Every finding on record at Hood River Post Acute

Based on Interview and record review it was determined the facility failed to ensure residents using psychotropic medications received gradual dose reductions for 4 of 5 sampled residents (#s 4, 8, 9, and 71) reviewed for medications. This placed residents at risk for unnecessary uses of psychotropic medications. Findings include:1. Resident 8 was admitted to the facility in 6/2024 with diagnoses including paranoid schizophrenia (mental health condition) and anxiety disorder (mental health condition). Resident 8's 12/13/25 Quarterly MDS indicated the resident received antipsychotic and antianxiety medications with no Gradual Dose Reduction (GDR) attempted and no documentation existed from the physician indicating a GDR was clinically contraindicated. Resident 8's 3/2026 Physician Orders included the following: - buspirone HCl Oral Tablet (antianxiety medication) 10 mg by mouth two times a day and 15 mg by mouth at bedtime for anxiety, active since 11/19/24. - perphenazine Oral Tablet 4 MG (antipsychotic medication) 4 mg by mouth two times a day, active since 6/4/24 Resident 8's 2/2026 and 3/2026 MARs revealed the resident received buspirone 10 mg twice per day, buspirone 15 mg at night, and perphenazine 4 mg twice per day as ordered. Resident 8's health record did not include documented evidence GDRs were attempted for buspirone or perphenazine, nor was there documented rationale for both medications why a GDR was clinically contraindicated. On 3/12/26 at 12:29 PM and 3/13/26 at 11:32 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 8. 2. Resident 9 was admitted to the facility in 2020 with diagnoses including bipolar disorder (mental health condition). Resident 9's 2/2025 Physician Orders included the following:- olanzapine (antipsychotic) 5 mg by mouth in the morning and 10 mg by mouth in the evening. Resident 9's 1/26/26 Quarterly MDS indicated the resident received an antipsychotic, no Gradual Dose Reduction (GDR) was attempted, and the physician did not document a GDR was clinically contraindicated. Resident 9's 2/2025 MARs through 2/2026 MARs revealed the resident received olanzapine BID as ordered. Resident 9's health record did not include documented evidence a GDR for olanzapine was attempted between 2/2025 and 2/2026 or a documented rationale why a GDR was clinically contraindicated. On 3/12/26 12:47 PM and on 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 9. 3. Resident 4 was admitted to the facility in 2007 with diagnoses including antisocial personality disorder (mental health condition) and dementia with behavioral disturbance. Resident 4's 8/1/25 Annual MDS indicated the resident received no Gradual Dose Reduction (GDR) was attempted and the physician did not document a GDR was clinically contraindicated. Resident 4's 2/2026 Physician Orders directed the facility staff to administer quetiapine fumarate (antipsychotic medication) 600 mg by mouth at bedtime. Resident 4's 2/2025 through 3/2026 MARs revealed the resident received quetiapine fumarate as ordered. Resident 4's health record did not include documented evidence a GDR was attempted or a documented rationale why a GDR was clinically contraindicated. On 3/12/26 12:40 PM and 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 4. 4. Resident 71 was admitted to the facility in 2024 with diagnoses including bipolar disorder (mental health condition). Resident 71's 7/2/25 Annual MDS indicated the resident received an antipsychotic, no Gradual Dose Reduction (GDR) was attempted, and the physician did not document a GDR was clinically contraindicated. Resident 71's 2/2025 Physician Orders for medications included the following: - olanzapine (antipsychotic) give 10 mg by mouth in the evening.- Depakote sprinkles oral capsule delayed release (mood stabilizer) to give 1750 mg by mouth in the morning and 2000 mg by mouth at bedtime. Resident 71's 2/2025 through 3/2026 MARs revealed the resident received olanzapine and Depakote medications as ordered. Resident 71's health record did not include documented evidence a GDR was attempted or a documented rationale why a GDR was clinically contraindicated. On 3/12/26 12:40 PM and 3/13/26 at 9:52 AM Staff 3 (RNCM) stated the resident was on a specialized unit and believed the residents on the Enhanced Care Unit (ECU) would not warrant a GDR due to their diagnoses. Staff 3 stated the residents on the ECU had their psychotropic medications and potential changes in condition reviewed monthly by the IDT (Intradisciplinary Team). Staff 3 was unable to provide the required GDR documentation for Resident 71.

Based on observation, interview, and record review it was determined the facility failed to ensure precautions were in place for 1 of 6 sampled hallways (400 hall) reviewed for enhanced barrier precautions. This placed the residents at risk of acquiring an infection. Findings include:CDC's 6/2021 Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities instructed EBP were recommended for residents with indwelling medical devices, regardless of multidrug-resistant organism colonization status. Resident 55 was admitted to the facility in 2/2026 with diagnoses including gastrostomy status (a tube placed directly into the stomach through a small opening in the belly used for administering nutrition, fluids, and medications).Resident 55's 2/10/26 admission orders included an order for enhanced barrier precautions (EBP) (protective measures taken by nursing home staff for residents with specific germs or medical devices).On 3/9/26 and 3/10/26 between the hours of 8:37 AM and 3:38 PM no EBP signage or PPE was observed inside or outside Resident 55's room.On 3/9/26 at 2:32 PM and 3/10/26 at 1:34 PM staff, including Staff 4 (CNA), were observed to complete cares with Resident 55 without wearing PPE beyond gloves.On 3/10/26 at 1:26 PM Staff 4 stated when providing care with residents with tube feeding, staff should wear a gown, mask, and gloves. Staff 4 stated a sign would be posted outside the resident's door if they were on EBP. Staff 4 confirmed Resident 55 did not have EBP in place and PPE was not used beyond wearing gloves. On 3/10/26 at 1:56 PM Staff 2 (DNS) acknowledged Resident 55 did not have EBP in place, confirmed EBP signage was not posted, and confirmed EBP was indicated for Resident 55 due to the resident's gastrostomy tube.

