to receive insulin based on the CBG level. Staff 1 stated she was responsible for checking Resident 1's bed time CBG. Staff 1 stated the insulin orders were computer generated and were located on the computer based MAR and not the DAR. Staff 1 stated in the early morning of 2/26/14 she logged onto the computer to change the location of the resident's CBG and insulin orders from the MAR to the DAR. In the middle of the process of changing the location of the orders the Internet browser "crashed". Staff 1 stated she logged back into the computer system and noted the CBG and insulin orders were no longer on the MAR. Staff 1 stated she thought if the insulin orders were not on the MAR the orders were successfully transferred to the DAR. Staff 1 stated she did not look to verify the resident's CBG and insulin orders were on the DAR. Staff 1 stated the oncoming nurse was from an agency and did not know the resident required CBG testing before meals and Resident 1's CBGs were not checked on 2/26/14 before breakfast, lunch or dinner. Staff 1 stated when she came on shift on 2/26/14 at 6:00 pm she immediately noticed Resident 1's orders did not appear on the DAR and looked at the MAR for the orders. The MAR also did not contain the resident's CBG and insulin orders. Staff 1 stated the resident was confused per the resident's baseline mental status but was more lethargic (less responsive). Staff 1 stated she then checked the resident's CBG and the CBG was "hi." Staff 1 administered the resident's insulin and called the resident's physician. The resident's CBG was re-checked per physician orders [REDACTED]." The resident's physician recommended the resident be sent to the hospital to treat the high glucose levels.

Based on observation, interview and record review it was determined that the facility failed to ensure a resident's call light had been placed within their reach for 1 of 3 sampled residents (#42 ) who were non-verbal and used a pressure pad call light (assistance device) to summon assistance. Surveyors intervened at the request of the resident on three occasions: on 7/23/12 at 3:19 pm and 3:53 pm, and on 7/26/12 at 8:33 am summoning staff for assistance. The measures used by the facility to ensure Resident 42 had continuous access to a call system were found to be unsuccessful and placed the resident at risk for respiratory distress and serious harm due to the lack of timely tracheal suctioning. An immediate jeopardy situation was called. Findings include: Resident 42 was readmitted in 4/2012 with [DIAGNOSES REDACTED].) According to the 4/7/12 hospital History and Physical physician's report, the resident had a tracheostomy with multiple hospital admissions for recurrent aspiration. The resident's medical history included chronic respiratory failure, asthma, and dysphagia requiring [DEVICE] feedings. The residents status was described as bedridden due to [DIAGNOSES REDACTED]. Resident 42's 5/7/12 quarterly nursing assessment identified the resident was non-verbal but was alert and oriented. The resident was able to identify the correct month, day, and year, and recognized staff names and faces. The resident was aware she resided in a nursing home. The resident communicated using yes/no head nods and generally was able to make her needs known. The resident was dependent on staff to meet all ADL needs. The 4/18/12 care plan regarding communication directed staff to speak clearly, listen closely to resident, monitor body language, maintain eye contact, and use visual gestures. There was no information as to how the resident would communicate her needs when staff were not in her room. On 7/23/12 the following events occurred: ***At 3:19 pm the resident was observed lying in bed with a tracheostomy humidifying mask device in place. Audible wet breath sounds were heard, the resident was coughing and exhibiting respiratory difficulty. The resident kept looking toward the head of the bed and gestured with head nods and then looked at the surveyor. Through asking yes/no questions the surveyor ascertained the resident needed assistance, suctioning and had her call light placed out of her reach. The resident's specialized touch pad call light had been placed on the bedside table near the other bed in the room. The surveyor activated the call light and another surveyor sought assistance for the resident. Staff 4, RA, responded to the call light and strategically placed the specialized touch pad call light under the resident's right elbow. ***At 3:25 pm, Staff 5, LPN, stated the resident required suctioning of her tracheostomy about four times per shift. ***At 3:28 pm Staff 6, RN, entered the room to assist the resident and subsequently provided suctioning. ***The resident was observed to have apparent contractures of her upper extremities. The resident's right elbow, wrist, and hand were contracted inward and her left arm was in a fixed extension at the elbow, wrist, and fingers. The resident was observed to minimally move her left arm and right elbow. A pulled privacy curtain separated the resident and her roommate. ***At 3:53 pm no staff were observed in the resident's room. The resident's specialized call light was not within reach and had been placed next to her buttocks. The situation was brought to the attention of Staff 3, RNCM, at that time. Staff 3, confirmed the resident's call light was not within the resident's reach. Staff 3, said the only way the resident could summon help was to use the specialized call light. The resident could not move the call light and was dependent on on staff for correct placement. Staff 3, stated "it's frustrating" regarding the lack of correct call light placement for the resident. ***At 3:55 pm, Staff 7, CNA, stated she had last checked the resident at 2:30 pm and had accidentally left the call light out of the resident's reach. At this time, every 15 minute checks were initiated by facility staff to monitor the resident's call light. ***In an interview at 4:17 pm, using a yes/no method of questioning, Resident 42 indicated the issue of the specialized call light outside of her reach and being unable to call for assistance was a problem on a daily basis and that sometimes she felt unsafe. ***Observations from 5:45 pm to 6:45 pm, the resident's call light had been placed within reach of her left hand after staff provided ADL care. The resident indicated to staff her tracheostomy needed to be suctioned and licensed staff provided that care. A 7/24/12 update to the resident's care plan directed "15 minute checks ensure call light within reach and (resident) can use before you leave room." Random observations on 7/24/12 from 7:30 am to 5:00 pm and on 7/25/12 from 8:15 am to 4:00 pm, the resident's call light was within reach of her left hand. On 7/26/12 the following events occurred: ***At 8:33 am the resident's call light was observed positioned near her pillow at the head of her bed and not within her reach. There were copious amounts of secretions around her tracheostomy and on her chest. When asked by the surveyor if she needed help, the resident nodded yes. The surveyor activated the resident's call light. Staff 8, CMA, responded and confirmed the resident's call light was not within her reach. ***At 8:35 am Staff 9, CNA, responded and wiped the secretions from the resident's chest. Staff 9, then notified the nurse the resident requested to be suctioned. In an interview at 8:40 am, with Staff 9, assigned to care for the resident, stated the following: she had not seen the resident since arriving on shift at 6:00 am, and believed the resident had last been checked on the night shift. When asked how often the resident was to be checked, Staff 9, responded, "oh, she's on q 15 minute checks, I'm bad." In an interview at 8:45 am, Staff 10, RN, stated she had last checked the resident's tube feeding about 7:00 am. Staff 10, couldn't specifically recall if she had checked the resident's call light placement but then said it was at the end of her hand near her fingers. Staff 10, said she had been off duty the day prior and just remembered the RNCM had care planned the resident for 15 minute checks. On 7/26/12 at 10:46 am, following consultation with the State agency survey supervisors, the surveyors informed Staff 1, Administrator, and Staff 2, DNS, that the failure of the current measures used by the facility to ensure Resident 42 continuous access to a call system and to assure timely response to her needs were found unsuccessful and constituted a situation of immediate jeopardy to the resident. Surveyors requested a plan of correction to immediately protect the resident from harm be developed and implemented. On 7/26/12 at 2:45 pm an initial plan of correction was provided by the facility that ensured residents safety regarding continuous access to a call system. It was reviewed by the survey team and the immediate jeopardy was abated on 7/26/12 at 2:45 pm.

