Every finding on record at Hillsboro Health and Rehabilitation

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNAs (#s 4, 5, 6, 7 and 8) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff. Findings include: On 8/20/26 at 11:43 AM annual performance reviews for Staff 4 (CNA), Staff 5 (CNA), Staff 6 (CNA), Staff 7 (CNA), and Staff 8 (CNA) were requested from Staff 1 (Administrator). Staff 1 stated annual performance reviews were not completed for any facility CNAs.On 8/21/26 at 11:22 AM Staff 12 (Human Resources) stated no facility CNAs received annual performance reviews because they were part of a union. On 8/21/26 at 1:26 PM Staff 1 stated his understanding was CNA staff did not require annual performance reviews because they were part of a union.

Based on observation, interview and record review it was determined the facility failed to ensure all insulin vials and pens were stored and labeled properly for 2 of 4 medication/treatment carts reviewed for medication storage. This placed residents at risk for receiving incorrect or expired insulin. Findings include:The facility policy as outlined in the Nursing Care Center Pharmacy Policy and Procedure Manual: Medication Storage, Storage of Medication last revised 1/2023 revealed, note the date on the label for insulin vials and pen when first used.On [DATE] at 9:30 AM the medication cart for the back half of the 300 hall was observed to contain three multidose insulin pens that were not labeled with open dates. Staff 3 (LPN Resident Care Manager) indicated multidose pens were to be labeled with a date when first opened to indicate the new expiration date when stored at room temperature. Staff 3 confirmed the labeling of the three insulin pens was not consistent with storage and labeling requirements. On [DATE] at 9:45 AM the medication/treatment cart for the 100 hall was observed to have nine total insulin sources (multidose pens or vials). Of the nine sources, five were observed with inadequate labeling. This included: two used insulin pens with no open date. The same cart contained two insulin pens and one insulin multidose vial in the drawer with no attached label to identify the resident to whom the insulin was prescribed. Unattached resident-specific medication labels were observed within a compartment containing multiple residents' insulin pens. Staff 3 (LPN Resident Care Manager) confirmed the insulin was not adequately labeled and removed them from service.

Based on interview and record review it was determined the facility failed to ensure medication was held when contraindicated for 3 of 6 sampled residents (#s 2, 3, 28) reviewed for hospitalization, unnecessary medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 2 admitted to the facility in 10/2025 with diagnoses including atrial fibrillation, heart failure, and high blood pressure. A physician order for carvedilol dated 10/4/25 stated to not administer carvedilol (a medication for heart failure and high blood pressure) for a systolic blood pressure (the top number of the blood pressure) less than 100 or a heart rate less than 60. A review of Resident 2's 6/2026 medication administration record revealed from 6/1/26 through 6/30/26 facility staff administered carvedilol twenty-two times with a documented heart rate of less than 60. A review of Resident 2's 7/2026 medication administration record revealed from 7/1/26 through 7/17/26 facility staff administered carvedilol thirteen times with a documented heart rate of less than 60. On 8/20/26 at 1:30 PM Staff 3 (LPN Resident Care Manager) and at 1:33 PM Staff 11 (MDS Coordinator) stated they were aware Resident 2 was administered carvedilol outside of the physician ordered parameters. Staff 11 stated staff were expected to follow and implement physician orders and ensure parameters were followed. 2. Resident 3 was admitted to the facility in 6/2025 with diagnoses including a stroke and heart failure. A review of Resident 3's Annual MDS revealed a BIMS score of 00 indicating she/he had severe cognitive impairment. Resident 3's 7/10/26 last signed physician orders indicated the resident was to receive amlodipine 10 MG one tablet daily, losartan 50 MG one tablet daily, carvedilol 3.125 MG BID and staff were to hold all three medications for HR (heart rate) less than 55 bpm (beats per minute). Resident 3's 7/2026 MAR indicated the following medications were administered to Resident 3 when her/his HR was less than 55 bpm: -7/2/26, HR was 51 at 5:00 PM and Staff 23 (CMA) administered carvedilol. -7/3/26, HR was 54 at 8:00 AM and Staff 15 (CMA) administered losartan and carvedilol. -7/11/26, HR was 51 at 5:00 PM and Staff 18 (LPN) administered carvedilol. -7/29/26, HR was 52 and Staff 24 (RN) administered amlodipine. On 8/20/26 at 10:57 AM Staff 15 stated she remembered administering the medication on 7/3/26 after rechecking the residents HR and it was above 55 bpm. Staff 15 acknowledged there was no record of Resident 3's HR being rechecked and determined to be above 55 bpm. On 8/20/26 at 2:48 PM Staff 18 stated she followed the physician orders for the parameters when administering Resident 3's medication. Staff 18 stated she remembered administering the medication on 7/11/26 after rechecking the residents HR and it was above 55 bpm. Staff 18 acknowledged there was no record of Resident 3's HR being rechecked determined to be above 55 bpm. On 8/20/26 at 2:59 PM an attempt to call Staff 23 was unsuccessful. On 8/21/26 at 11:36 AM Staff 3 (LPN Resident Care Manager) stated staff were to recheck Resident 3's vitals manually if they were below the physician ordered parameters and the new vital signs were to be entered into the MAR. Staff 3 confirmed Resident 3 was administered amlodipine, losartan and carvedilol on the identified dates with a documented HR less than 55 bpm. On 8/21/26 at 12:19 PM an attempt to call Staff 24 was unsuccessful. On 8/21/26 at 1:50 PM Staff 2 (Regional Director of Clinical Operations) stated nurses and CMAs were to read and follow the physician order, including the parameters, prior to administering medication. 3. Resident 28 was admitted to the facility in 12/2025 with diagnoses including heart failure and hypotension (low blood pressure). A review of Resident 28's physician orders revealed a 12/5/25 order for metoprolol (a medication used to treat heart failure) daily, hold for a systolic blood pressure (the top number) less than 110 or heart rate less than 60. A review of Resident 28's physician orders revealed a 12/5/25 order for sacubitril valsartan (a medication used to treat heart failure) twice a day, hold for systolic blood pressure less than 100. Resident 28's 7/2026 MAR revealed she/he received metoprolol six times and she/he received sacubitril valsartan three times when it was to be held based on blood pressure and heart rate parameters. Resident 28's 8/2026 MAR revealed she/he received metoprolol once when it was to be held based on blood pressure parameters. An 8/5/2025 facility investigation indicated Resident 28 received metoprolol nine times when it was to be held based on blood pressure and/or heart rate parameters. On 8/19/26 at 1:00 PM, Staff 9 (LPN) stated she was aware of the medication errors she made by giving Resident 28 medications which was to be held based on blood pressure and/or heart rate parameters. Staff 9 stated she received training for the medication error in early 8/2026. On 820/26 at 10:23 AM, Staff 15 (CMA) acknowledged the medication errors she made by giving Resident 28 medications which was to be held based on blood pressure and/or heart rate parameters. Staff 15 stated she received training for the medication error early 8/2026. On 8/20/26 at 1:22 PM, Staff 13 (RNCM) acknowledged Resident 28 received medications that were to be held based on blood pressure and/or heart rate parameters. Staff 13 stated staff were expected to follow orders and hold medications based on ordered parameters.

Based on observation and interview it was determined the facility failed to ensure a clean and sanitary environment for 1 of 2 medication storage room sinks reviewed for infection control. This placed staff and residents at risk for cross contamination of medication and treatment supplies. Findings include: On 8/21/26 at 9:30 AM the 300-hall medication storage room was observed to contain resident treatment supplies, overstock of over-the-counter medications, and various single use sterile resident care items. The sink was centrally located in the small storage room and had a dripping faucet. The sink contained buildup of pink and yellow sludge and a large area of black partially dried, slimy/gelatinous debris with irregular borders, hair, and bits of paper. Staff 3 (LPN Resident Care Manager) verbally endorsed the unsanitary state of the sink. On 8/21/26 11:16 AM Staff 3 stated the process for cleaning the medication rooms and sinks was variable and depended on the workload of nursing staff. Staff 3 stated generally the night shift nurse was responsible for cleaning the medication room, however there was no system in place for auditing cleanliness and there was no assignment for ensuring the sanitary environment of the medication rooms. Staff 3 endorsed the concern for the unsanitary condition of the sink in relation to the risk of storing clean and sterile supplies in the room. On 8/21/26 Staff 2 (Regional Director of Clinical Operations) stated the nursing staff were responsible for daily cleaning and organization of the medication rooms. Staff 2 endorsed there was no one individual assigned to complete the task. Staff 2 observed and validated the unsanitary state of the sink.

Based on observation, interview, and record review it was determined the facility failed to accurately document ADL care for 1 of 1 sampled resident (#6) reviewed for hospice. This place residents at risk for lack of care. Finding include: Resident 6 was admitted to the facility in 2023 with diagnoses including diabetes and dementia.A 5/17/26 provider order indicated Resident 6 was to receive nail care every Sunday.On 8/18/26 at 2:16 PM Resident 6's toenails were observed to be long and overgrown.A review of Resident 6's 7/2026 MAR indicated nail care was completed on 7/12/26, 7/19/26 and 7/26/26.A review of Resident 6's 8/2026 MAR indicated nail care was completed on 8/2/26, 8/9/26, and 8/16/26.On 8/19/26 at 3:11 PM, Staff 9 (LPN) stated Resident 6 refused nail care. The 7/2026 and 8/2026 MAR were reviewed with Staff 9 and she confirmed she documented on 7/12/26, 7/26/26, 8/2/26, and 8/9/26 that nail care was completed. Staff 9 stated Resident 6's nail care was not completed due to refusals.On 8/20/26 at 1:17 PM, Resident 6's toenails were observed with Staff 13 (RNCM). Staff 13 agreed Resident 6 needed nail care. Staff 13 stated staff were expected to document resident refusals if the resident refused care.On 8/21/26 at 10:25 AM, Staff 14 (LPN) acknowledged she documented nail care being completed on 7/19/26. Staff 14 stated she never completed nail care for Resident 6.On 8/21/26 at 10:46 AM, Staff 1 (Administrator) stated staff were expected to document refusals.Refer to F677.