Based on observation, interview, and record review it was determined the facility failed to ensure privacy was maintained when care was provided for 1 of 3 sampled resident (#11) reviewed for dignity. This placed residents at risk for a lack of privacy during care. Findings involved:The facility's Resident Rights Policy from 8/2019 revealed:-Employees shall treat all residents with kindness, respect, and dignity. Federal and states laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.Resident 11 was admitted to the facility in 2/2026 with diagnoses including cerebral infarction (blood flow blockage of a section of the brain which often results in death of brain cells), tracheostomy (surgical airway opening to facilitate breathing), and locked-in state (full consciousness but an inability to move or speak).A 2/18/26 admission MDS indicated Resident 11 to be in a comatose state with an inability to communicate.A 3/2/26 physician order included Resident 11's tracheostomy to be suctioned every six hours and as needed to prevent airway blockage.On 3/10/26 at 8:31 AM Staff 10 (Respiratory Therapist) was observed performing suctioning for Resident 11's tracheostomy with Resident 11's door fully open. Resident 11 was visible from the main hallway of the facility. During the suctioning, Resident 11 was observed lifting both of her/his legs one foot off her/his bed and tremoring strongly for approximately three seconds multiple times. Residents were observed looking into Resident 11's room from the hallway while the suctioning care was provided to Resident 11.On 3/11/26 at 1:00 PM Staff 10 was observed performing suctioning for Resident 11's tracheostomy with Resident 11's door fully open. Resident 11 was visible from the main hallway of the facility. During the suctioning, Resident 11's legs were observed lifting one foot off her/his bed while tremoring strongly for approximately three seconds a total of six times. During the reactions to suctioning, three staff members and two residents passed by Resident 11's room and looked into her/his room at Resident 11.On 3/11/26 at 1:17 PM Staff 10 stated Resident 11's legs lifted off the bed and shook when the suctioning tube was required to go more than two inches deep. Staff 10 stated Resident 11 grimaced during the suctioning process. Staff 10 stated she had never been instructed to have Resident 11's door closed when performing suctioning but understood maintaining privacy was important for all residents, but especially when a resident was unable to communicate or advocate for themselves.On 3/11/26 at 3:52 PM Witness 1 (Resident Representative) stated Resident 11 would not want her/his care to be provided visible to others and stated Resident 11's door should be closed when suctioning care was provided. Witness 1 stated she/he was uncomfortable knowing suctioning care was provided to Resident 11 with the door wide open. On 3/11/26 at 4:06 PM Staff 9 (LPN/Resident Care Manager) stated when suctioning care was provided, having the door closed was important for Resident 11's privacy.On 3/11/26 at 4:26 PM Staff 2 (DNS) confirmed Resident 11's door should remain closed to maintain privacy when tracheostomy care was provided.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 4 sampled residents (#82) reviewed for discharge. This placed residents at risk for lack of medical services. Findings include: Resident 82 was admitted to the facility in 9/2025 with diagnoses including seizures and anxiety.A physician order from 9/1/25 included 200 mg of lacosamide (antiseizure medication) to be administered twice a day for seizures.A physician order from 9/1/25 included 1 mg of clonazepam (antianxiety medication) to be administer twice a day for anxiety.Review of progress notes revealed Resident 82 transitioned home to an assisted living facility on 9/15/25. This note reports Resident 82 was provided his/her medications upon discharge.Review of Controlled Substance Log records from 9/2025 revealed Resident 82 had 33 tablets of lacosamide and 24 tablets of clonazepam which remained in the facility until they were disposed of on 11/9/25. Records showed the medications were not provided to Resident 82 upon discharge.On 3/10/26 at 2:31 PM Staff 9 (LPN/Resident Care Manager) stated residents discharge with their scheduled and PRN medications, but not general over the counter medications. Staff 9 stated antiseizure and antianxiety medications were types of medications a resident should be discharged home with.On 3/10/26 at 2:59 PM Staff 6 (RN) stated Resident 82 was to be provided her/his antiseizure and antianxiety medications upon discharge.On 3/10/26 at 3:04 PM Witness 2 (RN, External Facility Staff) reviewed Resident 82's records regarding her/his transfer home. Witness 2 stated Resident 82 was not provided with the remaining doses of lacosamide and clonazepam upon discharge which required these medication to be reordered. Witness 2 stated Resident 82 experienced increased anxiety as result of not having her/his anxiety and seizure medications available.On 3/11/26 at 9:05 AM Resident 82 stated she/he was afraid after learning she/he did not arrive to the new facility with all of her/his medications but did not experience any seizures or anxiety attacks as a result of missed medications.On 3/11/26 at 10:36 AM Staff 2 (DNS) confirmed Resident 82 should have been provided the remaining doses lacosamide and clonazepam upon her/his discharge from the facility.