Based on observation, interview and record review it was determined that the facility failed to ensure a resident's call light had been placed within their reach for 1 of 3 sampled residents (#42 ) who were non-verbal and used a pressure pad call light to summon assistance. The resident's physical disabilities required specific call light placement to assure independence in communicating needs. Surveyors intervened at the request of the resident on three occasions: on 7/23/12 at 3:19 pm and 3:53 pm, and on 7/26/12 at 8:33 am summoning staff for assistance. The measures used by the facility to ensure Resident 42 had continuous access to a call system were found to be unsuccessful and placed the resident at risk for respiratory distress and serious harm due to the lack of timely tracheal suctioning. An immediate jeopardy situation was called. Findings include: Resident 42 was readmitted in 4/2012 with [DIAGNOSES REDACTED].) According to the 4/7/12 hospital History and Physical physician's report, the resident had a [MEDICAL CONDITION] with multiple hospital admissions for recurrent aspiration. The resident's medical history included chronic [MEDICAL CONDITION], asthma, and dysphagia requiring [DEVICE] feedings. The residents status was described as bedridden due to [MEDICAL CONDITION]. Resident 42's 5/7/12 quarterly nursing assessment identified the resident was non-verbal but was alert and oriented. The resident was able to identify the correct month, day, and year, and recognized staff names and faces. The resident was aware she resided in a nursing home. The resident communicated using yes/no head nods and generally was able to make her needs known. The resident was dependent on staff to meet all ADL needs. The 4/18/12 care plan regarding communication directed staff to speak clearly, listen closely to resident, monitor body language, maintain eye contact, and use visual gestures. There was no information as to how the resident would communicate her needs when staff were not in her room to include the individualized placement of her call light. On 7/23/12 the following events occurred: ***At 3:19 pm the resident was observed lying in bed with a [MEDICAL CONDITION] humidifying mask device in place. Audible wet breath sounds were heard, the resident was coughing and exhibiting respiratory difficulty. The resident kept looking toward the head of the bed and gestured with head nods and then looked at the surveyor. Through asking yes/no questions the surveyor ascertained the resident needed assistance, suctioning and had her call light placed out of her reach. The resident's specialized touch pad call light had been placed on the bedside table near the other bed in the room. The surveyor activated the call light and another surveyor sought assistance for the resident. Staff 4, RA responded to the call light and strategically placed the specialized touch pad call light under the resident's right elbow. ***At 3:25 pm, Staff 5, LPN, stated the resident required suctioning of her [MEDICAL CONDITION] about four times per shift. ***At 3:28 pm Staff 6, RN, entered the room to assist the resident and subsequently provided suctioning. ***The resident was observed to have apparent contractures of her upper extremities. The resident's right elbow, wrist, and hand were contracted inward and her left arm was in a fixed extension at the elbow, wrist, and fingers. The resident was observed to minimally move her left arm and right elbow. A pulled privacy curtain separated the resident and her roommate. ***At 3:53 pm no staff were observed in the resident's room. The resident's specialized call light was not within reach and had been placed next to her buttocks. The situation was brought to the attention of Staff 3, RNCM, at that time. Staff 3, confirmed the resident's call light was not within the resident's reach. Staff 3, said the only way the resident could summon help was to use the specialized call light. The resident could not move the call light and was dependent on staff for correct placement. Staff 3, stated "it's frustrating" regarding the lack of correct call light placement for the resident. ***At 3:55 pm, Staff 7, CNA, stated she had last checked the resident at 2:30 pm and had accidentally left the call light out of the resident's reach. At this time, every 15 minute checks were initiated by facility staff to monitor the resident's call light. ***In an interview at 4:17 pm, using a yes/no method of questioning, Resident 42 indicated the issue of the specialized call light outside of her reach and being unable to call for assistance was a problem on a daily basis and that sometimes she felt unsafe. ***Observations from 5:45 pm to 6:45 pm, the resident's call light had been placed within reach of her left hand after staff provided ADL care. The resident indicated to staff her [MEDICAL CONDITION] needed to be suctioned and licensed staff provided that care. A 7/24/12 update to the resident's care plan directed "15 minute checks ensure call light within reach and (resident) can use before you leave room." However, the care plan did not provide specific placement instructions such as right or left to assure the resident was able to use it. Random observations on 7/24/12 from 7:30 am to 5:00 pm and on 7/25/12 from 8:15 am to 4:00 pm, the resident's call light was within reach of her left hand. On 7/26/12 the following events occurred: ***At 8:33 am the resident's call light was observed positioned near her pillow at the head of her bed and not within her reach. There were copious amounts of secretions around her [MEDICAL CONDITION] and on her chest. When asked by the surveyor if she needed help, the resident nodded yes. The surveyor activated the resident's call light. Staff 8, CMA, responded and confirmed the resident's call light was not within her reach. ***At 8:35 am Staff 9, CNA, responded and wiped the secretions from the resident's chest. Staff 9, then notified the nurse the resident requested to be suctioned. In an interview at 8:40 am, with Staff 9, assigned to care for the resident, stated the following: she had not seen the resident since arriving on shift at 6:00 am, and believed the resident had last been checked on the night shift. When asked how often the resident was to be checked, Staff 9, responded, "oh, she's on q 15 minute checks, I'm bad." In an interview at 8:45 am, Staff 10, RN, stated she had last checked the resident's tube feeding about 7:00 am. Staff 10, couldn't specifically recall if she had checked the resident's call light placement but then said it was at the end of her hand near her fingers. Staff 10, said she had been off duty the day prior and just remembered the RNCM had care planned the resident for 15 minute checks. On 7/26/12 at 10:46 am, following consultation with the State agency survey supervisors, the surveyors informed Staff 1, Administrator and Staff 2, DNS, that the failure of the current measures used by the facility to ensure Resident 42 continuous access to a call system and to assure timely response to her needs were found unsuccessful and constituted a situation of immediate jeopardy to the resident. The Surveyors requested a plan of correction to immediately protect the resident from harm be developed and implemented. On 7/26/12 at 2:45 pm an initial plan of correction was provided by the facility. It was reviewed by the survey team and the immediate jeopardy was abated on 7/26/12 at 2:45 pm. At 4:00 pm the facility provided a revised resident's plan of care related to her preference regarding call light placement.