Based on interview and record review it was determined the facility failed to ensure residents did not receive food they were allergic to for 1 of 4 sampled residents (#8) reviewed for food. This placed residents at risk for allergic reactions. Findings include:Resident 8 was admitted to the facility in 6/2026 with diagnoses including gastroesophageal reflux disease (GERD, a disease that causes acid reflux) and irritable bowel syndrome (IBS, a chronic condition that affects the intestinal system).A 6/9/26 Food Preference Evaluation indicated Resident 8 had an allergy to pork derived products.A 6/12/26 Care Conference Evaluation indicated Resident 8 had an allergy to pork derived products.A 6/26/26 Progress Note indicated Resident 8 received ham for dinner and orders were received for Benadryl for symptoms of an allergic reaction.On 8/17/26 at 10:26 AM, Resident 8 stated in June 2026 she/he was served ham which was on her/his food allergy list. Resident 8 stated she/he took one bite before she/he realized it was ham. Resident 8 stated pork derived products can cause a hemipelagic migraine condition (a migraine that can temporarily cause paralysis or weakness to one side of the body) which caused the left side of her/his body to become numb and unresponsive. Resident 8 stated she/he was concerned because the more times she/he had a hemiplegic migraine condition, the increased likelihood of permanent paralysis on one side of her/his body.On 8/20/26 at 10:43 AM, Staff 16 (LPN) stated on 6/26/26 he was in Resident 8's room with her/his roommate when he heard Resident 8 ask if the meat on her/his plate was ham. Staff 16 stated he confirmed it was indeed ham. Staff 16 stated the provider was notified, allergic reaction symptoms Resident 8 experienced when she/he consumed pork derived products, and orders were received for Benadryl.On 8/20/26 at 11:31 AM, Staff 17 (Dietary Manager) acknowledged Resident 8 received ham on 6/26/26. Staff 17 stated staff were expected to review each resident's allergies every time they served meals.On 8/20/26 at 12:43 PM, Staff 13 (RNCM) acknowledged Resident 8 received ham on 6/26/26. Staff 13 stated nursing staff were expected to check each tray to ensure residents did not receive food they were allergic to prior to delivering the tray to the resident.The deficient practice was identified as Past Noncompliance based on the following:On 6/26/26 the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and determined a staff member was unfamiliar with the new format for the tray cards and the allergies were missed.The Plan of Correction included:All residents' trays were reviewed to ensure no other resident received a food item that was on their allergy list. There were no further incidents identified.All staff were educated to read the tray cards with each meal to check for allergies and tray lines and meal service would not be interrupted.Nursing staff were educated not to interrupt tray line/meal service, to put requests on the white board on the kitchen door, and to check tray care for accuracy prior to passing the tray.

Based on interview and record review it was determined the facility failed to ensure residents received one on one supervision with meals for 1 of 1 sampled resident (#23) reviewed for nutrition. This placed residents at risk for weight loss. Findings include:Resident 23 was admitted to the facility in 2022 with diagnoses including vascular dementia and heart failure. Review of the 11/27/25 Annual MDS dated revealed Resident 23 had a BIMS score of 3 out of 15, indicating severe cognitive impairment.Resident 23's comprehensive care plan, dated 6/2/26, directed staff to provide one on one supervision during meals and ensure food was cut into bite-sized pieces.On 8/18/26 at 12:35 PM, Resident 23 was observed in bed with a meal tray. Staff set up the resident's tray left her/his room and closed the door. Resident 23 remained in bed and ate without one on one supervision.On 8/19/26 at 8:54 AM, Resident 23 was observed eating breakfast without one on one supervision.On 8/19/26 at 1:08 PM, Resident 23 was observed in bed and eating lunch without staff supervision.On 8/19/26 at 9:30 AM, Staff 20 (CNA) stated Resident 23 required one on one supervision during all meals and was not sure why.On 8/19/26 9:34 AM, Staff 22 (Registered Dietitian) stated Resident 23 required staff to be present and observing while she/he ate.On 8/19/26 at 2:38 PM, Staff 21 (CMA) stated, We just set her/him up and she/he eats alone.During an interview on 8/20/26 at 9:25 AM, Staff 13 (RNCM) confirmed the care plan directed staff to provide one on one supervision during meals and stated staff were expected to provide one on one supervision throughout the entire meal.

Based on observation, interview, and record review it was determined the facility failed to provide nail care and grooming for dependent residents for 2 of 6 sampled residents (#s 6 and 53) reviewed for ADLs and hospice. This placed residents at risk for discomfort related to untrimmed toenails and lack of personal hygiene. Finding include: 1. Resident 53 was admitted to the facility in 8/2020 with diagnoses including dementia and diabetes. Resident 53's Quarterly MDS dated [DATE] indicated the resident required partial/moderate assistance with personal hygiene, which included shaving. Resident 53 was observed on 8/17/26 at 10:54 AM, 8/18/26 at 8:22 AM, and on 8/19/26 at 8:42 AM with a significant amount of facial hair on her/his chin and upper lip, approximately a half inch long. On 8/17/26 at 10:54 AM Resident 53 stated she/he did not want to have facial hair on her/his chin and upper lip. Resident 53 stated she/he shaved herself/himself in the past, but staff did not assist her/him with shaving. On 8/19/26 at 10:50 AM Staff 10 (CNA) observed Resident 53's facial hair and stated Resident 53 had a lot of facial hair, which needed to be taken care of. Staff 10 indicated Resident 53 expressed that she/he did not want the facial hair and wanted it removed. On 8/19/26 at 11:10 AM Staff 9 (LPN) observed Resident 53's facial hair and acknowledged the resident needed to be shaved. On 8/19/26 at 2:42 PM Staff 1 (Administrator) stated he was aware of Resident 53's facial hair and discussed with the resident a few weeks earlier that her/his facial hair needed to be taken care of. 2. Resident 6 was admitted to the facility in 2023 with diagnoses including diabetes and dementia. A 5/17/26 provider order indicated Resident 6 was to receive nail care every Sunday. A 7/22/26 hospice progress note indicated the facility was responsible for management of Resident 6's ADLs. On 8/18/26 at 2:16 PM, Witness 1 (Family Member) stated concern with Resident 6's toenails. Resident 6's toenails were observed to be long, the right and left first toes were thick and overgrown and the right and left 2nd and 3rd toenails were starting to curl into her/his skin. A review of Resident 6's 7/2026 MAR indicated she/he had nail care completed on 7/12/26, 7/19/26 and 7/26/26. A review of Resident 6's 8/2026 MAR indicated she/he had nail care completed on 8/2/26, 8/9/26, and 8/16/26. On 8/19/26 at 3:11 PM, Staff 9 (LPN) stated Resident 6 refused nail care. The 7/2026 and 8/2026 MARs were reviewed with Staff 9 and she confirmed she documented on 7/12/26, 7/26/26, 8/2/26, and 8/9/26 that nail care was completed. Staff 9 stated Resident 6's nail care was not completed due to refusals. Staff 9 stated Hospice staff came and helped with nail care. On 8/20/26 at 1:17 PM, Resident 6's toenails were observed with Staff 13 (RNCM). Staff 13 agreed Resident 6 needed nail care, and she would reach out to hospice for a podiatry referral. Staff 13 stated staff were to document resident refusals if the resident refused care. On 8/21/26 at 10:25 AM, Staff 14 (LPN) acknowledged she documented nail care was completed for Resident 6 on 7/19/26. Staff 14 stated she never completed nail care for Resident 6. On 8/21/26 at 10:46 AM, Staff 1 (Administrator) stated staff were expected to complete nail care per the orders and if Resident 6 refused, staff were expected to document the refusal.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 sampled resident (#5) reviewed for accidents. This placed residents at risk for injury due to accidents. Findings include:Resident 5 admitted in 7/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side.Resident 5's 7/18/25 care plan indicated Device: Seat belt-gait belt from home and Mobility Device: Electric wheelchair, assist resident with seat belt.A 7/20/25 progress note indicated Resident 5 was found on the floor, stated she/he slid out of her wheelchair and called emergency from her/his personal cell phone. Resident 5 had a laceration on her/his leg and was bleeding. Resident 5 was taken to the hospital for evaluation.On 8/8/25 at 12:28 PM, Staff 12 stated Resident 5 slipped out of her/his wheelchair and onto the floor. He further stated he could not get Resident 5's seat belt around her/him because it was too small. He was unsure if use of the seat belt was in the care plan and stated he did not inform anyone the seat belt was too small because it was known.On 8/8/25 at 3:17 PM, Resident 5 reported she/he fell on the floor and her/his leg was bleeding. She/he yelled for help, but no one came. Resident 5 indicated she/he was scared and called 911 and was taken to the hospital. On 8/12/25 at 10:31 AM, Staff 22 (LPN) stated she saw Resident 5 during the morning medication pass. She did not know if Resident 5 was wearing a seat belt when she/he fell and was not sure if she/he was care-planned for its use.On 8/12/25 at 1:19 PM, Staff 1 (Administrator) stated he expected all staff to follow the care plan to prevent accidents.