Based on interview and record review it was determined the facility failed to thoroughly investigate falls for 1 of 2 sampled residents (#83) reviewed for accidents. This placed residents at risk for further falls. Findings include:Resident 83 was admitted to the facility in 3/2025 with diagnoses includine Alzhimer's Disease and insomnia.A public complaint was made on 12/10/25 which alleged the facility failed to have intervention in place to mitigate Resident 83's falls.A 4/3/25 facility investigation indicated on 3/21/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/3/25 facility investigation indicated on 3/23/25 Resident 83 was observed self ambulating in the hall near the nurse's station and Resident 83 was observed to fall.A 4/3/25 facility investigation indicated on 3/26/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/3/25 facility investigation indicated on 3/27/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/3/25 facility investigation indicated on 3/30/25 Resident 83 was observed falling in the hallway. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/6/25 facility investigation indicated on 3/24/25 Resident 83 was observed to fall in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/14/25 facility investigation indicated on 4/8/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 4/14/25 facility investigation indicated on 4/11/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 5/1/25 facility investigation indicated on 4/27/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 5/1/25 facility investigation indicated on 5/1/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 5/19/25 facility investigation indicated on 5/16/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 6/25/25 facility investigation indicated on 6/10/25 Resident 83 was observed standing up for her/his wheelchair and falling to the floor. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 6/25/25 facility investigation indicated on 6/18/25 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 7/11/25 facility investigation indicated on 7/2/25 Resident 83 was found on the floor of the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 7/11/25 facility investigation indicated on 7/9/25 Resident 83 was found on the floor of her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 9/19/25 facility investigation indicated on 8/30/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 10/2/25 facility investigation indicated on 9/13/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 11/3/25 facility investigation indicated on 10/5/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 11/3/25 facility investigation indicated on 10/19/25 Resident 83 had a witnessed fall onto the floor. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 12/7/25 facility investigation indicated on 11/9/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 12/7/25 facility investigation indicated on 11/12/25 Resident 83 was found on the floor in the hallway. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 1/4/26 facility investigation indicated on 12/6/25 Resident 83 was found on the floor in her/his room. The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A 3/1/26 facility investigation indicated on 2/8/26 Resident 83 was found on floor in the hallway, The investigation did not include an analysis of the root cause or the fall, or whether care planned interventions were effective, or if any additional interventions were put in place.A review of Resident 83's medical record revealed she/he passed away on 2/24/26.On 3/11/26 at 11:40 AM, Staff 2 (DNS) stated investigation were expected to be completed within five business days. Staff 2 stated the fall investigations for the falls on 3/21/25, 3/23/25, 3/24/25, 3/26/25, 6/10/25, 6/18/25, 7/2/25, 8/30/25, 9/13/25, 10/5/25, 10/19/25, 11/9/25, 11/12/25, 12/6/25, and 2/8/26 were completed late. Staff 2 stated the fall investigations were not through, were missing the root cause analysis for the falls, and were missing interventions put in place to help prevent further falls or help prevent injuries from falls.

Based on observation, interview and record review it was determined the facility failed to ensure residents received care and services related to the use of an indwelling catheter for 1 of 2 sampled residents (#56) reviewed for catheter care. This placed residents at risk for catheter care complications. Findings include: The facility's 9/1/24 policy and procedure related to indwelling catheters indicates care of residents' catheters includes monitoring for signs of complications.Resident 56 was admitted to the facility in 9/2025 with a diagnosis of acute and chronic respiratory failure with hypoxia (a potentially life-threatening condition where the lungs cannot adequately oxygenate the blood).Resident 56's health record revealed she/he was her/his own representative and was cognitively intact.A review of Resident 56's 9/24/25 admission and 12/25/25 Quarterly MDS assessments revealed she/he had an indwelling suprapubic catheter.Resident 56's 10/1/25 Care Plan indicated the facility was to follow up with urology consults as ordered.A progress note written by Staff 5 (Attending Physician) on 11/20/25 at 8:31 AM revealed Resident 56 complained her/his suprapubic catheter leaked at the stoma which left her/his bed wet. The note indicated if Resident 56's suprapubic catheter was leaking, staff were to refer to urology for an exchange or different size.A handwritten note from Staff 5 requested staff to refer Resident 56 to Urology to care for her/his leaking suprapubic catheter was uploaded to her/his health record on 11/20/25.A nursing progress note written by Staff 6 (RN) on 1/24/26 at 5:57 PM revealed a large amount of urine leaking around suprapubic catheter. On 3/9/26 at 11:29 AM Resident 56 stated, I wish they could fix my catheter. It leaks and I end up being wet on my belly and it is uncomfortable. Resident 56 pointed to a wet area low on her/his garment and stated, I don't like to feel wet.On 3/12/26 at 12:04 PM Staff 7 (CNA) stated she performed peri care around Resident 56's suprapubic catheter stoma because it leaked. Staff 7 stated she used a warm wet washcloth to keep Resident 56 as clean and dry as possible whenever she provided incontinence care and whenever urine leaked from the stoma. Staff 7 stated Resident 56 let staff know when she/he leaked urine from her/his stoma.On 3/12/2026 at 3:20 PM Staff 4 (CNA) stated he was aware Resident 56's suprapubic catheter leaked and she/he complained about her/his belly feeling wet. Staff 4 stated this was pretty much the norm and CNAs perform peri care around the stoma, cleaned the area and regularly placed an absorbent pad below the stoma to help absorb the leaking urine. On 3/12/26 at 3:23 PM Staff 8 (LPN) stated the stoma for Resident 56's suprapubic catheter was too big which caused it to leak urine. Staff 8 stated she observed Resident 56's stoma regularly and CNAs had to provide peri care to the stoma to ensure the site was clean and dry because it leaked urine daily. Staff 8 stated she did not know if a urology referral and appointment were made.On 3/12/26 at 3:39 PM Staff 9 (LPN/RCM) stated she was aware Resident 56's suprapubic catheter stoma leaked continuously and it was bothersome. Staff 9 stated she was aware of Staff 5's order to refer Resident 56 to Urology but confirmed the referral was not made. Staff 9 stated she expected a referral to be made to urology when a suprapubic catheter stoma leaked.