Based on interviews and record reviews it was determined the facility failed to provide the necessary care and services regarding a surgical wound for 1 of 3 sampled residents (#1). Resident 1 required hospitalization for infection of the surgical wound. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The local hospital history and physical dated 6/9/11 indicated in March 2011 the resident was found to have an [MEDICATION NAME] abscess at C5-C6 (spinal cord) with staphylococcus aureus (bacterial infection). The resident went into [MEDICAL CONDITION] that required intubation. Her/his abscess required two surgical decompressions and ultimately a C5 carpectomy (removal of carpal bone) with vertebral body replacement with mesh. The surgery created an unstable C-spine and required the resident to be placed in a halo device (piece of equipment that encircles and is fixed to the head to stabilize cervical spine). The spinal cord was damaged and the resident was a quadriparetic (weakness and altered sensation of the body below the neck). The assessment/plan indicated the resident's posterior neck staples were to be removed after 6/14/11 according to the neurosurgeon's orders. There were no local hospital physician's orders to the facility on [DATE] regarding care for the resident's neck staples. The facility's 6/28/11 Admission Nursing Data Base form completed by Staff 3 (RN) included a description of the condition of the resident's skin upon admission. The form had an outline of the front and back of the resident's body. The documentation indicated the resident had halo pins on the back of her/his head. A line was drawn down from the resident's neck to the middle of the resident's back, between the shoulder blades. A question mark was written under the line on the back. The form contained an area to document the location of the skin impairment. The resident's form indicated the resident had a healing incision on the resident's spine. On 6/28/11 at 7:35 pm, Staff 3 (RN) wrote an Interdisciplinary Progress Note (IPN) to indicate the resident had a halo and clamshell device to provide spine support. The IPN indicated it was difficult to visualize the resident's neck and unable to visualize her/his chest and back. Staff 3 wrote staples were evident to incision on back at top of neck, old sanguineous (bloody) drainage seen on dressing. Staff 3 was able to visualize the top two inches of the resident's neck. Staff 3 indicated the surgeon was to be called on 6/29/11 to clarify the physician's order and the care plan. On 6/29/11 at 1:10 pm, Staff 3 (RN) wrote an IPN to indicate the neurosurgeon's office was contacted and a message was left about physician's orders for staple removal. There was no evidence the neurosurgeon responded to the message left by Staff 3. There was no evidence the facility contacted the neurosurgeon again about the observations of the staples. An 8/9/11 IPN written at 12:00 pm by Staff 5 (RN) revealed halo clam shell mechanism covering chest and back. Staff 5 wrote she "found drsg (dressing) on back under Halo mechanism with lg (large) amount purulent (pus) drainage and foul odor. Attempted cleansing of site, cannot assess skin or remove drsg without removal of Halo mechanism. Did not remove drsg d/t (due to) having to pull it out and unknown what is below drsg-possibility of shearing skin/wound. neurosurgeon's office called and left message-waiting return call for soon appt (appointment) or advice. Made second call to neurosurgeon's office ...." An 8/9/11 IPN written at 2:10 pm by Staff 4 (RNCM) revealed neurosurgeon's office was called again regarding probable infection of staples to back. Another message was left with the neurosurgeon's office that the resident needed to be seen as soon as possible due to likely infection. An 8/9/11 IPN written at 4:20 pm by Staff 4 revealed the neurosurgeon was upset the resident's staples had not already been removed. The neurosurgeon had given orders to the local hospital for the staples to be removed on 6/14/11, prior to the resident's admission to the facility on [DATE]. Staff 4 indicated the local hospital physician's orders did not include care for staples or back wounds on admission. Staff 4 indicated on the morning of 8/9/11 Staff 5 (RN) alerted Staff 4 (RNCM) of the probable infection of the resident's upper back staples/wound. An 8/10/11 IPN written at 1:00 pm by Staff 4 (RNCM) indicated the resident was admitted to the local hospital for infection to back surgical incision. Staff 4 informed Staff 1 (Administrator) and Staff 2 (DNS) of the situation. An 8/10/11 IPN written at 5:00 pm by Staff 2 (DNS) revealed Staff 2 was notified the physician ordered the resident's sutures to be removed at hospital prior to being admitted to the facility. "We began checking into this when she/he was admitted earlier from hospital and physician office visit. She/he was admitted to the hosp (hospital) from (neurosurgeon's) office and (neurosurgeon) told us that he had called (local hospital) for them to remove the staples on 6/13/11, on 6/14/11 and again on 6/17/11. She/he admitted to us on 6/28/11 with only orders to treat halo pin sites when I got report that physician had told us of his call to (local hospital) on three separate days I called (local hospital) and talked with Quality Care Supervisor and told her the situation. She assured me she would look into this." An interview on 8/23/11 at 11:00 am with Staff 3 (RN) revealed when she conducted the skin assessment of the resident on 6/28/11 she observed the staples on the resident's neck. Staff 3 stated she read the resident's history and physical from the local hospital and saw the neurosurgeon's order for the removal of the resident's staples after 6/14/11. Staff 3 stated she called the neurosurgeon's office and left a message regarding the observations of the staples. Staff 3 stated she did not write a fax to the neurosurgeon. Staff 3 stated she verbally told Staff 4 (RNCM) of the observations of the resident's staples and the message to the neurosurgeon. Staff 3 stated she did not write a note to Staff 4. Staff 3 stated she had the next three days off. Staff 3 stated she did not check to see if there was a response from the neurosurgeon regarding the resident's staples. Staff 3 stated she did not initiate a skin assessment sheet for the facility staff to monitor the dressing on the back of the resident's neck. Staff 3 stated the resident's clam shell was adjusted by the local orthotics company. When Staff 3 worked with Resident 1 again the clam shell covered the resident's neck area where the staples had been observed. Staff 3 stated the resident showed no signs and symptoms to indicate the resident had an infection. An interview on 8/23/11 at 12:58 pm with Staff 4 (RNCM) revealed Staff 4 could not recall being told by Staff 3 (RN) of the observation of the staples on the back of Resident 1's neck on 6/28/11 or 6/29/11. Staff 4 stated once the staples were observed a skin sheet describing the observation needed to be completed, documentation of the observation needed to be completed on the 24 hour report so the charge nurses on the oncoming shifts, Staff 4 (RNCM) and Staff 2 (DNS) would have been aware of the observation. Staff 4 stated the procedure would have assured the neurosurgeon's office was contacted again if there was no response to Staff 3's (RN) telephone call. Staff 4 stated the procedure the charge nurses were to follow in contacting the physician's office was to call the physician and leave a message, call again the next day and if no response to send a fax to the physician. If there was still no response from the physician, the charge nurse was to involve the Staff 4 (RNCM), Staff 2 (DNS) and Staff 1 (Administrator) for assistance. Staff 4 stated she was not aware of the staples and dressing on the resident's neck until 8/9/11. An interview on 8/23/11 at 1:50 pm with Staff 2 (DNS) revealed Staff 3 (RN) wrote the 6/28/11 and 6//29/11 IPNs and completed the resident's Admission Database form on 6/28/11. Staff 2 stated she was not aware of the IPNs until after the resident was discharged to the hospital on [DATE]. Staff 2 (DNS) stated Staff 3 (RN) did not inform Staff 2 and Staff 4 (RNCM) of the observations of the resident's staples. Staff 2 stated Staff 3 did not identify the observation on the Wound or Pressure Ulcer Identification Form and did not document the observation in the 24 hour report to alert the charge nurses working on the subsequent shifts of the observations. An interview on 8/23/11 at 3:00 pm with Staff 2 (DNS) revealed the resident was seen by the nurse practitioner on 7/5/11 and the primary care physician on 7/19/11. Staff 2 indicated the resident's wounds were not observed during the facility visits. On 8/24/11 at 9:00 am Staff 2 (DNS) provided a Record of Coaching/Counseling signed by Staff 1 (Administrator) Staff 2 and Staff 3 (RN). The form indicated Staff 3 failed to follow the facility's policy/procedures regarding reporting. Staff 3 failed to add Resident 1 had staples under halo to 24 hour reporting, did not complete a skin sheet for the area on the resident's back with the staples and did not report the observation of the staples on the Nursing Data base form. An interview on 8/24/11 at 9:05 am with Staff 5 (RN) revealed on 8/9/11 at 6:00 am she received report from Staff 6 (night shift charge nurse/LPN). Staff 6 told Staff 5 that she was in training on the day Resident 1 was admitted to the facility. Staff 6 asked Staff 5 to check to see if the resident's staples had been removed. Staff 5 stated Staff 6 indicated the idea just came to her to have Staff 5 check the resident's staples. Staff 5 stated she was not aware of the resident's staples prior to 8/9/11. Staff 5 stated she was able to see a small portion of the ABD (highly absorbent dressing that provides and protects large wounds) visible from underneath the clam shell of the halo. Staff 5 stated she looked down underneath the clam shell and it looked like green pus on the ABD. Staff 5 stated she used gloves and a clean ABD and determined there was definitely pus on the ABD. Staff 5 stated she was able to see the top staple on the resident's neck. Staff 5 stated the resident was usually in bed and she cleaned the halo pin sites (two on the front of the resident's head and two pins on the back of the resident's head). Staff 5 stated the resident did not display any signs and symptoms of an infection. An interview on 8/24/11 at 9:45 am with Staff 6 (LPN) revealed 6/28/11 was the first day Staff 6 worked at the facility and was in training regarding the facility's policies and procedures. Staff 6 stated she had previous work experience as an LPN. Staff 6 stated she remembered Resident 1's admission to the facility. Staff 6 stated she was in the resident's room when the resident was assisted into bed by the transport service. Staff 6 stated she saw seven staples on the resident's back underneath the clam shell of the halo. Staff 6 stated she reported her observations to Staff 3 (RN). Staff 6 stated she reviewed the resident's chart with Staff 3 and they determined the resident's staples were to have been removed at the local hospital after 6/14/11. Staff 6 stated she did not follow up with contacting the neurosurgeon because she had reported her concerns to Staff 3 (RN charge nurse). Staff 6 stated she assumed the RN would have completed the follow up. Staff 6 acknowledged she worked with the resident after 6/28/11 though the resident was always in bed during the night shift. Staff 6 stated she thought Resident 1 looked as if she/he was deteriorating. Staff 6 was asked what she meant by "deteriorating." Staff 6 stated the resident's face was not as full as it had been upon admission. Staff 6 stated on 8/9/11 she just happened to think about the resident's admission and the staples and asked Staff 5 (RN) to check the resident's condition. Staff 6 stated the resident did not exhibit any signs and symptoms of infection. An interview on 8/24/11 at 11:40 am with Staff 7 (CNA) revealed the resident received a bed bath daily. Staff 7 was not aware of any staples or stitches on her/his back or having a fever. An interview on 8/24/11 at 1:00 pm with Staff 1 (Administrator) and Staff 2 (DNS) revealed the local orthotics company made a facility visit on 7/1/11 to adjust the resident's clam shell device. Staff 2 stated when the clam shell device was adjusted it covered the staples and incision on the resident's neck. Staff 1 and Staff 2 were asked if there was a facility investigation regarding the resident's staples. Staff 2 indicated the 8/10/11 IPN was the facility investigation. Staff 1 and 2 indicated the local hospital did not follow physician's orders with the removal of the neck staples after 6/14/11. The local hospital did not provide the facility with physician's orders regarding the staples and wound care. Staff 1 (Administrator) indicated the facility followed physician's orders from the local hospital.

Based on interviews and record reviews, it was determined the facility failed to communicate the observation of staples on the back of the resident's neck upon admission. The staples had not been removed as ordered at the local hospital. The facility failed to ensure the resident's physician was informed the staples had not been removed for 1 of 3 sampled residents (#1). This resulted in Resident 1 having the staples in for eight weeks longer than ordered. Resident 1 was hospitalized for [REDACTED]. Findings include: State Board of Nursing Standards of Practice for Licensed Practical Nurse and Registered Nurses [PHONE NUMBER](1)(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. Scope of Practice Standards for Registered Nurses 85-045-0060 (2) Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client's condition or needs, the Registered Nurse shall: (a) Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by: (A) Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Distinguishing abnormal from normal data, sorting, selecting, recording, analyzing, synthesizing and reporting the data; (C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed; (D) Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status; and (E) Validating data by utilizing available resources, including interactions with the client and health team members. (b) Establish and document nursing diagnostic statements and/or reasoned conclusions which serve as the basis for the plan or program of care ... (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to the context of care, including emergency measures, interpretation of medical orders, medication administration, independent nursing activities, nursing, medical and interdisciplinary orders, health teaching and health counseling; and (B) Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner. (e) Evaluating client responses to nursing interventions and progress toward desired outcomes. (A) Outcome data shall be used as a basis for reassessing the plan of care and modifying nursing interventions; and (B) Outcome data shall be collected, documented and communicated to appropriate members of the healthcare team. (3) Standards related to the Registered Nurse's responsibility for collaboration with an interdisciplinary team. The Registered Nurse: (a) Functions as a member of the healthcare team to collaborate in the development, implementation and evaluation of integrated client-centered plans of care; (b) Demonstrates knowledge of roles of members of the interdisciplinary team; (c) Communicates with other relevant personnel regarding integrated client-centered plans of care; and (d) Makes referrals as necessary and ensures follow-up on those referrals.... Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The local hospital history and physical dated 6/9/11 indicated in March 2011 the resident was found to have an [MEDICATION NAME] abscess at C5-C6 (spinal cord) with staphylococcus aureus (bacterial infection). The resident went into [MEDICAL CONDITION] that required intubation. Her/his abscess required two surgical decompressions and ultimately a C5 carpectomy (removal of carpal bone) with vertebral body replacement with mesh. The surgery created an unstable C-spine and required the resident to be placed in a halo device (piece of equipment that encircles and is fixed to the head to stabilize cervical spine). The spinal cord was damaged and the resident was a quadriparetic (weakness and altered sensation of the body below the neck). The assessment/plan indicated the resident's posterior neck staples were to be removed after 6/14/11 according to the neurosurgeon's orders. There were no local hospital physician's orders to the facility on [DATE] regarding care for the resident's neck staples. The facility's 6/28/11 Admission Nursing Data Base form completed by 6/28/11 by Staff 3 (RN) included a description of the condition of the resident's skin upon admission. The form had an outline of the front and back of the resident's body. The documentation indicated the resident had halo pins on the back of her/his head. A line was drawn down from the resident's neck to the middle of the resident's back, between the shoulder blades. A question mark was written under the line on the back. The form contained an area to document the location of the skin impairment. The resident's form indicated the resident had a healing incision on the resident's spine. On 6/28/11 at 7:35 pm, Staff 3 (RN) wrote an Interdisciplinary Progress Note (IPN) to indicate the resident had a halo and clamshell device to provide spine support. The IPN indicated it was difficult to visualize the resident's neck and unable to visualize her/his chest and back. Staff 3 wrote staples were evident to incision on back at top of neck, old sanguinous (bloody) drainage seen on dressing. Staff 3 was able to visualize the top two inches of the resident's neck. Staff 3 indicated the surgeon was to be called on 6/29/11 to clarify the physician's order and care plan. On 6/29/11 at 1:10 pm, Staff 3 (RN) wrote an IPN to indicate the neurosurgeon's office was contacted and a message was left about physician's orders for staple removal. There was no evidence the neurosurgeon responded to the message left by Staff 3. There was no evidence the facility contacted the neurosurgeon again about the observations of the staples. An 8/9/11 IPN written at 12:00 pm by Staff 5 (RN) revealed halo clam shell mechanism covering chest and back. Staff 5 wrote she "found drsg (dressing) on back under Halo mechanism with lg (large) amount purulent (pus) drainage