Based on interview and record review, the facility failed to investigate allegations of abuse for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 6 admitted 1/2025 with diagnoses including dementia.Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25. She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident.Resident 6 was not able to be interviewed as she/he was no longer in the facility.On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10's room, and she observed them kissing on 6/9/25. She stated staff re-directed Resident 6 away from Resident 10.On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity. On 8/12/25 at 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence that the incident was investigated, and it was the Administrator's responsibility to complete the investigation.

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 6 admitted 1/2025 with diagnoses including dementia.Resident 6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25. She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money. She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident.Resident 6 was not able to be interviewed as she/he was no longer in the facility.On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10's room and she observed them kissing on 6/9/25. She stated staff re-directed Resident 6 away from Resident 10.On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity. On 8/12/25 @ 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence the event was reported to the State Agency and that it was his responsibility to report to the State Agency.

Based on interview and record review it was determined the facility failed to provide appropriate dosing of opioid medications for 1 of 6 sampled residents (#45) reviewed for medications. This placed residents at risk for complications related to narcotic medications. Findings include: Resident 45 was admitted in 3/2025 with diagnoses included alcoholic cirrhosis of the liver (severe liver disease) with ascites (abnormal build-up of fluid in the space between the organs and the lining of the abdomen). Resident 45's 4/17/25 physician order indicated the resident was to be administered two tablets of oxycodone (opioid pain medication) every four hours as needed for pain levels of eight to 10 out of 10. Resident 45's 5/2025 MAR indicated the resident was administered two tablets of oxycodone when her/his pain levels were less than eight as follows: -5/1: for pain levels of 6 and 7. -5/2: for pain levels of 5 and 6. -5/3: for pain levels of 4 and 5. -5/4: for pain levels of 5 and 6. -5/5: for a pain level of 6. -5/8: for pain levels of 4 and 5. -5/7: for a pain level of 7. -5/8: for pain levels of 4 and 5. -5/9: for a pain level of 7. -5/10: for a pain level of 6. -5/11: for a pain level of 7. -5/12: for a pain level of 5. -5/14: for pain levels of 6 and 7. -5/16: for a pain level of 6. -5/18: for a pain level of 5. -5/19: for a pain level of 3. -5/20: for a pain level of 7. -5/21: for a pain level of 7. On 5/19/25 at 9:20 AM, Resident 45 stated she/he had back pain and they keep putting me on opioids when the muscle rub worked better. Resident 45 stated staff were more strict with the muscle cream than the opioid medication. On 5/21/25 at 2:27 PM, Staff 9 (LPN) reviewed Resident 45's MAR and stated on 5/9/25 and 5/16/25 he did not ask Resident 45 her/his pain level because the resident would just state 10 if asked so he always dispensed two oxycodone pills to the resident. Staff 9 stated he just recorded a number in the pain level section and should have recorded an eight. On 5/21/25 at 2:34 PM, Staff 17 (RN) reviewed Resident 45's MAR and stated on 5/11/25 she mistakenly administered two oxycodone pills when she/he should have administered one pill. On 5/22/25 at 8:15 AM, Staff 8 (LPN) stated Resident 45 usually experienced pain and was clear in communicating if she/he was painful. Staff 8 reviewed Resident 45's MAR and stated on 5/3/25, 5/4/25, 5/5/25 and 5/8/25, she administered two oxycodone pills when only one oxycodone should have been administered. On 5/22/25 at 8:27 AM, Staff 3 (RNCM) reviewed Resident 45's MAR and confirmed the resident was administered two oxycodone pills when she/he should have received one pill on the identified days. On 5/22/25 at 8:44 AM, Staff 2 (DNS) stated physician orders should be implemented and followed. Staff 2 acknowledged staff did not follow the parameters for the administration of Resident 45's oxycodone.

Based on interview and record review it was determined the facility failed to conduct weekly skin observations and evaluations to identify pressure ulcers and administer treatments timely treatment for 1 of 3 sampled resident (#359) reviewed for pressure ulcers. This placed residents at risk for complications related to unavoidable skin breakdown and not receiving care to treat pressure ulcers in a timely manner. Findings include: Resident 359 was admitted to the facility in 3/2024 with diagnoses including Alzheimer's disease (a progressive disorder which primarily affects the brain and leads to cognitive decline) and diabetes mellitus. A review of Resident 359's 3/18/24 admission MDS revealed she/he had severe cognitive impairment, had pressure ulcers, was at risk for the development of additional pressure ulcers and was dependent on staff for bed mobility. The Pressure Ulcer/Injury CAA indicated the facility provided Resident 359 with a pressure relieving mattress for her/his bed to minimize the pressure on her/his bony prominences while in bed. Resident 359's 3/22/24 care plan related to her/his pressure ulcers and risk for further skin breakdown indicated staff were to reposition her/him frequently, inspect her/his skin while providing cares and notify the nurse of any new skin conditions. A review of Resident 359's Weekly Skin Observations revealed no new skin impairments were identified on 8/7/24, 8/20/24, 8/30/24 or 9/13/24. The next reported Weekly Skin Observation was completed 35 days later on 10/17/24 and indicated Resident 359 developed an irregularly-shaped unstageable pressure ulcer (obscured full-thickness skin and tissue loss) 8 cm long and 10 cm wide on her/his coccyx (the last bone at the base of the spine). A hospice bath aide progress note dated 8/23/24 indicated Resident 359 had a new open sore on her/his bottom. Staff 11 (Resident Care Manager/LPN) signed the note and indicated, noted. A review of the facility's 10/16/24 investigation of Resident 359's open wound revealed the following: -A skin assessment completed on 10/15/24 indicated Resident 359 had an unstageable coccyx pressure injury with a dressing covering the area; -There was no previously written order for a dressing to be placed; -A coccyx pressure injury was noted on 8/26/24 in a hospice progress note and indicated Will fax new wound care orders; -The treatment order for the coccyx pressure injury was received on 9/20/24 but was implemented or followed up on; and -The facility determined there was a breakdown regarding the skin/wound management process and lack of nurse follow up regarding orders. A 10/18/24 progress note created by Staff 3 (RNCM) indicated Resident 359's coccyx pressure ulcer appeared to be a terminal ulcer. On 5/21/25 AT 4:18 PM Staff 3 stated the initial wound was discovered on 8/23/24 and a new wound dressing order was placed on 8/26/24 but was overlooked and not implemented. Staff 3 stated she first observed Resident 359's coccyx pressure wound on 10/18/24, noting it was a larger wound at the time and was then identified as a [NAME] pressure ulcer (a type of pressure ulcer that rapidly develops in the final stages of life, often appearing on the coccyx or other bony prominences). On 5/22/25 at 2:33 PM Staff 20 (LPN) stated Resident 359's hospice provider visited her/him twice each week, checked her/him for any changes and asked CNAs if there was anything new. Staff 20 stated CNAs repositioned Resident 359 every two hours due to the resident's fragile skin. Staff 20 stated Resident 359's hospice caregiver discovered the new wound on resident 359's coccyx during a regular visit but he did not recall the date. On 5/22/25 at 2:48 PM Staff 19 (CNA) stated Resident 359 required assistance from two staff to reposition because her/his skin was fragile and she/he was limp and unable to help the CNAs with the repositioning process. Staff 19 stated she was aware of Resident 359's multiple pressure ulcers but was unaware of any new pressure ulcers to the resident's bottom. On 5/22/25 at 4:33 PM Staff 11 stated on 8/23/24 Resident 359's hospice provider observed a new open wound on the resident's bottom which was not previously observed or charted by staff in Weekly Skin Observations. Staff 11 stated hospice staff left him a handwritten note regarding the new wound. Staff 11 stated he did not act on the note because he had been out of the facility for more than a week, he did not ensure the information was provided to the oncoming nurse and instead assumed a nurse would see the note. On 5/23/25 at 8:53 AM Staff 21 (Former Administrator) stated Resident 359's hospice provider stated they faxed orders to treat the new pressure wound identified on 8/23/24 but the orders were not received and the resident was not provided care for the new wound when. Staff 21 stated the wound on 8/23/24 was blanchable (a type of pressure injury characterized by intact skin with a localized area of redness that turns white when pressed with a finger). On 5/23/25 at 9:29 AM, Staff 2 (DNS) stated she worked as the Regional Support Nurse during Resident 359's stay. Staff 2 stated staff were required to complete Weekly Skin Observations, which would trigger weekly skin evaluations for any new wounds. Staff 2 stated staff were expected to obtain and implement treatment orders for new skin impairments, maintain consistent wound care documentation, and follow facility protocols. She acknowledged staff's failure to document Resident 359's skin condition and follow up on orders, which led to inadequate evaluation and delayed treatment. Staff 2 stated Resident 359's pressure ulcer was discovered by hospice on 8/23/24, before facility staff identified the wound. Staff 2 further stated regular observations and documentation should have identified the new skin impairment to enable timely treatment and prevent wound deterioration.