Based on observation, interview, and record review it was determined the facility failed to maintain healthy parameters of nutritional status for 1 of 2 sample residents (#10) reviewed for nutrition. This placed residents at risk for impaired nutrition. Findings include:Resident 10 was admitted to the facility in 2/2026 with diagnoses including a Stage 3 Pressure Ulcer (a deep, full-thickness skin wound, often appearing as a crater, where the skin has broken down completely, exposing the fatty subcutaneous tissue) to her/his sacral region and left heel and moderate protein-calorie malnutrition.A 2/5/26 care plan indicated Resident 10 was at risk for nutritional imbalance due to a diagnosis of malnutrition.A review of Resident 10's weights revealed the following:-2/11/26 200 lbs-2/17/26 190 lbs-3/5/26 179.8 lbsA review of the 2/4/26 Skin Issues Evaluations revealed Resident 10 had a Stage 3 Pressure Ulcer on her/his left ankle and sacrum at admission.A 2/12/26 Nutrition at Risk Evaluation revealed Resident 10 was started on a protein supplement twice a day due to wounds.A 2/13/26 physician order revealed Resident 10 had orders for a nutritional supplement twice a day.A review of a 2/23/26 Skin Issues Evaluations revealed Resident 10's pressure ulcer on her/his sacrum worsened to a Stage 4 Pressure Ulcer (wounds that involve complete tissue loss with exposure of muscle, tendon, or bone).A 2/26/26 Nutrition at Risk Evaluation revealed Resident 10 was refusing her/his nutritional supplement and Resident 10 was consuming the protein supplement.A review of 2/2026 and 3/2026 MARs revealed Resident 10 refused the nutritional supplement which was started on 2/13/26.On 3/11/26 at 8:29 AM, Resident 10 was observed in bed with her/his breakfast tray in front of her/him, Resident 10 appeared to be sleeping and not eating.On 3/12/26 at 9:28 AM Resident 10 was observed sleeping in bed with her/his breakfast tray in from of her/him and food on her/his chest.A 3/12/26 review of Resident 10's meal intake for the last 30 days from date of review, revealed Resident 10 ate 50% or less than of her/his meals or refused the meal 37 times. The documentation revealed Resident 10 was offered a health shake or ensure six times and refused 13 times.On 3/12/26 at 11:05 AM Staff 13 (RNCM) stated the expectation was if a resident consumes 50% or less of their meal, an alternate or meal replacement was offered. Staff 13 stated a protein supplement, and a nutritional supplement was started on 2/5/26, but Resident 10 has refused the nutritional supplement. Staff 13 confirmed Resident 10 had a significant weight loss and there were no interventions put in place since the weight loss occurred.On 3/12/26 at 11:31 AM, Staff 2 (DNS) acknowledged Resident 10 had experienced significant weight loss and no interventions had been implemented in response to the decline. Staff 2 stated discussions regarding hospice care had occurred with the family; however, the family was not yet ready for Resident 10 to transition to hospice services.

Based on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 2 of 2 sample residents (#s 10 and 14) reviewed for advance directives. This placed residents at risk for healthcare decisions to be in conflict with resident wishes. Findings include:1. Resident 10 was admitted to the facility in 2/2026 with diagnoses including hypertension (high blood pressure).A care plan dated 2/5/226 indicated Resident 10 was a full code, her/his advanced directive would be honored, and her/his advanced directive would be in the medical record at all times.A review of Resident 10's medical record revealed no evidence of an advanced directive.On 3/10/26 at 1:13 PM, Staff 2 (DNS) stated Resident 14 did not have an advanced directive and education was initiated regarding the difference between an advanced directive and a POLST (Physician Order for Life Sustaining treatment). Staff 2 stated the expectation was for the RCM or the Social Service Director to ensure if a resident has an advanced directive, it was obtained and scanned into the resident's chart. 2. Resident 14 was admitted to the facility in 2/2026 with diagnoses including asthma.A 2/10/26 Baseline Care Plan Person-Centered Care Planning Evaluation revealed Resident 14's advanced directive had been reviewed with Resident 14.A review of Resident 14's medical record revealed no evidence of an advanced directive.On 3/10/26 at 1:13 PM, Staff 2 (DNS) stated Resident 14 did not have an advanced directive and education was initiated regarding the difference between an advanced directive and a POLST (Physician Order for Life Sustaining treatment). Staff 2 stated the expectation was for the RCM or the Social Service Director to ensure if a resident has an advanced directive, it was obtained and scanned into the resident's chart.