and foul odor. Attempted cleansing of site, cannot assess skin or remove drsg without removal of Halo mechanism. Did not remove drsg d/t (due to) having to pull it out and unknown what is below drsg-possibility of shearing skin/wound. neurosurgeon's office called and left message-waiting return call for soon appt (appointment) or advise. Made second call to neurosurgeon's office...." An 8/9/11 IPN written at 2:10 pm by Staff 4 (RNCM) revealed neurosurgeon's office was called again regarding probable infection of staples to back. Another message was left with the neurosurgeon's office that the resident needed to be seen as soon as possible due to likely infection. An 8/9/11 IPN written at 4:20 pm by Staff 4 revealed the neurosurgeon was upset the resident's staples had not already been removed. The neurosurgeon had given orders to the local hospital for the staples to be removed on 6/14/11, prior to the resident's admission to the facility on [DATE]. Staff 4 indicated the local hospital physician's orders did not include care for staples or back wounds on admission. Staff 4 indicated on the morning of 8/9/11 Staff 5 (RN) alerted Staff 4 (RNCM) of the probable infection of the resident's upper back staples/wound. An 8/10/11 IPN written at 1:00 pm by Staff 4 (RNCM) indicated the resident was admitted to the local hospital for infection to back surgical incision. Staff 4 informed Staff 1 (Administrator) and Staff 2 (DNS) of the situation. An interview on 8/23/11 at 11:00 am with Staff 3 (RN) revealed when she conducted the skin assessment of the resident on 6/28/11 she observed the staples on the resident's neck. Staff 3 stated she read the resident's history and physical from the local hospital and saw the neurosurgeon's order for the removal of the resident's staples after 6/14/11. Staff 3 stated she called the neurosurgeon's office and left a message regarding the observations of the staples. Staff 3 stated she did not write a fax to the neurosurgeon. Staff 3 stated she verbally told Staff 4 (RNCM) of the observations of the resident's staples and the message to the neurosurgeon. Staff 3 stated she did not write a note to Staff 4. Staff 3 stated she had the next three days off. Staff 3 stated she did not check to see if there was a response from the neurosurgeon regarding the resident's staples. Staff 3 stated she did not initiate a skin assessment sheet for the facility staff to monitor the dressing on the back of the resident's neck. An interview on 8/23/11 at 12:58 pm with Staff 4 (RNCM) revealed Staff 4 could not recall being told by Staff 3 (RN) of the observation of the staples on the back of Resident 1's neck on 6/28/11 or 6/29/11. Staff 4 stated once the staples were observed a skin sheet describing the observation needed to be completed, documentation of the observation needed to be completed on the 24 hour report so the charge nurses on the oncoming shifts, Staff 4 (RNCM) and Staff 2 (DNS) would have been aware of the observation. Staff 4 stated the procedure would have assured the neurosurgeon's office was contacted again if there was no response to Staff 3's telephone call. Staff 4 stated the procedure the charge nurses were to follow in contacting the physician's office was to call the physician and leave a message, call again the next day and if no response to send a fax to the physician. If there was still no response from the physician, the charge nurse was to involve the Staff 4 (RNCM), Staff 2 (DNS) and Staff 1 (Administrator) for assistance. Staff 4 stated she was not aware of the staples and dressing on the resident's neck until 8/9/11. An interview on 8/23/11 at 1:50 pm with Staff 2 (DNS) revealed Staff 3 (RN) wrote the 6/28/11 and 6/29/11 IPNs and completed the resident's Admission Database form on 6/28/11. Staff 2 stated she was not aware of the IPNs until after the resident was discharged to the hospital on [DATE]. Staff 2 (DNS) stated Staff 3 (RN) did not inform Staff 2 (DNS) and Staff 4 (RNCM) of the observations of the resident's staples. Staff 2 stated Staff 3 did not identify the observation on the Wound or Pressure Ulcer Identification Form and did not document the observation in the 24 hour report to alert the charge nurses working on the subsequent shifts of the observation. On 8/24/11 at 9:00 am Staff 2 (DNS) provided a Record of Coaching/Counseling signed by Staff 1 (Administrator) Staff 2 and Staff 3 (RN). The form indicated Staff 3 failed to follow the facility's policy/procedures regarding reporting. Staff 3 failed to add Resident 1 had staples under halo to 24 hour reporting, did not complete a skin sheet for the area on the resident's back with the staples and did not report the observation of the staples on the Nursing Data base form. An interview on 8/24/11 at 9:05 am with Staff 5 (RN) revealed on 8/9/11 at 6:00 am she received report from Staff 6 (night shift charge nurse/LPN). Staff 5 said Staff 6 had been in training on the day Resident 1 was admitted to the facility. Staff 5 had been asked by Staff 6 to check to see if the resident's staples had been removed. Staff 5 stated Staff 6 indicated the idea just came to her to have the resident's neck checked. Staff 5 stated she was not aware of the resident's staples prior to 8/9/11. Staff 5 stated she was able to see a small portion of the ABD (highly absorbent dressing that provides and protects large wounds) visible from underneath the clam shell of the halo. Staff 5 stated she looked down underneath the clam shell and it looked like green pus on the ABD. Staff 5 stated she used gloves and a clean ABD and determined there was definitely pus on the back of the resident's neck. Staff 5 stated she was able to see the top staple on the resident's neck. Staff 5 then alerted Staff 4 (RNCM) of her findings. Staff 5 stated the resident was usually in bed and she cleaned the halo pin sites (two on the front of the resident's head and two pins on the back of the resident's head). Staff 5 stated the resident did not display any signs and symptoms of an infection. An interview on 8/24/11 at 9:45 am with Staff 6 (LPN) revealed 6/28/11 was the first day she worked at the facility. Staff 6 stated she was in training regarding the facility's policies and procedures. Staff 6 stated she remembered Resident 1's admission to the facility and was in the resident's room when the resident was assisted into bed by the transport service. Staff 6 stated she saw seven staples on the resident's back underneath the clam shell of the halo. Staff 6 stated she reported her observations to Staff 3 (RN). Staff 6 stated she reviewed the resident's chart with Staff 3 and they determined the physician's orders indicated the resident's staples were to be moved at the local hospital on [DATE]. Staff 6 stated she did not follow up with contacting the neurosurgeon because she had reported her concerns to Staff 3 (RN charge nurse). Staff 6 stated she assumed the RN would have completed the follow up. Staff 6 acknowledged she worked with the resident after 6/28/11 though the resident was always in bed during the night shift. Staff 6 stated the resident had no signs and symptoms of an infection though she thought Resident 1 looked as if she/he was deteriorating. Staff 6 was asked what she meant by "deteriorating." Staff 6 stated the resident's face was not as full as it had been upon admission. Staff 6 stated on 8/9/11 she just happened to think about the resident's admission and the staples. Staff 6 asked Staff 5 (RN) to check the resident's condition. Refer to F-309.

Based on interview and record review it was determined that Staff 2, RNCM, failed to provide to an admitting facility a complete post-discharge plan of care that included the current diabetic management treatment protocol for 1 of 3 residents (Resident # 1) who were diabetic and discharged to other care settings. Resident 1 did not receive insulin after discharge from the facility and was admitted to the hospital's Intensive Care Unit in a comatose state with a critically high blood sugar level. Findings include: Review of the Oregon State Board of Nursing, Nurse Practice Act, Scope of Practice Standards for Registered Nurses [PHONE NUMBER] revealed "3 (c) Communicates with other relevant personnel regarding integrated client-centered plans of care; and (d) Makes referrals as necessary and ensures follow-up on those referrals." Resident 1 was admitted to the facility in 11/2010 with a [DIAGNOSES REDACTED]. The resident also had physician orders [REDACTED]. On 12/17/10 the resident discharged to a second nursing facility. A review of the Treatments and Medications sections of the Discharge Plan of Care, completed by Staff 2, RNCM, and dated 12/17/10, revealed the resident's insulin and CBG regimen had not been added to either of these sections. The Discharge Plan of Care was sent to the second facility. In an interview on 12/22/10 at 12:00 pm, Staff 2, RNCM, stated she knew the resident was a diabetic and had been taking insulin. Staff 2 stated she had completed the treatment and medication portion of the resident's Discharge Plan of Care. Staff 2 stated she knew the resident's insulin regimen was in front of the TAR but forgot to reference those records when completing the Discharge Plan of Care. Refer to F284 for additional information.