Based on interview and record review it was determined the facility failed to respond to a change of condition and provide respiratory interventions timely for 1 of 1 resident reviewed (# 41) for change of condition. This placed residents at risk for respiratory distress. Findings include: Resident 41 admitted to the facility in 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease and atrial fibrillation. The facility undated Standing Orders for oxygen indicated the goal of supplemental oxygen was to maintain saturations above 89% for residents with COPD. The orders indicated oxygen may go up to 2 liters before the provider was to be urgently notified. The 10/30/23 Care Plan directed staff to monitor Resident 41 for difficulties breathing and signs or symptoms of acute respiratory insufficiency. A Facility Report Incident indicated at 7:00 AM on 12/16/24, Resident 41 was found to have oxygen saturations of 64%. Resident 41's oxygen saturations were checked an additional two more times which were below 70%. Staff 5 (CNA) informed Staff 9 (LPN) several times as well as Staff 11 (Resident Care Manager/LPN) of Resident 41's low oxygen saturations. Staff 11 indicate he was busy, and took him time to address the concern. Staff 11 acknowledged oxygen was not given to the Resident 41. The resident was not sent out of the hospital until 2:00 PM and was diagnosed with hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions.) respiratory failure. The report concluded a lack of evaluation, treatment and urgency was found by the facility nurses. The report further indicated although the resident's condition may have not been prevented, an evaluation and initiation of oxygen may have provided relief and comfort to Resident 41. The 12/16/24 hospital noted indicated Resident 41 arrived at the hospital on 1 to 2 liters of oxygen. Resident 41 denied any shortness of breath, however, was found to have oxygen saturations in the low 70's at the nursing facility. During the resident's emergency department stay she/he was between 1 to 2 liters of oxygen and room air. On 5/19/25 at 9:47 AM Resident 41 stated she/he could not recall the incident on 12/16/24. Resident 41 stated she/he did not use oxygen. On 5/20/25 at 11:58 AM Staff 5 stated she was Resident 41's CNA on 12/16/24. Staff 5 stated on the morning of 12/16/24, Resident 41's oxygen saturations fluctuated between 64 to 68%. Staff 5 stated she told Staff 9 and Staff 11 of the resident's low oxygen saturations. Staff 5 stated the resident was not at her/his baseline and did not look well. Staff 5 stated Resident 41 was not given any oxygen and the resident was not sent out of the hospital until 2:00 PM. On 5/20/25 at 1:12 PM Staff 9 stated on 12/16/24, Staff 5 reported to him of Resident 41's low oxygen saturations. Staff 9 stated he checked the resident and was able to get her/his oxygen levels up by gravity and had the resident take deep breaths. Staff 9 stated Resident 41's oxygen saturations fluctuated between 80 to 90 percent. Staff 9 stated the first intervention should have been to provide oxygen to Resident 41, but he did not. Staff 9 stated oxygen saturations should be at 95 percent and below 90 percent was concerning. Staff 9 stated Resident 41 was not sent out to the hospital until the afternoon. On 5/21/25 at 9:51 AM Staff 11 stated on 12/16/24 he was not informed by Staff 5 of Resident 41's low oxygen saturations until 1:00 PM to 1:30 PM. Staff 11 stated he told Staff 9 to send the resident out to the hospital. Staff 11 further stated oxygen should be administetered for oxygen saturations below 92%. On 5/22/24 at 9:51 AM Staff 2 (DNS) stated when Resident 41's low saturations were reported to Staff 9, he should have reassessed Resident 41 and the first intervention should have been to provide the resident with oxygen. Staff 2 stated the standard of practice was to complete a full set of vitals, implement appropriate interventions, make a determination and either send the resident to the hospital or contact the physician if the resident was not in distress. Staff 2 acknowledged Resident 41 was not provide appropriate and timely respiratory interventions on 12/16/24.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 1 of 4 sampled resident (#43) reviewed for ADLs. This placed residents at risk for poor grooming. Findings include: Resident 43 was admitted to the facility in 3/2025 with diagnoses including nephrogenic diabetes insipidus (a medical disorder that occurs when your kidneys cannot properly balance bodily fluids) and ataxia (impaired muscle control that can affect walking, balance and the coordination of hand movements). A review of Resident 43's 5/3/25 admission MDS revealed she/he was cognitively intact and required supervision or touching assistance to complete personal hygiene tasks. Resident 43's care plan dated 4/28/25 revealed she/he received maximal/substantial assistance with showers on Sunday and Wednesday evenings and required supervision/touch assistance for grooming and personal hygiene. On 5/19/25 at 11:04 AM Resident 43 was observed to have a thick cluster of dark hairs growing from her/his chin. Resident 43 stated she/he was unable to shave independently because she/he could not control her/his hand movements. Resident 43 stated she/he was supposed to receive assistance to shave on her/his shower days and asked the CNAs to assist with shaving her/his shin hairs. On 5/22/25 at 2:13 PM Staff 18 (CNA) reported he worked with Resident 43 and should have offered to shave her/his chin because she/he was unable to shave independently. On 5/22/25 at 2:16 PM Staff 9 (LPN) stated he worked with Resident 43 regularly. Staff 9 stated Resident 43 was able to hold a razor but needed cueing to pick it up. Staff 9 stated he expected CNAs to help Resident 43 to shave herself/himself because she/he was unable to shave independently. On 5/22/25 at 2:42 PM Staff 19 (CNA) stated Resident 43 was unable to shave herself/himself because her/his hands were shaky and the resident was supposed to be shaved on her/his shower days. Staff 19 stated Resident 43 was not offered to be shaved this week. On 5/23/25 at 9:21 AM Staff 2 (DNS) stated she expected Resident 43 and other residents who required assistance with ADLs to receive assistance automatically. Staff 2 acknowledged Resident 43 was not provided appropriate ADL care and Resident 43 should not have to ask for assistance.

Based on observation, interview and record review it was determined the facility failed to develop a resident centered care plan for 1 of 1 sampled resident (#1) reviewed for activities. This placed residents at risk for a lack of meaningful, purposeful and preferred activities and unmet psychosocial needs. Findings include: Resident 1 admitted to the facility in 12/2023 with diagnoses including dementia. The 3/1/25 Annual MDS assessed Resident 1 with a BIMS of three, which indicated severe cognitive impairment. The MDS Activity Preferences section indicated she/he found reading materials and the news somewhat important to her/him. Music, animals, going out in the fresh air and doing her/his favorite activities were very important. The 3/25/25 Activity Progress Note: Annual Review evaluation indicated Resident 1 was independent with activities and did not get out of bed. Resident 1 enjoyed The Daily Chronicle (flyer which provides reading, puzzles, coloring pages and other reading activities) and talking to family on the phone. The evaluation indicated Resident 1 was dependent for transportation on others and the problems indicated she/he did not get out of bed. Record review of Resident 1's Activity Participation from 4/23/25 tthrough 5/21/25 revealed the resident had not attended Bingo in the past 30 days. Resident 1 was documented to participate in the reading from the activity cart in her/his room frequently. A observation and interview on 5/19/25 at 1:07 PM revealed Resident 1 had no reading materials in reach of her/him. No music or television were on and the window blinds were open. Resident 1 stated she/he had not been busy for many years and would like to get out and do something which she/he liked to do. Resident 1 stated she/he enjoyed reading murder mystery, thriller and suspense books. The resident stated she/he did not recieve books to read. On 5/20/25 at 1:49 PM Resident 1 was observed in her/his bed with no lights on in the room, the blinds were slightly open and no reading material was within reach. No music or television was on and the curtain was pulled to not enable her/him to see into the hallway. Resident 1 smiled and stated she/he was not doing anything when asked. On 5/21/25 at 10:10 AM and 2:19 PM Resident 1 was observed in bed with no reading materials in reach, no music playing, and the blinds were open. At 2:19 PM the resident waved at the surveyor in the hallway and smiled. The 5/21/25 Care Plan indicated Activity Preferences documented in the ADL section. The intervention was ACTIVITY PREFERENCES: (SPECIFY). No other information was found in the care plan to direct staff to assist Resident 1 for her/his leisure, recreational, diversional or purposeful activities. Resident 1's 5/21/25 Kardex (a in room care plan) for Activity Participation directed staff to bring the resident to bingo. No additional activity preferences documented. On 5/22/25 at 11:27 AM Staff 22 (CNA) stated they obtained their information to care for the resident from the Kardex. When asked what activities Resident 1 enjoyed, Staff 22 stated Resident 1 preferred to stay in bed in her/his room. On 5/22/25 at 12:23 PM Staff 9 (CNA) stated they obtained their information to care for residents from the Kardex. Staff 9 stated Resident 1 liked to stay in bed and family was involved. On 5/23/25 at 9:09 AM Staff 23 (Activities Director) confirmed Resident 1 did not attend Bingo as directed in the Care Plan, no refusals to attend were documented and the resident preferred to stay in bed. Staff 23 acknowledged she had personally read The Daily Chronicle at bedside for Resident 1. Staff 23 stated Resident 1 was able to read printed reading material and sometimes used a magnifier glass. Staff 23 was aware Resident 1 enjoyed to read murder mystery type books but could not recall when the Resident was last provided a book to read or opportunity listen to a talking book. Staff 23 confirmed the Kardex and Care Plan did not direct staff to provide resident center leisure or diversional activity opportunities. On 5/23/25 at 11:08 AM Staff 1 (Executive Director) acknowledged he expected all residents to have a person-centered care plan for activities and all staff should be able to provide opportunities to assist residents in meaningful activities. Staff 1 confirmed he expected Resident 1 to have additional information in the Kardex and Care Plan for activities.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 5 of 7 days reviewed for RN staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: A review of the facility's DCSDRs on 5/1/25, 5/5/25, 5/6/25, 5/7/25, 5/12/25, 5/13/25 and 5/14/25 revealed the postings inaccurately reflected the facility's RN coverage on the following days: -5/5, 5/6, 5/12, 5/13 and 5/14. On 5/22/25 at 12:15 PM, Staff 14 (Staffing Coordinator) confirmed the facility's DCSDRs inaccurately reflected RN coverage on 5/5/25, 5/6/25, 5/12/25, 5/13/25 and 5/14/25.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were completed for 21 out of 67 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: A review of the Direct Care Staff Daily Reports dated 12/1/23 through 2/5/24 revealed 21 out of 67 days the Resident census, CNA and/or RN hours were blank for one or more shifts for the following days: -12/1/23 -12/2/23 -12/5/23 -12/6/23 -12/7/23 -12/8/23 -12/9/23 -12/10/23 -12/12/23 -12/14/23 -12/15/23 -12/16/23 -12/19/23 -12/20/23 -12/21/23 -12/22/23 -12/23/23 -12/24/23 -1/6/24 -2/1/24 -2/2/24 On 2/8/24 at 10:59 AM Staff 6 (Activities Director/Staffing Coordinator) acknowledged the incomplete Resident census and CNA and/or RN hours for the days identified.