Based on observation, interview, and record review it was determined the facility failed to store foods at appropriate temperatures for 1 of 3 kitchen refrigerators reviewed for food safety. The facility's failure was determined to be an immediate jeopardy situation because raw meat stored outside of an acceptable temperature was planned to be used for an upcoming meal. Findings include: According to the U.S. Food and Drug Administration's Food Code 2022, (Chapter 3, Section 501.13), food shall be thawed under refrigeration that maintains the food temperature at 41 degrees F or less. Chapter 3, Section 501.13 goes on to say, improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. On 9/23/24 at 10:24 AM an initial inspection of the kitchen was performed. During this inspection an internal refrigerator thermometer read 45 degrees F. This refrigerator contained uncooked meat thawing, bacon, various salad dressings, cooked ham, cooked pulled pork, salami, pasteurized eggs, pasteurized cheeses and butter. On 9/25/24 at 11:20 AM the same refrigerator was inspected and the internal thermometer read 49 degrees F. This refrigerator contained the same items observed on 9/23/24 as well as uncooked beef being thawed. On 9/25/24 at 11:20 AM Staff 8 (Dietary Director) stated the fridge had problems staying cool for a few weeks. Staff 8 stated she thought this was either due to the location of the fridge or due to a problem with the door not fully closing and staying closed. Information was provided to Staff 8 regarding the temperature being at 49 degrees F and no action was taken by Staff 8. On 9/26/24 at 8:53 AM the Refrigerator Temperature Log for 9/2024 was reviewed and contained the following information: - 9/1: 50 F at 6:00 PM, - 9/2: 42 F at 6:00 PM, - 9/4: 43 F at 6:00 PM, - 9/5: 44 F at 6:00 PM, - 9/6: 46 F at 6:00 PM, - 9/7: 47 F at 6:00 PM, - 9/10: 42 F at 6:00 PM, - 9/15: 46 F at 6:00 PM, - 9/18: 43 F at 7:00 AM, - 9/18: 42 F at 6:00 PM, - 9/19: 42 F at 6:00 PM, - 9/22: 42 F at 9:00 AM, - 9/22: 42 F at 3:00 PM, - 9/23: 42 F at 7:00 AM, - 9/23: 43 F at 7:00 PM and - 9/24: 43 F at 2:00 PM. On 9/26/24 at 10:54 AM Staff 8 repeated she thought the problem was just the door not fully closing and checked to ensure the door was fully closed. Staff 8 repeated previous information about the refrigerator having had problems for a few weeks and added Staff 19 (Maintenance Director) was maybe notified about it. Records of this notification were requested, but no records were provided. On 9/26/24 at 10:54 AM Staff 8 was requested to check the temperature of the uncooked beef which was observed to be 41.3 degrees F. No action was taken by Staff 8 after the temperature check. On 9/26/24 at 11:05 AM Staff 19 stated he had not been informed of the refrigerator temperatures being outside of the acceptable range until 9/26/24. On 9/26/24 at 1:20 PM Staff 8 was requested to check the temperature of the uncooked beef which was found to be at 42.9 degrees F with one thermometer. To ensure temperature accuracy, a second thermometer was used which read 42.6 degrees F. Staff 8 stated the uncooked beef had been in the fridge to thaw since 9/24/24. Staff 8 said she had planned on cooking the beef on 9/27/24 but then said, I guess I'll do it tonight. On 9/26/24 at 2:44 PM the facility was notified of the Immediate Jeopardy (IJ) situation beginning 9/1/24 and an immediacy removal plan was requested. On 9/26/24 at 4:44 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: - No foodborne illness had been identified. - All food was removed from the refrigerator and disposed. - The refrigerator was taken out of service. - New foods would be purchased to serve to residents. - All kitchen refrigerators would be checked for correct temperatures - The Administrator would educate the Dietary Manager and all dietary staff on 9/26/24 on the importance of refrigerator temperatures and action that should occur immediately with any food temperature concerns. Education would include storage, thawing, cooking and danger zone temperatures as well as when to dispose of any food that is in question. If dietary staff does not answer, they will be educated prior to their shift. - The Administrator would educate maintenance on the importance of placing a malfunctioning refrigerator out of service and action that should occur immediately with any food temperature concerns. - The Administrator of designee would audit refrigerator temperature logs daily for one week, then weekly for three weeks and then monthly for two months. - The findings would be brought to QAPI (Quality Assurance and Performance Improvement) for two months to ensure substantial compliance is met. - The Administrator would be responsible to ensure compliance. On 9/27/24 at 10:03 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.

Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents for 1 of 2 units observed for required postings. This placed residents at risk for lack of information on how to file a complaint or how to report concerns. Findings include: On 9/23/24 at 11:00 AM the required postings to indicate how residents can contact the State Survey Agency, the State licensure office, adult protective services and LTCO were observed in a hallway outside of the facility's locked enhanced care unit (ECU). Neither posting was observed inside the ECU. On 9/25/24 at 3:30 PM Resident 1 stated she/he had no idea where to access the contact information for pertinent State agencies or the LTCO and she/he was interested to know this information. Resident 1 stated she/he was unable to leave the ECU without a staff escort. On 9/25/24 at 10:55 AM Staff 1 (Administrator) acknowledged the findings of this investigation and confirmed ECU residents could not access the required postings without staff assistance.

Based on observation and interview it was determined the facility failed to ensure sanitary laundry services were provided for 2 of 6 halls reviewed for infection control. This placed residents at risk for cross contamination. Findings include: On 9/24/24 at 12:57 PM and at 1:10 PM Staff 20 (Laundry Services) was observed to deliver clean resident clothing throughout the 400 and 500 Halls and used a small uncovered laundry cart. The laundry cart was left unattended while Staff 20 delivered resident clothing from room to room. On 9/27/24 at 10:02 AM Staff 1 (Administrator) acknowledged that clean resident clothing should be covered while being delivered.

Based on observation, interview and record review it was determined the facility failed to ensure residents were allowed to retain personal possessions for 1 of 1 sampled resident (#9) reviewed for choices. This placed residents at risk for diminished quality of life. Findings include: Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Resident 9's 8/6/24 Admission MDS indicated the resident was cognitively intact and did not exhibit any mood symptoms or behaviors. The MDS also indicated it was very important to the resident to take care of her/his personal belongings. On 9/23/24 at 12:15 PM Resident 9 was observed in her/his wheelchair in the dining room. Resident 9 stated she/he wanted to speak with the State Surveyor but wanted Witness 1 (Family Member) to be present for the conversation via her/his cell phone. Resident 9 stated she/he would check out her/his cell phone from the office and then meet in her/his room. On 9/23/24 at 1:05 PM the State Surveyor spoke with Resident 9 in her/his room with Witness 1 available on the resident's cell phone. Resident 9 stated she/he was allowed to have her/his cell phone between the hours of 9:00 AM to 7:00 PM when she/he had to return it to the office. Resident 9 and Witness 1 stated the facility restricted Resident 9's access to her/his cell phone at night since admission. They were told Resident 9 needed to learn to depend on [the facility] and felt as if they could not fight the restriction. Resident 9 further stated she/he did not like it and felt upset [she/he] could not call [her/his] mom when [she/he] wanted to. On 9/24/24 at 1:18 PM Staff 22 (CNA) and at 1:30 PM Staff 21 (CNA) stated they did not know why Resident 9 was not allowed to maintain her/his cell phone. On 9/24/24 at 2:33 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated she would not be surprised if [Resident 9] wanted it [her/his cell phone] all the time. Staff 23 further stated staff were concerned Resident 9's roommate would take the phone so it was brought into the office to charge. No evidence was found in Resident 9's clinical record to indicate why the resident was not allowed to maintain her/his cell phone. On 9/24/24 at 3:47 PM Staff 1 (Administrator) acknowledged the findings of this investigation and stated she expected residents to be able to maintain their own cell phones unless a behavior care plan was in place to indicate otherwise.