Based on interview and record review it was determined the facility failed to provide to an admitting facility a complete post-discharge plan of care that included the resident's diabetes and insulin administration for 1 of 3 residents (Resident # 1) who were diabetic and discharged to other care settings. Resident 1 did not receive insulin after discharge from the facility and was admitted to the hospital's Intensive Care Unit in a comatose state with a critically high blood sugar level. Findings include: Resident 1 was admitted to the facility in 11/2010 with a [DIAGNOSES REDACTED]. The resident also had physician orders [REDACTED]. A review of the TAR notebook revealed the insulin administration records were kept in front of the notebook, separate from other treatments the resident was receiving. According to the 12/2010 insulin administration records the resident received insulin before each meal and at 7:00 am and 4:00 pm. In addition, on most days the resident also received a sliding scale dose of insulin at breakfast, lunch and dinner. On Friday, 12/17/10 the resident was discharged to a second nursing facility. A review of discharge documents sent to the second facility revealed a Discharge Plan of Care dated 12/17/10. The discharge documents also included a 12/2/10 hospital medication list which showed the resident was receiving insulin daily at the hospital; however, a review of the Discharge Plan of Care revealed the resident's current diabetes and insulin administration was omitted from the Plan of Care. The discharge documents also included the resident's 12/2010 MARs and TARs but not the insulin administration records that were kept in front of the TAR notebook. According to medial records obtained from the second facility where the resident was admitted on [DATE], the resident did not receive insulin at the facility on 12/17/10, 12/18/10 and 12/19/10. The facility had not received information about the resident's insulin regimen that had been followed at the previous facility. On Sunday, 12/19/10 the resident was discovered to be non-responsive and was transported to the hospital at 8:30 am. According to a 12/19/10 hospital emergency room report the resident was admitted to the hospital non-responsive with a blood sugar level greater than 500 and in a state of Diabetic Ketoacidosis ([MEDICAL CONDITION] with metabolic acidosis.) The resident was placed in the Intensive Care Unit and required mechanical assistance to breathe. In an interview on 12/22/10 at 10:30 am Staff 1, Social Services, stated before the resident discharged from the facility she faxed to the second facility the resident's latest MAR, TAR and Discharge Plan of Care. Staff 1 stated nursing staff list the resident's current treatments and medications on the Discharge Plan of Care before it is faxed to the admitting facility. Staff 1 stated she was not aware insulin records were kept in the front of the treatment book. Staff 1 stated she had faxed only the treatment records that were under Resident 1's room number tab which was behind the insulin records. In an interview on 12/22/10 at 12:00 pm, Staff 2, RNCM, stated she knew the resident was a diabetic and had been taking insulin. Staff 2 stated she had completed the treatment and medication portion of the resident's Discharge Plan of Care. Staff 2 stated she knew the resident's insulin regimen was in front of the TAR but forgot to reference those records when completing the Discharge Plan of Care.

Based on interview and record review it was determined the facility failed to develop and implement care planned interventions to prevent accidents for 1 of 3 residents (#2) who were at risk for falls. Resident 2 sustained a laceration to the left lower leg, was transported to the hospital and received 44 sutures. Findings include: Resident 2 was admitted to the facility in 10/2010 with [DIAGNOSES REDACTED]. According to a 10/12/10 admission comprehensive nursing assessment the resident required 2-person, extensive assistance, for transfers and was at risk for falls. A care plan dated 10/15/10 indicated the resident required maximum assistance for transfers; however, the care plan did not specify how the resident was to be transferred such as 1-person assist, 2-person assist, mechanical lift, etc. According to a 11/11/10 physical therapy discharge summary the resident required 75% assistance with 2-persons for transfers. According to an Incident/Accident Report, on 11/24/10 at 9:15 pm the resident sustained [REDACTED]. The report indicated the resident had cut her leg on the wheelchair. The resident was transported to the hospital where she received 44 sutures to her leg. The resident returned to the facility at 10:45 pm. An investigation of the 11/24/10 incident by Staff 2, DNS, indicated Staff 3, CNA, had transferred the resident alone. The investigation indicated the resident was screened by therapy who determined the resident required 2-person assistance for transfers. Staff 3 was "counseled" on the resident's transfer status and where to obtain resident information "per status sheets (pocket care plan) and care plan." In interviews on 12/7/10 at 10:30 am and 12/9/10 at 2:40 pm, Staff 2 stated the transfer status had not been on the resident's care plan since her admission; the intervention "2-person transfer" was put on the care plan on 12/7/10 by Staff 2. In addition, Staff 2 stated on the 11/24/10 evening shift the resident status sheets had not been available to staff for Resident 2's unit. Staff 2 stated the RNCM had not put them out for the resident's unit; the RNCM was currently not working at the facility. Staff 2 stated she went to the facility the evening of 11/24/10 and placed the 2-person transfer intervention on the resident's status sheet. Staff 2 could not recall if the 2- person transfer intervention had been on the status sheet prior to 11/24/10. In interview on 12/7/10 at 12:30 pm, Staff 3 stated he had not been assigned to Resident 2's unit the evening of 11/24/10. Staff 3 stated he responded to the resident's call light and assisted her to bed. Staff 3 stated he had not transferred the resident before 11/24/10. Staff 3 stated the status sheets for the residents were not available on 11/24/10.

Based on interview and record review it was determined the facility failed to ensure physician ordered measures were implemented to prevent dehydration for 1 of 3 residents (#1) who were at risk for dehydration. Resident 1 was transported to the hospital on [DATE] and was found to have "an approximate 4 liter free water deficit." Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with physician orders [REDACTED]." A review of the resident's 10/29/10 admission comprehensive nursing assessment revealed the factors that put the resident at risk for dehydration were not addressed or assessed in the assessment. The resident's current care plan did not identify dehydration as a problem area nor were the physician ordered fluid parameters identified on the resident's care plan or the 10/2010 and 11/2010 MAR and TAR. According to 11/12/10 Weekly Nutrition at Risk meeting notes, during the previous week the resident's combined average fluid intake for all three meals (breakfast, lunch and dinner) was 31 ounces. The following week the combined average for all three meals was 31 ounces. The resident's 10/2010 and 11/2010 meal monitor indicated the resident had not consumed 2 liters of fluid on any days; in addition, there were multiple days where the fluid intake section was blank for either breakfast, lunch, dinner or all three. A review of the medical record did not indicate the facility had acknowledged the resident had not been meeting the physician ordered fluid minimum nor was there an assessment of the barriers which prevented the resident from meeting the fluid minimum. According to nursing notes, on 11/27/10 the resident was noted to have a decreased level of consciousness with confusion. The resident's mucous membranes were dry and the resident's eyes were dry and sunken. The resident was transported to the hospital. According to a 11/27/10 hospital History and Physical the resident was noted to have dry mucous membranes and have "an approximate 4 liter free water deficit." In an interview on 12/6/10 at 11:00 am, Staff 1, CNA, who had worked with the resident, stated she was not aware of a fluid enhancement program for the resident. Staff 1 stated that if the resident had been on a fluid enhancement program it would be identified on the care plan. In an interview on 12/8/10 at 1:30 pm, Staff 2, DNS, acknowledged the resident's dehydration had not been assessed or care planned and the physician ordered fluid minimum was not documented as being provided.