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: Observations of the facility's general environment and residents' rooms from 2/5/24 through 2/9/24 identified the following issues: -Dirty floor vents inside the beauty shop, outside the beauty shop, outside of rooms [ROOM NUMBERS]. -Four dime sized holes on the wall next to the timeclock. -One brown water stained ceiling tile in the main dining area near the kitchen entrance, two brown water stained ceiling tiles outside room [ROOM NUMBER]. -Gouged/damaged walls with paint missing behind resident beds in Rooms 109, 114-1, 114-2, 208-2, 312 and 315. -Lights not working on Hall 100 outside rooms [ROOM NUMBERS], Hall 200 outside rooms [ROOM NUMBERS], and Hall 300 outside the therapy room. -room [ROOM NUMBER]'s door had missing pieces of wood leaving sharp/jagged edges on the doorframe. -room [ROOM NUMBER]'s door had missing pieces of wood resulting in sharp/jagged edges. -room [ROOM NUMBER]'s doorframe corner guard was lifted and pulled away from the doorframe. -rooms [ROOM NUMBERS] had unaccessable overbed light cords that were approximately 2 inches in length. On 2/9/24 at 10:22 AM Staff 1 (Interim Executive Director) and Staff 7 (Maintenance Director) acknowledged the identified issues and stated the repairs were needed.

Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 32, 34, 36 and 42) reviewed for choices, care plans and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus, GERD (acid reflux), hypertension (high blood pressure) and chronic congestive heart failure (heart condition which can result in rapid weight gain from fluid build-up). a. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 stated she/he received her/his Rybelsus (diabetic medication) late everyday. Resident 36 stated the medication was supposed to be taken before breakfast and staff brought it with the rest of her/his medications after breakfast. Resident 36's 2/2024 Physician Orders included Rybelsus 7 mg everyday for diabetes mellitus 2. The order included the following instructions: - Must be given 30 minutes before first food/beverage/other medications with plain water. On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she/he did not receive any of her/his medications yet. On 2/6/24 at 8:24 AM Staff 19 (LPN) was observed to administer Resident 36's Rybelsus medication. On 2/6/24 at 8:34 AM Staff 19 reviewed Resident 36's Rybelsus order and acknowledged the order indicated the medication was to be administered with plain water before any other food, beverages and medications. Staff 19 stated it was not always possible to administer everyone's medications on time and confirmed Rybelsus was not administered 30 minutes before the resident's first food, beverage and other medications. On 2/8/24 at 1:17 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 acknowledged Resident 36's physician order for Rybelsus was not followed and the medication was not administered before food, beverages and other medications. Staff 2 stated she expected staff to follow physician orders and administer medications as ordered. b. Resident 36's 2/2024 Physician Orders included omeprazole 20 mg, twice daily before meals. On 2/6/24 at 7:58 AM Resident 36 was observed with her/his breakfast meal partially consumed. Resident 36 stated she did not receive any of her/his medications yet. On 2/6/24 at 8:33 AM Staff 19 (LPN) was observed to administer Resident 36's omeprazole medication. On 2/6/24 at 8:34 AM Staff 19 reviewed Resident 36's omeprazole order and acknowledged the order indicated the medication was ordered to be administered before meals. Staff 19 stated it was not always possible to administer everyone's medications on time and confirmed Resident 36's omeprazole was not administered before breakfast as ordered. On 2/8/24 at 1:17 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 acknowledged Resident 36's physician order for omeprazole was not followed and stated she expected staff to follow physician orders and administer medications before meals when indicated. c. Resident 36's 1/2024 Physician Orders included Milk of Magnesia Suspension (MOM), give 30 ml by mouth as needed for constipation. If resident does not have a bowel movement for three days, administer milk of magnesia per physician order on day four. Resident 36's 1/2024 Bowel Movement Flowsheet revealed the resident did not have a bowel movement for four days on 1/28/24, 1/29/24, 1/30/24 and 1/31/24. Resident 36's 1/2024 MAR revealed MOM was not administered as ordered for bowel care. On 2/8/24 at 1:31 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated Resident 36 should have received MOM for bowel care on 1/31/24 and acknowledged the MOM Physician Orders were not followed. d. Resident 36's 1/2024 Physician Orders included the following: - obtain daily weight: notify the provider for clinical signs or symptoms of fluid overload or for weight gain of greater than five pounds in one week related to congestive heart failure. Resident 36's 1/2024 TAR revealed the resident's weight was not obtained on the following 13 dates: - 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/12/24, 1/14/24, 1/16/24, 1/20/24, 1/25/24, 1/26/24, 1/27/24 and 1/31/24. On 2/8/24 at 1:35 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated she expected physician orders to be followed and staff should have obtained Resident 36's daily weights as ordered. e. Resident 36's 2/2024 Physician Orders included the following: - Humulin R (insulin), inject three units subcutaneously before meals related to type 2 diabetes mellitus. On 2/6/24 at 12:30 PM Staff 21 (RN) entered Resident 36's room and told the resident she needed to administer her/his insulin. Resident 36's lunch meal was observed on her/his table and no food remained on the plate. Resident 36 stated You're late, I just ate my whole lunch. Staff 21 acknowledged she was running behind and administered Resident 36's insulin. On 2/8/24 at 1:18 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation and acknowledged staff did not follow the insulin order. f. Resident 36's 1/2024 Physician Orders included the following: - metoprolol succinate extended release (medication for high blood pressure), give 100 mg two times a day related to hypertension. Hold for systolic blood pressure lower than 110 or heart rate less than 55. Resident 36's 1/2024 MAR revealed the following dates and times when resident's systolic blood pressure was lower than 110 and the resident received metoprolol succinate: - 1/1/24 at 6:00 PM; - 1/7/24 at 8:00 AM and 6:00 PM; - 1/18/24 at 8:00 AM. On 2/8/24 at 1:20 PM Staff 2 (DNS) and Staff 20 (Divisional Director of Clinical Operations) were notified of the findings of this investigation. Staff 2 stated staff should not have administered the metoprolol when Resident 36's systolic blood pressure was outside the ordered parameters and acknowledged the physician orders were not followed. 2. Resident 32 was admitted to the facility in 7/2023 with diagnoses including depression. On 2/5/24 at 1:13 PM Resident 32 stated in 9/2023 she/he did not receive her/his antidepressant medication for several days. Resident 32 stated she/he did not recall if she/he experienced negative side effects as a result of the missed medications. Resident 32's 9/2023 Physician Orders included escitalopram oxalate (antidepressant) 20 mg one time a day for depression. Resident 32's 9/2023 MAR revealed escitalopram was marked 00 and not administered on the following eight days: - 9/3/23, 9/4/23, 9/5/23, 9/6/23, 9/7/23, 9/8/23, 9/9/23 and 9/10/23. On 2/9/24 at 9:42 AM Staff 9 (RNCM) reviewed Resident 32's 9/2023 MAR and acknowledged it was marked with 00 which indicated the medication was not available and not administered. Staff 9 stated she was unsure why Resident 32's escitalopram was not administered as ordered and she was unable to provide rationale for why the medication was marked as unavailable as it was available in the facility's supply kit. 3. Resident 42 was admitted to the facility in 12/2023 with diagnoses including fracture of the arm. Resident 42's 12/14/23 Admission MDS indicated the resident was cognitively intact. Resident 42's 12/5/23 Hospital Discharge Summary indicated the following: - follow up with orthopedics for [arm] fracture. Resident 42's 1/15/24 Physician Order included please schedule follow-up with orthopedics per the discharge summary if not already done and repeat right humerus 2-view (x-ray of right upper arm). Review of Resident 42's health record revealed no orthopedic appointment was scheduled and no x-ray of the resident's right arm was obtained. On 2/5/24 at 11:55 AM Resident 42 stated she/he broke her/his right arm, used a sling and was unable to bear weight or use her/his right arm since her/his admission to the facility. Resident 42 stated there was no follow-up appointment with orthopedics or communication from staff regarding the use or weight-bearing status of her/his arm since she/he admitted to the facility. On 2/8/24 at 11:34 AM Staff 22 (LPN Resident Care Manager) stated it was her responsibility to respond to physician orders and schedule follow-up appointments. Staff 22 stated she worked in the facility for just a few weeks and thought Staff 2 (DNS) took care of Resident 42's orthopedic appointment and right arm x-ray. On 2/8/24 at 1:44 PM Staff 2 and Staff 20 (Divisional Director of Clinical Operations) reviewed the 12/5/23 Hospital Discharge Summary and the 1/15/24 Physician Order. Staff 2 stated she thought Staff 22 made the orthopedic appointment and scheduled the x-ray tests. Staff 2 acknowledged Resident 42's Physician Orders were not followed. 43691 4. Resident 34 was admitted to the facillity in 1/2024 with diagnoses including hypertension (high blood pressure). Resident 34's 1/16/24 physician order instructed staff to provide amlodipine beslyate once a day for hypertension, but to not administer if Resident 34's systolic blood pressure (SBP [upper blood pressure number]) was less than 110 and heart rate was less than 60 beats per minute. Review of the 1/2024 MAR revealed Resident 34 received amlodipine beslyate from 1/17/23 through 1/23/23 with no record of her/his blood pressure or heart rate being assessed upon medication administration. Review of Resident 34's 1/2024 MAR also revealed Resident 34 received amlodipine beslyate on 1/24/23 with her/his heart rate recorded at 55 beats per minute at the time of medication administration. Resident 34 also received amlodipine beslyate on 1/27/23 and her/his SPB was recorded at 103 at the time of medication administration. On 2/9/24 at 8:54 AM Staff 2 (DNS) confirmed Resident 34's blood pressure and heart rate were not recorded upon administration of amlodipine beslyate from 1/17/23 through 1/23/23 and Resident 34 received this medication outside of the ordered parameters on 1/24/23 and 1/27/23.