Based on interview and record review it was determined the facility failed to ensure a consent was obtained prior to administering antidepressant medications to residents for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 21 was admitted to the facility in 8/2023 with diagnoses including fracture and dementia. Resident 21's 8/25/23 Physician Order indicated the resident was prescribed mirtazapine (antidepressant) for major depressive disorder. Resident 21's 8/2023 through 9/2024 MARs revealed the resident received mirtazapine daily. Review of Resident 21's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of mirtazapine. On 9/25/24 at 10:57 AM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) reviewed Resident 21's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of mirtazapine and confirmed a consent was not obtained from Resident 21 or her/his representative prior to the resident starting the medication.

Based on interview and record review it was determined the facility failed to ensure a safe system for a resident's self-administration of medication for 1 of 2 sampled residents (#6) reviewed for care planning. This placed residents at risk for adverse medication reactions. Findings include: Resident 6 admitted to the facility in 2022 with a diagnosis of multiple sclerosis. An 6/25/24 quarterly MDS revealed Resident 6 was cognitively intact. A 3/10/22 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of multiple medications. The form also indicated Resident was 6 was not to be left unattended while medication was being administered. A 4/1/24 Self-Administration of Medication form revealed Resident 6 was assessed to be capable of self-administration of Ventolin (respiratory medication) only. On 9/23/24 at 12:56 PM Staff 18 (RN) was observed to leave four unidentified medications at Resident 6's bedside and then left the room. When questioned Staff 18 stated she believed Resident 6 had a medication administration assessment completed that allowed Resident 6 to take her/his medications independently. Staff 18 confirmed she left medications with Resident 6 while she/he was unattended. On 9/24/24 at 2:27 PM staff 27 (CNA) stated in the evenings she observed medications left at Resident 6's bedside while she/he was unattended. On 9/25/24 at 2:31 PM Staff 2 (DNS) was made aware of the details of the medication self administration assessment as well as the observation of medications being left in resident 6's room while she/he was unattended. As of 9/27/24 at 9:57 AM no further information had been provided.

Based on interview and record review it was determined the facility failed to ensure residents had access to their personal funds on an ongoing basis for 2 of 2 sampled residents (#s 1 and 9). This placed residents at risk for lack of access to personal funds. Findings include: 1. Resident 1 was admitted to the facility in 10/2017 with diagnoses including borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships). Resident 1's 7/18/24 Quarterly MDS indicated the resident was cognitively intact. On 9/24/24 at 9:22 AM Resident 1 stated she/he was only able to access her/his money during the day time. On 9/24/24 at 1:13 PM Staff 22 (CNA) stated if a resident wanted access to their money, she would direct the resident to wait for staff from the CFL (Center for Living, the community mental health program overseeing the facility's enhanced care unit). Staff 22 stated CFL staff were in the facility every day from approximately 9:00 AM to 7:00 PM. On 9/24/24 at 1:24 PM Staff 21 (CNA) stated she did not deal with any money things and the CFL was responsible for dealing with that. Staff 21 stated she told residents who wanted their money, you have to wait for CFL staff to get here. On 9/24/24 at 2:17 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated residents did not get their money if CFL staff were not available. On 9/25/24 at 8:44 AM Staff 25 (LPN) stated she did not know how to access resident money when CFL staff were not available. On 9/25/24 at 10:53 AM Staff 1 (Administrator) acknowledged the findings of this investigation. Staff 1 stated residents should have access to their money all of the time. 2. Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Resident 9's 8/6/24 Admission MDS indicated the resident was cognitively intact. On 9/23/24 at 1:03 PM the State Surveyor spoke with Resident 9 in her/his room with Witness 1 (Family Member) available on the resident's cell phone. Resident 9 and Witness 1 stated the resident was not able to access her/his money after 7:00 PM on weekdays and past 4:00 PM on the weekends. On 9/24/24 at 1:13 PM Staff 22 (CNA) stated if a resident wanted access to their money, she would direct the resident to wait for staff from the CFL (Center for Living, the community mental health program overseeing the facility's enhanced care unit). Staff 22 stated CFL staff were in the facility every day from approximately 9:00 AM to 7:00 PM. On 9/24/24 at 1:24 PM Staff 21 (CNA) stated she did not deal with any money things and the CFL was responsible for dealing with that. Staff 21 stated she told residents who wanted their money, you have to wait for CFL staff to get here. On 9/24/24 at 2:17 PM Staff 23 (Enhanced Care Unit Program Supervisor) stated residents did not get their money if CFL staff were not available. On 9/25/24 at 8:44 AM Staff 25 (LPN) stated she did not know how to access resident money when CFL staff were not available. On 9/25/24 at 10:53 AM Staff 1 (Administrator) acknowledged the findings of this investigation. Staff 1 stated residents should have access to their money all of the time.