Based on observation, interviews and record reviews, it was determined the facility failed to give a PRN diuretic medication, perform weights and notify the physician as ordered for 3 of 3 sampled residents (#s 1, 2 and 3) with [DIAGNOSES REDACTED]. Findings include: 1. Resident 2, a long time resident of the facility, was admitted with [DIAGNOSES REDACTED]. Ischemic [MEDICAL CONDITION] is defined as a lack of oxygen to the heart. [MEDICAL CONDITION] is defined as the heart is unable to meet the demands of the body, causing a build up of fluid and a weight gain. Treatment includes the use of diuretic medications (medications that remove excess fluid from the body). The resident was receiving hospice services for Ischemic [MEDICAL CONDITION] and [MEDICAL CONDITION]. Hospice was responsible for managing the resident's medications. Review of the TARs and MARs for March 2010 through May 2010 revealed the resident's weight was monitored daily. According to the MARs, the resident received diuretic medications including [MEDICATION NAME] and [MEDICATION NAME] every day and Potassium Chloride 20 meq PO tid. Potential side effects of diuretic medications include hypokalemia (low potassium levels in the body). Hypokalemia can cause cardiac arrhythmias. There were multiple changes in the doses of the diuretic medications based on the resident's weights. According to the NN dated 6/8/10 at 9:00 pm the resident refused to go to the dining room for dinner due to fatigue. Hospice was notified and orders were received to monitor the resident and contact them if the resident's condition worsened. The NN indicated on 6/9/10 at 5:00 am the resident's speech was slurred, but the resident answered questions appropriately. Hospice was notified at 5:35 am and orders were received to transport the resident to the hospital. The resident was hospitalized from [DATE] to 6/11/10. Review of the re-admission physician's orders [REDACTED]. The physician's orders [REDACTED]. If the resident's weight was 155 pounds or over and the resident gained one or more pounds in a 24 hour period, the resident was to receive [MEDICATION NAME] 10 mg PRN in addition to the routine daily diuretics. On 6/22/10 blood was drawn for a Basic Metabolic Panel (BMP). The results were marked "Critical" with the potassium level results at 2.4. Normal potassium levels are 3.5 to 5.5. According to the NN, Hospice was notified on 6/22/10 at 10:00 am. Physician orders [REDACTED]. The last dose of [MEDICATION NAME] 100 mg was given at 9:00 am on 6/22/10. Review of the June 2010 MAR indicated [REDACTED]. The last dose was given at 9:00 am on 6/21/10. This RN surveyor was unable to locate the physician's orders [REDACTED]. Staff 1 (Administrator) and Staff 3 (RNCM) were informed on 10/27/10 at 2:45 pm. Staff 1 stated Staff 4 (medical records) would be asked to locate the physician's orders [REDACTED]. According to the June 2010 TAR, on 6/23/10 the resident's weight was documented at 150 pounds; on 6/24/10 the resident's weight was 144 pounds; on 6/25/10 the resident's weight was 145 pounds; on 6/26/10 the resident's weight was 148.6 pounds and on 6/27/10 the resident's weight was 160 pounds a 11.4 pound, 7.1% weight gain in a 24 hour period. On 6/27/10 the resident's weight was 161 pounds; On 6/28/10 the resident refused to be weighed. On 6/29/10 the residents weight was 164.5 pounds. The resident experienced a 15.9 pound, 9.6% weight gain from 6/26/10 to 6/29/10, a period of four days. Review of the June 2010 MAR indicated [REDACTED]. Review of the NN dated 6/30/10 at 6:15 pm revealed the resident's "wt (weight) (arrow upwards) about 10 lbs (pounds)... The NN indicated the resident was "lethargic" (fatigued). Hospice was notified. The NN indicated at 8:00 pm the PRN 10 mg [MEDICATION NAME] had been given. On 7/1/10 the NN further indicated Hospice had contacted the facility to ensure the resident received the PRN 10 mg [MEDICATION NAME] if the weight was 155 pounds or greater. In an interview on 10/27/10 at 2:45 pm Staff 1 (Administrator) and Staff 2 (RNCM) were informed the PRN [MEDICATION NAME] 10 mg had not been given as ordered. No additional information was provided. In an interview on 10/27/10 at 3:20 pm Witness 1 (Hospice RN) stated the resident was on Hospice due to end stage cardiac issues. Witness 1 indicated when the resident's potassium level was critical, the diuretic [MEDICATION NAME] was discontinued. Witness 1 stated the routine every day [MEDICATION NAME] 10 mg had been discontinued on 6/21/10. Witness 1 indicated it was important to closely monitor the resident's weight, diuretic use and potassium levels. 2. Resident 1, a long time resident of the facility, was admitted with [DIAGNOSES REDACTED]. Treatment includes the use of diuretic medications (medications that remove excess fluid from the body). Review of the monthly Physicians Recap Orders dated 10/1/10 revealed a physician's orders [REDACTED]. [REDACTED]. According to the March 2010 through June 2010 MARs, the [MEDICATION NAME] 40 mg PO every day was administered as ordered. Review of the July 2010 through October 27, 2010 TARs revealed the following: In July 2010 the resident's weight was not monitored daily on nine occasions as ordered; In August 2010 the resident's weight was not monitored daily on 10 occasions as ordered; In September 2010 the resident's weight was not monitored daily on nine occasions as ordered and from October 1, 2010 through October 27, 2010 the resident's weight was not monitored daily on seven occasions as ordered. In an interview on 10/27/10 at 2:45 pm Staff 1 (Administrator) and Staff 2 (RNCM) were informed the weights had not been obtained daily as ordered. No additional information was provided. In an interview on 10/27/10 at 12:55 pm Staff 12 (CNA/RA) stated he did not work weekends. Staff 12 indicated the CNAs were responsible for obtaining the weights on weekends. Staff 12 acknowledged some of the weights were not done daily as ordered. 3 a. Resident 3, a long time resident of the facility was admitted with [DIAGNOSES REDACTED]. Review of the NN dated 8/11/10 at 5:45 pm the resident was noted to have bilateral lower extremity [MEDICAL CONDITION]. On 8/12/10 a telephone physician's orders [REDACTED]. On 8/17/10 a telephone physician's orders [REDACTED]. The 8/17/10 telephone physician's orders [REDACTED]. Review of the August 2010 MAR, the [MEDICATION NAME] 40 mg, Potassium Chloride 20 meq and the [MEDICATION NAME] 25 mg had been administered as ordered. According to the TAR from 8/17/10 through 8/31/10, the resident was not weighed daily as ordered on six occasions. The resident did not gain three or more pounds in a 24 hour period. Review of the NN dated 9/1/10 at 6:00 pm revealed the resident complained of chest pain, was flushed and sweating. 