Based on observation, interview and record review it was determined the facility failed to ensure licensed staff provided care and services according to professional standards of practice and licensure requirements for 6 of 6 licensed nurses (#s 3, 5, 7, 8, 10, and 16) related to a resident's change of condition. Staff failed to identify, comprehensively assess and intervene timely for an acute change in a resident's condition for 1 of 3 sampled residents (#1) reviewed for change of condition. This failure, determined to be an immediate jeopardy situation, resulted in a delay of identification and assessment of symptoms and a delay in emergent treatment for [REDACTED]. As a result, Resident 1 was hospitalized , placed on hospice care and passed away on 10/21/20. Findings include: Oregon State Board of Nursing Scope of Practice Standards for Licensed Practical Nurses (OAR [PHONE NUMBER]) indicated the following: 2. Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation. a. Conduct and document initial and ongoing focused nursing assessments of the health status of clients by: A. Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care; B. Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; D. Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status; d. Implement the plan of care by: 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. Oregon State Board of Nursing Scope of Practice Standards for Registered Nurses (OAR [PHONE NUMBER]) indicated the following: 2. Standards related to the Registered Nurse's responsibility for nursing practice implementation. 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; D. Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status; d. Implement the plan of care by: 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. Conduct Derogatory to the Standards of Nursing (OAR [PHONE NUMBER]) indicated the following: 1. Conduct related to the client's safety and integrity: b. Failing to take action to preserve or promote the client's safety based on nursing assessment and judgement. 3. Conduct related to communication: b. Incomplete recordkeeping regarding client care; including but not limited to, failure to document care given or other information important to the client's care; h. Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co-worker) in an ongoing and timely manner; 4. Conduct related to achieving and maintaining clinical competency: b. Failing to conform to the essential standards of acceptable and prevailing nursing practice. Resident 1 admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. Resident 1's 11/25/19 Admission MDS and 8/27/20 Quarterly MDS Section C: Cognitive Patterns and Section G: Functional Status assessed the resident with BIMS 15 (cognitively intact), supervision to extensive assist for ADLs and no impairments to either shoulder, elbow, wrist or hand. A progress note written by Staff 5 (LPN) dated 10/16/20 at 11:20 AM indicated Resident was sent out to the hospital after exhibiting symptoms such as anomic [MEDICAL CONDITION] (difficulty expressing words) and an inability to use the right arm. Resident also complained of slight chest pains. VS (vital signs) 114/86, 88, 97.3, 18 and 97%. No other assessments such as facial symmetry, change in mental status or vision changes were noted. No additional details such as onset time of symptoms were documented. Resident 1's 10/16/20 Hospital Admission History and Physical indicated Resident 1 was admitted to the hospital for right upper extremity weakness. The records indicated the patient states her/his right upper extremity has been weak for about 36 hours while her/his residence noticed it today and called 9-1-1. When asked when her/his symptoms of right upper paralysis started, she/he relayed the afternoon of 10/15/20. She/he stated she/he believes that it progressed to its right upper flaccid (soft, limp, weak) state over the day on 10/15/20. The physical exam assessed Resident 1's extremities as exception flaccid paralysis of the right upper extremity from the shoulder. The diagnostic studies revealed ataxia (loss of coordination of the muscles) and stroke suspected. Resident 1's 10/20/20 Nursing Facility Transfer Orders indicated the discharge [DIAGNOSES REDACTED]. On 10/20/20 at 4:50 PM Witness 1 (Complainant) stated on 10/16/20 he responded to an emergent call to the facility. Witness 1 stated Staff 5 (LPN) reported Resident 1 was exhibiting symptoms of a stroke, had intermittent dysphasia (impairment of the ability to communicate) and altered mental status since since Wednesday 10/14/20. Upon arrival to the facility, Witness 1 stated Resident 1 was alert, understood what was going on and her/his right arm was completely flaccid. Witness 1 stated Resident 1 reported she/he was unable to use her/his right arm since Wednesday 10/14/20 night. A progress note dated 10/20/20 at 5:17 PM indicated Resident 1 was readmitted to the facility on hospice level of care. On 10/21/20 during the time of survey, no observations of Resident 1 were conducted due to end of life cares. Resident 1 passed away. On 10/21/20 at 12:06 PM and 12:18 PM Staff 4 (CNA) and Staff 6 (CNA) stated prior to hospitalization and readmit to the facility, Resident 1 was alert, oriented, talkative and able to use her/his right arm to grasp and pull on the bedrail for repositioning. Staff 6 stated since Resident 1 returned to the facility the prior evening, she/he was not responsive. On 10/21/20 at 12:30 PM Staff 5 (LPN) stated he arrived to work on Friday morning 10/16/20 and Staff 16 (RN) reported Resident 1 hadn't been right the last two nights. She/he was having trouble rolling. Staff 5 stated he checked on Resident 1 that morning at an unspecified time and the resident could not use her/his right arm, it was completely flaccid and swollen and the resident was having trouble speaking. Staff 5 stated he told Staff 3 (RNCM) he thought Resident 1 had a stroke. Staff 5 stated Resident 1's vital signs were good and he called the doctor. Staff 5 stated Resident 1 later complained of chest pain and the doctor had not called back by the time Resident 1 was sent out. Staff 5 failed to call 9-1-1 immediately after identifying signs and symptoms of a stroke such as right arm flaccidity and trouble speaking. On 10/22/20 at 9:33 AM Staff 7 (LPN) stated she worked on Thursday evening 10/15/20 (one day after the first symptoms were identified). Staff 7 (LPN) stated Staff 3 (RNCM) told her Resident 1 had right arm weakness. Staff 7 stated between 4:00 PM and 5:00 PM she checked Resident 1's capillary refill (color return to the finger or fingernail after applying pressure) and it was good, the resident's hand was warm and she/he had feeling and the resident had no pain. Staff 7 stated Resident 1 was unable to lift her/his right arm at all and this was unusual. Staff 7 stated she reported this finding to Staff 3 (RNCM). Staff 7 stated later in the shift, Staff 15 (CNA) reported Resident 1 was unable to use her/his right arm. Staff 7 stated she obtained a full set of vital signs and called the on-call physician. The physician ordered blood tests. A review of Resident 1's health record revealed no documentation of vital signs the evening of 10/15/20 and no other assessments such as facial symmetry, change in mental status, vision changes, body symmetry, and grip strength. Staff 7 failed to call 9-1-1 immediately after identifying signs and symptoms of a stroke such as new onset right arm weakness and/or paralysis. On 10/22/20 at 12:00 PM Staff 8 (RN) stated she was assigned to Resident 1 for the day shift Thursday 10/15/20 (one day after the first symptoms were identified). Staff 8 stated Resident 1 was screaming and refusing everything which was unusual. Staff 8 stated at the beginning of her shift, Staff 18 (CNA) reported Resident 1 was unable to use her/his right arm at all. Staff 8 stated she told Staff 3 (RNCM). Staff 8 stated she was unable to assess Resident 1 related to Resident 1's increased distress, screaming and refusals. A review of Resident 1's health record for day shift Thursday 10/15/20 revealed no documentation of Resident 1's inability to use her/his right arm, the resident's unusual behavior and refusals. There was no documentation of an assessment or attempts to assess the resident. There was no documentation noting Resident 1's change of condition or notification to the physician, RNCM or family. Staff 8 failed to further investigate and assess Resident 1's new onset right arm weakness, failed to notify the physician and failed to call 9-1-1 immediately related to signs and symptoms of a stroke. On 10/22/20 at 1:06 PM Staff 11(CNA) stated on Friday 10/16/20 morning she reported to Staff 5 (LPN) Resident 1 was unable to move half her/his body and could not use her/his right arm at all. Staff 11 stated Staff 5 responded he already knew, had called the doctor and was waiting for Staff 3 (RNCM) to arrive. Staff 11 stated later in the shift, she reminded Staff 5 again about Resident 1's change in condition. Staff 5 failed to call 9-1-1 immediately after report of Resident 1's signs and symptoms of a stroke including inability to move half her/his body and inability to use her/his right arm. On 10/23/20 at 5:13 AM Staff 16 (LPN) stated on Thursday 10/15/20 night shift a CNA and Staff 7 (LPN) told him Resident 1's mood was changed and she/he was unable to use her/his right arm and hand. Staff 16 stated he was unable to complete an assessment but stated he could see Resident 1's arm was not moving and thought it was just muscle stiffness. Staff 16 stated he also noticed the resident had a complete mood change. A review of Resident 1's health record for 10/15/20 night shift revealed no documentation of an assessment to include vital signs, facial symmetry, change in mental status, vision changes, body symmetry and grip strength. Staff 16 failed to call 9-1-1 immediately after report of Resident 1's signs and symptoms of a stroke including change in mental status and new onset right arm paralysis. On 10/23/20 at 11:00 AM Staff 10 (LPN) stated she was assigned to Resident 1 on Wednesday evening shift 10/14/20 (date of identification of symptoms). Staff 10 stated Resident 1 refused cares and medications and complained of feeling weak which was unusual. Staff 10 stated when she saw Resident 1, she/he was holding onto her/his right hand and the resident complained her/his right hand and whole body felt weak. Staff 10 stated she checked Resident 1's capillary refill and massaged her/his hand. Staff 10 stated Resident 1's vital signs were fine. A review of Resident 1's health record for 10/14/20 evening shift revealed no documentation of further assessments to include vital signs, facial symmetry, change in mental status, body symmetry and grip strength. Staff 10 failed to complete a comprehensive assessment related to Resident 1's change of condition and failed to call 9-1-1 immediately after Resident 1's signs and symptoms of a stroke including new onset weakness. On 10/23/20 at 12:33 PM Staff 18 (CNA) stated she worked with Resident 1 from Wednesday 10/14/20 night shift through the morning of Thursday 10/15/20. Staff 18 stated at approximately 1:30 AM, she told Staff 16 (LPN) Resident 1 was unable to use her/his right arm and wouldn't talk or laugh as usual. Staff 18 stated she also reported Resident 1's change of condition to the oncoming Staff 8 (RN) and Staff 9 (CMA). A review of Resident 1's health record for 10/14/20 through 10/15/20 night shift revealed no vital signs and no assessments to include facial symmetry, change in mental status and grip strength. Staff 16 failed to conduct a comprehensive assessment of Resident 1and failed to call 9-1-1 immediately after notification of Resident 1's signs and symptoms of a stroke including new onset right arm/hand paralysis and change in mental status. On 10/27/20 at 10:55 AM Staff 3 (RNCM) stated the process for identifying and reporting a resident's change in condition was to have staff run it by her in order to discuss next steps. If the situation was emergent, Staff 3 expected nursing staff to notify the physician. Staff 3 stated she talked to Resident 1 on Thursday 10/15/20 around 5:00 PM and Resident 1's cognition was fine. Staff 3 stated around 5:15 PM or so, (one day after onset of symptoms were identified) Staff 7 (LPN) reported to her Resident 1 could not move her/his arm. Staff 3 stated she went in very briefly and saw Resident 1 and did not conduct a physical assessment but she could see Resident 1 was unable to move her/his right arm. Staff 3 stated Resident 1 was speaking and she/he seemed tired. Staff 3 stated she directed Staff 7 to call the physician, obtain a capillary blood glucose level and get vital signs. A review of Resident 1's health record for 10/15/20 evening revealed no vital signs, no blood glucose level and no evidence of a physical assessment to include facial symmetry, body symmetry and grip strength. Staff 3 failed to conduct a physical assessment, failed to follow up on Resident 1's change in condition and right arm paralysis and failed to call 9-1-1 immediately after Resident 1 was observed with new onset right arm paralysis. On 10/27/20 at 11:44 AM findings of this investigation were reviewed with Staff 2 (DNS). Staff 2 stated there were practical things the nursing staff should have done better. Staff 2 stated she expected staff to conduct full assessments, document their findings, make notes and record vital signs. Staff 2 stated nursing staff should have placed Resident 1 on alert to ensure shift to shift communication regarding Resident 1's change of condition and supervisors should have been notified. Staff 2 stated if a resident was exhibiting signs and symptoms of a stroke, staff should conduct a full assessment of arms, legs, eyes and movement and then call 9-1-1. On 10/27/20 at 4:10 PM Staff 1 (Administrator) and Staff 2 were informed of the immediate jeopardy (IJ) situation, IJ templates were provided and an immediate IJ removal plan was requested. On 10/27/20 at 6:55 PM the facility submitted a removal plan which was accepted by the surveyor. The IJ Removal Plan indicated the facility would implement the following actions: - Immediate evaluation of all residents in the facility conducted by the nursing management team to determine if any other residents have been affected; - Education on identifying a change of condition, intervening timely and adding residents with noted changes on alert monitoring; - Education to include e-interact tool for change of condition, stop and watch and SBAR; - Full investigation initiated of this incident to include a root cause analysis. On 10/27/20 at 7:12 PM Staff 1 was observed gathering staff for an in-service and Staff 2 was observed conducting resident assessments. On 10/28/20 from 11:35 AM through 3:54 PM interviews were conducted with Staff 3 (RNCM), Staff 4 (CNA), Staff 6 (CNA), Staff 7 (LPN), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (CNA), Staff 12 (RN), Staff 13 (Agency CNA), Staff 14 (LPN), Staff 15 (CNA), Staff 17 (RN), Staff 20 (CNA), Staff 21 (LPN), Staff 22 (CNA). Staff verified they received training and education related to identifying, documenting, monitoring, reporting, notifying and responding to residents' change of condition. On 10/28/20 at 4:00 PM Staff 1 provided documentation of completed assessments of all residents in the facility and stated there were no residents who were negatively affected. Staff 1 provided verification that licensed nursing staff received the required training and education. On 10/29/20 at 1:20 PM Staff 1 and Staff 2 verified all elements of the IJ removal plan were completed.

Based on observation, interview and record review it was determined the facility failed to identify, comprehensively assess and intervene timely for an acute change in a resident's condition for 1 of 3 sampled residents (#1) reviewed for change of condition. This failure, determined to be an immediate jeopardy situation, resulted in a delay of identification and assessment of symptoms and a delay in emergent treatment for [REDACTED]. As a result, Resident 1 was hospitalized , placed on Hospice Care and passed away on 10/21/20. This placed all residents at risk for unidentified change of condition, delay of treatment and serious harm and/or death. Findings include: The American Stroke Association advised to use the letters in FAST to identify stroke symptoms: - Facial drooping (does one side droop or is it numb? Ask the person to smile. Is it lopsided or uneven?) - Arm weakness (Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?) - Speech difficulty (Is speech slurred or jumbled? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence) - Time (Call 9-1-1 immediately) The American Stroke Association advised if someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 or emergency medical services immediately. Receiving timely stroke treatment is an important and critical step to recovery and survival. Immediate treatment may minimize the long-term effects of stroke and even prevent death. Resident 1 admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. Resident 1's 11/25/19 Admission MDS and 8/27/20 Quarterly MDS Section C: Cognitive Patterns and Section G: Functional Status assessed the resident with BIMS 15 (cognitively intact), supervision to extensive assist for ADLs and no impairments to either shoulder, elbow, wrist or hand. A progress note written by Staff 5 (LPN) dated 10/16/20 at 11:20 AM indicated Resident was sent out to the hospital after exhibiting symptoms such as anomic [MEDICAL CONDITION] (difficulty expressing words) and an inability to use the right arm. Resident also complained of slight chest pains. VS (vital signs) 114/86, 88, 97.3, 18 and 97%. No other assessments such as facial symmetry, change in mental status or vision changes were noted. No additional details such as onset time of symptoms were documented. Resident 1's 10/16/20 Hospital Admission History and Physical indicated Resident 1 was admitted to the hospital for right upper extremity weakness. The records indicated the patient states her/his right upper extremity has been weak for about 36 hours while her/his (facility) noticed it today and called 911. When asked when her/his symptoms of right upper paralysis started, she/he relayed the afternoon of 10/15/20. She/he stated she/he believes that it progressed to its right upper flaccid (soft, limp, weak) state over the day on 10/15/20. The physical exam assessed Resident 1's extremities as exception flaccid paralysis of the right upper extremity from the shoulder. The diagnostic studies revealed ataxia (loss of coordination of the muscles) and stroke suspected. Resident 1's 10/20/20 Nursing Facility Transfer Orders indicated the hospital discharge [DIAGNOSES REDACTED]. On 10/20/20 at 4:50 PM Witness 1 (Complainant) stated on 10/16/20 he responded to an emergent call to the facility. Witness 1 stated Staff 5 (LPN) reported Resident 1 was exhibiting symptoms of a stroke, had intermittent dysphasia (impairment of the ability to communicate) and altered mental status since since Wednesday 10/14/20. Upon arrival to the facility, Witness 1 stated Resident 1 was alert, understood what was going on and her/his right arm was completely flaccid. Witness 1 stated Resident 1 reported she/he was unable to use her/his right arm since Wednesday 10/14/20 night. Resident 1's health record indicated on 10/20/20 at 5:17 PM Resident 1 was readmitted to the facility on hospice level of care. On 10/21/20 during the time of survey, no observations of Resident 1 were conducted due to end of life cares. Resident 1 passed away. On 10/21/20 at 12:06 PM and 12:18 PM Staff 4 (CNA) and Staff 6 (CNA) stated prior to hospitalization and readmit to the facility, Resident 1 was alert, oriented, talkative and able to use her/his right arm to grasp and pull on the bedrail for repositioning. Staff 6 stated since Resident 1 returned to the facility the prior evening, she/he was not responsive. On 10/21/20 at 12:30 PM Staff 5 (LPN) stated he arrived to work on Friday morning 10/16/20 (six nursing shifts after onset of symptoms) and Staff 16 (RN) reported Resident 1 hadn't been right the last two nights. She/he was having trouble rolling. Staff 5 stated he checked on Resident 1 that morning at an unspecified time and the resident could not use her/his right arm, it was completely flaccid and swollen and the resident was having trouble speaking. Staff 5 stated he told Staff 3 (RNCM) he thought Resident 1 had a stroke. Staff 5 stated Resident 1's vital signs were good and he called the doctor. Staff 5 stated Resident 1 later complained of chest pain and the doctor had not called back by the time Resident 1 was sent out. On 10/22/20 at 9:33 AM Staff 7 (LPN) stated she worked the evening shift Thursday 10/15/20 (fourth nursing shifts after onset of symptoms). Staff 7 (LPN) stated Staff 3 (RNCM) told her Resident 1 had right arm weakness. Staff 7 stated between 4:00 PM and 5:00 PM she checked Resident 1's capillary refill (color return to the finger or fingernail after applying pressure) and it was good, the resident's hand was warm and she/he had feeling and the resident had no pain. Staff 7 stated Resident 1 was unable to lift her/his right arm at all and this was unusual. Staff 7 stated she reported this finding to Staff 3 (RNCM). Staff 7 stated later in the shift, Staff 15 (CNA) reported Resident 1 was was unable to use her/his right arm. Staff 7 stated she obtained a full set of vital signs and called the on-call physician. The physician ordered blood tests. On 10/22/20 at 12:00 PM Staff 8 (RN) stated she was assigned to Resident 1 for the day shift Thursday 10/15/20 (third nursing shift after onset of symptoms) Staff 8 stated Resident 1 was screaming and refusing everything which was unusual. Staff 8 stated at the beginning of her shift, Staff 18 (CNA) reported Resident 1 was unable to use her/his right arm at all. Staff 8 stated she told Staff 3 (RNCM). Staff 8 stated she was unable to assess Resident 1 related to Resident 1's increased distress, screaming and refusals. On 10/22/20 at 1:06 PM Staff 11 (CNA) stated on Friday 10/16/20 morning (sixth nursing shift after onset of symptoms) she reported to Staff 5 (LPN) Resident 1 was unable to move half her/his body and could not use her/his right arm at all. Staff 11 stated Staff 5 responded he already knew, had called the doctor and was waiting for Staff 3 (RNCM) to arrive. Staff 11 stated later in the shift, she reminded Staff 5 again about Resident 1's change in condition. On 10/23/20 at 5:13 AM Staff 16 (LPN) stated on Thursday 10/15/20 night shift (fifth nursing shift after onset of symptoms) a CNA and Staff 7 (LPN) told him Resident 1's mood was changed and the resident was unable to use her/his right arm and hand. Staff 16 stated he was unable to complete an assessment, the resident had a complete mood change and the resident's arm was not moving. Staff 16 stated he thought Resident 1's change of condition was just muscle stiffness. On 10/23/20 at 11:00 AM Staff 10 (LPN) stated she was assigned to Resident 1 on Wednesday evening shift 10/14/20 (first nursing shift; onset of symptoms). Staff 10 stated Resident 1 refused cares and medications and complained of feeling weak which was unusual. Staff 10 stated when she saw Resident 1, she/he was holding onto her/his right hand and the resident complained her/his hand and her/his whole body felt weak. Staff 10 stated she checked Resident 1's capillary refill and massaged her/his hand. Staff 10 stated Resident 1's vital signs were fine. On 10/23/20 at 12:33 PM Staff 18 (CNA) stated she worked with Resident 1 from Wednesday 10/14/20 night shift through the morning of Thursday 10/15/20. Staff 18 stated at approximately 1:30 AM, she told Staff 16 (LPN) Resident 1 was unable to use her/his right arm and wouldn't talk or laugh as usual. Staff 18 stated she also reported Resident 1's change of condition to the oncoming Staff 8 (RN) and Staff 9 (CMA). On 10/27/20 at 10:55 AM Staff 3 (RNCM) stated the process for identifying and reporting a resident's change in condition was to have staff run it by her in order to discuss next steps. If the situation was emergent, Staff 3 expected nursing staff to notify the physician. Staff 3 stated she talked to Resident 1 on Thursday 10/15/20 around 5:00 PM and Resident 1's cognition was fine. Staff 3 stated around 5:15 PM or so, Staff 7 (LPN) reported to her Resident 1 could not move her/his arm. Staff 3 stated she went in to Resident 1's room very briefly and saw Resident 1. Staff 3 stated she did not conduct a physical assessment but she could see Resident 1 was unable to move her/his right arm. Staff 3 stated Resident 1 was speaking and she/he seemed tired. Staff 3 stated she directed Staff 7 to call the physician, obtain a capillary blood glucose level and get vital signs. On 10/27/20 at 11:44 AM findings of this investigation were reviewed with Staff 2 (DNS). Staff 2 stated there were practical things the nursing staff should have done better. Staff 2 stated she expected staff to conduct full assessments, document their findings, make notes and record vital signs. Staff 2 stated nursing staff should have placed Resident 1 on alert to ensure shift to shift communication regarding Resident 1's change of condition and supervisors should have been notified. Staff 2 stated if a resident was exhibiting signs and symptoms of a stroke, staff should conduct a full assessment of arms, legs, eyes and movement and then call 9-1-1. Review of Resident 1's health record revealed lack of evidence to support the facility identified, comprehensively assessed and intervened timely related to Resident 1's acute change of condition as evidenced by the following: - Staff failed to call 9-1-1 immediately after Resident 1 exhibited signs and symptoms of a stroke such as new onset right arm weakness, flaccidity and paralysis, trouble speaking and change in mental status; - Staff failed to further investigate, assess and reassess reports and observations of Resident 1's changes of condition; - Staff failed to document identified changes and interventions related to Resident 1's changes in condition. - Resident 1's Vital Signs Report revealed an incomplete set of vital signs were documented on 10/14/20 at 7:13 AM; the vital signs did not include Resident 1's blood pressure, pulse or respirations. No vital signs were documented again until 10/15/20 at 7:21 AM (three nursing shifts after onset of symptoms). No vital signs were documented in correspondence with reports of changes in condition on 10/14/20 evening shift, 10/14/20 night shift, 10/15/20 evening shift and 10/15/20 night shift. No other vital signs were documented until 10/16/20 at 11:20 AM, the day Resident 1 was sent to the hospital. On 10/27/20 at 4:10 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to identify, assess and intervene timely to Resident 1's changes of condition. IJ templates were provided and an immediate IJ removal plan was requested. On 10/27/20 at 6:55 PM the facility submitted a removal plan which was accepted by the surveyor. The IJ Removal Plan indicated the facility would implement the following actions: - Immediate evaluation of all residents in the facility conducted by the nursing management team to determine if any other residents have been affected; - Education on identifying a change of condition, intervening timely and adding residents with noted changes on alert monitoring; - Education to include e-interact tool for change of condition, stop and watch and SBAR; - Full investigation initiated of this incident to include a root cause analysis. On 10/27/20 at 7:12 PM Staff 1 was observed gathering staff for an in-service and Staff 2 was observed conducting resident assessments. On 10/28/20 from 11:35 AM through 3:54 PM interviews were conducted with Staff 3 (RNCM), Staff 4 (CNA), Staff 6 (CNA), Staff 7 (LPN), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (CNA), Staff 12 (RN), Staff 13 (Agency CNA), Staff 14 (LPN), Staff 15 (CNA), Staff 17 (RN), Staff 20 (CNA), Staff 21 (LPN), Staff 22 (CNA). Staff verified they received training and education related to identifying, documenting, monitoring, reporting, notifying and responding to residents' change of condition. On 10/28/20 at 4:00 PM Staff 1 provided documentation of completed assessments of all residents in the facility and stated there were no residents who were negatively affected. Staff 1 provided verification that licensed nursing staff received the required training and education. On 10/29/20 at 1:20 PM Staff 1 and Staff 2 verified all elements of the IJ removal plan were completed.