911 was called and the resident was sent to the emergency room . The resident was hospitalized from [DATE] to 9/3/10. Review of the hospital history and physical examination markedly short of breath." The resident received [MEDICATION NAME] intravenously (IV). The [DIAGNOSES REDACTED]." [MEDICAL CONDITION] is defined as the heart is unable to meet the demands of the body, causing a build up of fluid and a weight gain. Treatment includes the use of diuretic medications (medications that remove excess fluid from the body). The admission physician's orders [REDACTED]. Review of the September 2010 MAR, the [MEDICATION NAME] 40 mg, Potassium Chloride 20 meq and the [MEDICATION NAME] 25 mg had been administered as ordered. According to the TAR from 9/1/10 through 9/27/10, the resident was weighed on 9/1/10 and on 9/14/10. No other weights were documented on the TAR between 9/1/10 and 9/14/10. On 10/27/10 at 2:45 pm Staff 1 (Administrator) and Staff 2 (RNCM) were informed of the weights documented on the TAR for September 2010. On 10/28/10 at 9:15 am Staff 1 provided a Weight Record Flowsheet that had additional weights documented for September 2010. Review of the Weight Record Flowsheet revealed the following: On 9/7/10, the resident's weight was documented at 248.8 lbs. On 9/21/10 the resident's weight was documented at 254.4 lbs, a nine pound weight gain from 9/14/10. No evidence could be located to indicate the physician was notified of the nine pound weight gain from 9/14/10 to 9/21/10 as ordered. No other weights for September 2010 could be located. b. On 9/28/10 a telephone physician's orders [REDACTED]. The physician was to be notified if the resident gained three or more pounds in a 24 hour period. The September 2010 TAR was changed on 9/28/10 to weigh the resident every Monday, Wednesday and Friday, not every other day as ordered. Review of the TAR and the Weight Record Flowsheet for 10/1/10 through 10/28/10 revealed the resident was to be weighed every Monday, Wednesday and Friday, not every other day as ordered. On 10/6/10 the resident's weight was documented at 246.6 lbs. On 10/11/10 the resident's weight was documented at 250.1 lbs, a 3.5 lb weight gain. No evidence could be located to indicated the resident's physician was notified as ordered. Observation of the resident on 10/28/10 at 11:10 am revealed the resident sitting in her wheelchair. The resident's color was pink and her breathing was regular. No shortness of breath was observed and there was no bilateral lower leg [MEDICAL CONDITION] noted. In an interview on 10/27/10 at 2:45 pm Staff 1 (Administrator) was informed the weights had not been obtained daily as ordered, the physician had not been notified when the resident gained three or more pounds and the resident was not weighed every other day as ordered. No additional information was provided. In an interview on 10/27/10 at 12:55 pm Staff 12 (CNA/RA) stated he did not work weekends. Staff 12 indicated the CNAs were responsible for obtaining the weights on weekends. Staff 12 acknowledged some of the weights were not done daily as ordered. Staff 12 stated since he did not work weekends, he made the choice to weigh the resident every Monday, Wednesday and Friday. In an interview on 10/28/10 at 2:10 pm Staff 13 (RNCM) acknowledged the resident's weights had not been done daily as ordered, the physician had not been notified when the resident gained three or more pounds and the resident should have been weighed every other day as ordered instead of Monday, Wednesday and Friday. Staff 13 stated an assessment for [MEDICAL CONDITION] signs and symptoms would be completed, the physician notified regarding the frequency of the weights and when to contact the physician about weight gain.

Based on interviews and record review, it was determined the facility failed to follow up on a documented concern regarding a routine medication for 1 of 3 sampled residents (#2) with [DIAGNOSES REDACTED]. Findings include: Review of the Oregon State Board of Nursing, Nurse Practice Act, Scope of Practice for All Licensed Nurses [PHONE NUMBER] (2) (B) revealed a licensed nurse is responsible for "Sorting, selecting, reporting and recording the data; (3) (f) "Consult with nurses and other health team members and make referrals if necessary." Resident 2, a long time resident of the facility, was admitted with [DIAGNOSES REDACTED]. Ischemic [MEDICAL CONDITION] is defined as a lack of oxygen to the heart. [MEDICAL CONDITION] is defined as the heart is unable to meet the demands of the body, causing a build up of fluid and a weight gain. Treatment includes the use of diuretic medications (medications that remove excess fluid from the body). The resident was receiving hospice services for Ischemic [MEDICAL CONDITION] and [MEDICAL CONDITION]. Hospice was responsible for managing the resident's medications. Review of the TARs and MARs for March 2010 through May 2010 revealed the resident's weight was monitored daily. According to the MARs, the resident received diuretic medications including [MEDICATION NAME] and [MEDICATION NAME] every day and Potassium Chloride 20 meq PO tid. Potential side effects of diuretic medications include hypokalemia (low potassium levels in the body). Hypokalemia can cause cardiac arrhythmias. There were multiple changes in the doses of the diuretic medications based on the resident's weights. According to the NN dated 6/9/10 the resident was sent to the hospital due to a change in mental status, slurred speech and general weakness. The resident was hospitalized from [DATE] to 6/11/10. Review of the re-admission physician's orders [REDACTED]. The physician's orders [REDACTED]. If the resident's weight was 155 pounds or over and the resident gained one or more pounds in a 24 hour period, the resident was to receive [MEDICATION NAME] 10 mg PRN in addition to the routine daily diuretics. On 6/22/10 blood was drawn for a Basic Metabolic Panel (BMP). The results were marked "Critical" with the potassium level results at 2.4. Normal potassium levels are 3.5 to 5.5. According to the NN, Hospice was notified on 6/22/10 at 10:00 am. Physician orders [REDACTED]. The last dose of [MEDICATION NAME] 100 mg was given at 9:00 am on 6/22/10. Review of the June 2010 MAR indicated [REDACTED]. The last dose was given at 9:00 am on 6/21/10. This RN surveyor was unable to locate the physician's orders [REDACTED]. Staff 1 (Administrator) and Staff 3 (RNCM) were informed on 10/27/10 at 2:45 pm. Staff 1 stated Staff 4 (medical records) would be asked to locate the physician's orders [REDACTED]. Review of the Hospice Interdisciplinary Progress Notes dated 6/23/10 revealed "follow-up from yesterday, 6/22/10. Pt's (patient's) K+ (potassium) low 2.4. MARs checked. New orders implemented. Pt (patient) now has no routine diuretics in place. Discussed plan of care with ....." According to the June 2010 TAR, on 6/23/10 the resident's weight was documented at 150 pounds; on 6/24/10 the resident's weight was 144 pounds; on 6/25/10 the resident's weight was 145 pounds; on 6/26/10 the resident's weight was 148.6 pounds and on 6/27/10 the resident's weight was 160 pounds a 11.4 pound, 7.1% weight gain in a 24 hour period. In an interview on 10/27/10 at 2:45 pm Staff 2 (RNCM) stated nothing had been documented regarding the meeting on 6/23/10 with Witness 1 (Hospice RN). Staff 2 indicated a follow up with the Hospice physician or the resident's physician regarding the lack of routine diuretic use should have been done. In an interview on 10/27/10 at 3:20 pm Witness 1 (Hospice RN) stated the resident was on Hospice due to end stage cardiac issues. Witness 1 indicated when the resident's potassium level was critical, the diuretic [MEDICATION NAME] was discontinued. Witness 1 stated the routine every day [MEDICATION NAME] 10 mg had been discontinued on 6/21/10. Witness 1 indicated it was important to closely monitor the resident's weight, diuretic use and potassium levels. In an interview on 10/28/10 at 11:15 am Staff 5 (RN) stated the routine diuretics had been discontinued in June 2010 after critical potassium results were received. Staff 5 indicated she had attended the meeting with Witness 1 and Staff 2 on 6/23/10 to discuss no routine diuretics and the parameters of the PRN diuretic. Staff 5 stated, "I'm not sure how it turned out" when asked about routine diuretic use.