Based on interview and record review the facility failed to prevent 1 of 1 (#1) residents from falling to the ground when a Hoyer Lift was used. The fall caused Resident 1 an acute fracture of the clavicle along with increased pain. Findings include: Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The careplan indicated a Hoyer Lift was used for assisting Resident 1 to bed. As of 4/2017 Resident 1 was on hospice. The nurses notes indicated on 4/2/17 at 8:00 pm Resident 1 was found on the floor under her/his Hoyer lift. Staff 1 (CNA) told Staff 2 (LPN) the sling broke and Resident 1 hit her/his head and leg on the Hoyer lift. The resident's extremities could be moved and was placed into bed. Resident 1 had an abrasion on the left side of her/his head. Resident 1 refused to have her/his left shoulder examined. The resident's daughter and hospice was informed. On 4/3/17 a radiology report indicated Resident 1 had an acute fracture of the clavicle (collarbone). A summary of findings from the Event Report Investigation/Summary indicated Staff 1 (CNA) was assigned to assist Resident 1 with a Hoyer lift transfer. Staff 1 attempted to transfer Resident 1 with the Hoyer Lift with no assistance from other staff. During the transfer the hoyer sling tore near the strap causing the resident to fall. A conclusion of the Event Report Investigation/Summary indicated Staff 1 (CNA) did not ask for another staff member to assist her during the transfer of Resident 1. On 7/20/17 at 9:56 am Staff 1 (CNA) stated she was putting the residents into bed. She used the Hoyer lift by herself to transfer Resident 1. The resident fell out of the Hoyer lift to the ground. On 7/21/17 at 10:12 am Staff 2 (LPN) stated Staff 1 (CNA) used the Hoyer lift alone and Resident 1 fell to the ground. Resident 1 had pain in her/his left shoulder.