Based on observation and interview it was determined the facility failed to maintain a homelike environment and adequate hot water temperatures for 1 of 1 facility shower room reviewed for a homelike environment. This placed residents at risk for a cluttered and damaged shower environment as well as cold showers. Findings include: On 9/23/24 at 10:23 AM Resident 32 stated the water in main shower room was too cold. On 9/26/24 at 7:43 AM Resident 100 stated the water would go hot for a bit and then suddenly get cold. On 9/26/24 at 7:01 AM Staff 11 (CNA) stated she started the shower way ahead of time so the water could warm up. Staff 11 stated sometimes the water was too cold. On 9/26/24 at 7:56 AM staff 19 (maintenance director) tested the shower water temp after five or more minutes and it was 87 degrees F. Staff 19 indicated which hot water heater supplied the shower and the temperature gauge read 99 degrees F. On 9/27/24 at 7:26 AM Staff 1 (Administrator) tested the shower water temperature and it reached 94 degrees Fahrenheit. On 9/27/24 at 7:26 AM the main shower room was observed with sections of baseboard missing from the three partition walls on the left side of the shower room leaving exposed unfinished, uncleanable sheetrock. The partition wall furthest from the door had significant chunks and gouges near the base. The ceiling above the non-functioning side of the shower room appeared torn and potentially damaged by water. The vent above the non-functioning shower was observed to be dirty and the light bulb was exposed. The drain cover was also missing in the functional shower resulting in an approximately three inch hole in the floor and was a potential source of injury. 09/27/24 10:17 AM Staff 1 (Administrator) confirmed the damage and un-homelike state of the shower room as well as the hot water temperatures being out of the aceptable range.

Based on interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 2 sampled residents (#s 9 and 26) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: The facility's 9/2024 PASARR Policy and Procedure directed the following: -If a Level II evaluation was indicated, the social worker would ensure a LMPH (licensed mental health professional) was scheduled to evaluate within a timely period. -If there was a significant change of condition that could affect a resident's diagnosed need for a PASARR Level II, staff should refer for a new PASARR Level II. -Follow up as needed per federal PASARR rules. 1. Resident 9 was admitted to the facility in 7/2024 with diagnoses including Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania) and cerebral palsy (a group of conditions that affect movement and posture and caused by damage that occurs to the developing brain, most often before birth). Resident 9's 7/31/24 PASARR Level I indicated the resident experienced indicators of both serious mental illness and a developmental disability. A review of Resident 9's Social Service Notes from 8/1/24 through 8/13/24 revealed a PASARR Level II was requested to address the resident's indicators of developmental disability but not her/his indicators of serious mental illness. On 9/25/24 at 9:39 AM Staff 4 (Social Services Director) stated PASARR Level IIs for serious mental illness were completed by the Center for Life (CFL), the organization who managed the facility's enhanced care unit, and she was not sure why the PASARR Level II for Resident 9 for her/his diagnosed serious mental illness had not been completed. On 9/25/24 at 10:56 AM Staff 1 (Administrator) acknowledged the findings of this investigation and provided no additional information. 2. Resident 26 was admitted to the facility in 1/2021 with diagnoses including anxiety and depression. Resident 26's 1/21/21 PASARR Level I indicated the resident did not have indicators of either serious mental illness or a developmental disability. A 6/21/23 PASARR Level II revealed Staff 4 (Social Services Director) requested a Level II evaluation for Resident 26 as the resident experienced a dramatic increase in paranoid delusions. A review of Resident 26's clinical record revealed the resident was hospitalized from 3/3/24 to 3/6/24. Resident 26 readmitted to the facility with a new PASARR Level I which indicated the resident had indicators of serious mental illness. No evidence was found in Resident 26's clinical record to indicate an additional PASARR Level II was requested to address the resident's new onset of serious mental illness indicators. On 9/26/24 at 3:47 PM Staff 4 (Social Services Director) stated Resident 26 was not physically aggressive in 6/2023 when the resident received her/his initial PASARR Level II. Staff 4 stated the resident had experienced a significant change of condition in 3/2024 on account of worsening behaviors and she should have requested an additional PASARR Level II following the resident's hospitalization but she did not. On 9/27/24 at 9:37 AM Staff 1 (Administrator) was informed of the findings and provided no additional information.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 2 of 4 sampled residents (#s 14 and 35) reviewed for weights and assistive devices. This placed residents at risk for unmet needs. Findings include: 1. Resident 14 was admitted to the facility in 6/2020 with diagnoses including dementia and parkinsonism (difficulty with movement). Resident 14's 7/2/24 Annual MDS revealed the resident was moderately cognitively impaired. A Care Plan dated 7/11/24 revealed Resident 14 used a mobility bar on the left side of the bed for inhanced bed mobility. Observations from 9/23/24 through 9/27/24 revealed Resident 14 did not have a mobility bar in place while the resident was in bed. On 9/26/24 at 9:51 AM Staff 11 (CNA) stated Resident 14 should have a bed mobility bar on her/his bed to help her/him with positioning while in bed. On 9/26/24 at 10:59 AM Staff 9 (LPN Resident Care Manager) stated Resident 14 had a mobility bed assist rail on her/his bed to assist with positioning and movement. On 9/27/24 at 9:10 AM Staff 2 (DNS) confirmed Resident 14's care plan had not been updated to reflect the resident no longer needed the mobility bar. 2. Resident 35 was admitted to the facility in 3/2023 with diagnoses including delusional disorders, depression and edema. Resident 35's Quarterly MDS revealed the resident was cognitively intact. A Care Plan dated 9/21/24 revealed Resident 35 used bilateral 1/4 inch rails on her/his bed due to a self-performance deficit. Observations from 9/23/24 through 9/27/24 revealed Resident 35 did not have bilateral 1/4 inch rails on her/his bed while the resident was in bed. On 9/24/24 at 3:01 PM Staff 24 (CNA) stated Resident 35 did not use any bed mobility devices. On 9/24/24 at 3:31 PM Staff 5 (RNCM) stated Resident 35 did not use bilateral bars and stated the care plan had not been updated. On 9/27/24 at 9:10 AM Staff 2 (DNS) confirmed Resident 35's care plan had not been updated to reflect the resident no longer needed the bilateral 1/4 inch rails while in bed. 3. Resident 35 was admitted to the facility in 3/2023 with diagnoses including delusional disorders, depression and edema. A Care Plan dated 9/21/24 revealed Resident 35 was to have her/his weight obtained daily due to diuretic therapy from edema. Resident 35's Quarterly MDS revealed the resident was cognitively intact. Review of Resident 35's clinical record revealed a 4/5/24 physician order for the resident to be weighed weekly. On 9/24/24 at 3:01 PM Staff 24 (CNA) stated Resident 35 was to be weighed everyday in the mornings. On 9/24/24 at 3:31 PM Staff 5 acknowledged Resident 35's care plan had not been revised to reflect Resident 35 was to be weighed weekly. On 9/24/24 at 3:52 PM Staff 2 (DNS) was informed of the findings. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to provide an on-going program to support individual activity interests and preferences for 1 of 2 sampled residents (#25) reviewed for activities. This placed residents at risk for lack of social interaction and isolation. Findings include: The facility's 3/2019 Activities Policy and Procedure indicated the following: -Each resident's physical, mental, spiritual, psychosocial and leisure choices as well as preferences for participation in activities will be assessed. This assessment will occur on admission, annually and with condition changes. -A monthly calendar shall be posted in designated areas of the facility. The scheduled activities will be planned at an appropriate frequency to provide diverse activity/recreational programs that address various cognitive and functional levels and meet the needs of the residents. Resident 25 was admitted to the facility in 1/2021 with a diagnoses including dementia and depression. Resident 25's 1/17/24 Annual MDS indicated the resident experienced short and long term memory loss, was severely impaired for decision making and her/his activity preferences were listening to music, doing things with groups of people, participating in favorite activities and spending time outdoors. The 3/28/24 Care Plan indicated the following: -Resident 25 was dependent on staff to meet emotional, intellectual, physical and social needs, dementia and physical limitations. -The resident's activity goal was to attend/participate in activities of choice 2-4 times weekly by next review date. -Ensure the activities the resident is attending are compatible with known interests and preferences. -Ensure the activities the resident is attending are compatible with individual needs and abilities. -Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. -The resident needs one-to-one bedside/in-room visits and activities if unable to attend out of room events. A review of the facility's Activity Logs from 8/26/24 through 9/25/24 indicated Resident 25 received four one-to-one activities and did not participate in any group activities. Random observations of Resident 25 from 9/23/24 through 9/26/24 from 9:13 AM to 2:50 PM revealed the resident to be either in bed or in his/her wheelchair at the nurses station or in his/her room. No music was observed to play in the resident's room or at the nurses station. On 9/25/24 at 2:45 PM Staff 26 (CNA) stated Resident 25 was non-verbal, did not participate in activities and spent her/his day either sitting at the nurses station or sleeping in her/his room. On 9/26/24 at 9:28 AM Staff 11 (CNA) stated Resident 25 was non-verbal and was unable to make choices about activities or her/his rountine. Staff 11 stated the resident was in her/his room a lot and they were unaware of any activity interests outside of music. On 9/25/24 at 3:06 PM and 9/26/24 at 4:28 PM Staff 7 (Activities Director) indicated Resident 25 was non-verbal and unable to make activity choices. Staff 7 stated he did not do much one-on-one activites with the resident and was unable to articulate the resident's favorite activities outside of listening to music. Staff 7 stated he attempted a sensory mat with the resident at one point but had not attempted any additional sensory activities. On 9/27/24 at 10:04 AM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information.

Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while transferring residents for 1 of 1 sampled resident (#31) reviewed for accidents. This failure resulted in avoidable skin tears to Resident 31's right arm. Findings include: Resident 31 was admitted to the facility in 9/2023 with diagnoses including stroke and kidney failure. Resident 31's Quarterly MDS dated [DATE] indicated the resident was moderately impaired in cognition. Resident 31's Care Plan dated 10/3/23 identified the resident was at risk for falls due to muscle weakness. Interventions on the care plan included: Two-person transfers with a hoyer lift, staff were to anticipate the resident's needs and to keep the call light and personal items within reach. A 12/6/23 Facility Reported Incident indicated Resident 31 was provided care by Staff 11 (CNA) and Staff 15 (CNA) during a transfer from bed to her/his wheelchair and sustained two skin tears to her/his right forearm. Staff 11 reported the injury happened while they assisted the resident with a transfer. Staff 18 (RN) assessed the resident and cleaned the skin tears which measured 1.5 cm each, and were horseshoe shaped. On 9/26/24 at 10:02 AM Staff 11 stated she recalled the incident on 12/5/23 when she was assisting Resident 31 with a transfer. Staff 11 stated she was not familiar with Resident 31 and the incident happened very quickly. Staff 11 acknowledged Resident 31 required two-person hoyer assistance with transfers and the care plan was not followed. On 9/26/24 at 5:16 PM Staff 2 (DNS) stated Resident 31 required two-person assistance with a hoyer for transfers at the time of the incident. Staff 2 stated the care plan was not followed by Staff 11 and Staff 15, a hoyer lift should have been used for the transfer. Staff 2 stated it was her expectation the care plans were always followed.

Based on observation, interview and record review it was determined the facility failed to provide catheter care for 1 of 3 sampled residents (#23) reviewed for catheter care. This failure resulted in Resident 23 hospitalization with heart abnormalities, urinary infection and psychological distress. Findings include: Resident 23 admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Record review of the [DIAGNOSES REDACTED]. The 3/10/19 Annual MDS indicated Resident 23 has a BIMS score of 15 (cognitively intact) and a suprapubic catheter (tube to drain urine from bladder though belly incision). Resident 23's 9/2019 Physician Order, start date 7/2018, prescribed facility staff to irrigate suprapubic catheter daily with 30 ML acetic acid 0.25%, one time a day. Allow flush to sit in bladder 30 minutes, then start drain (clamp and unclamp the catheter tube). The 9/1/19 TAR indicated the staff were to complete the suprapubic catheter irrigation on the night shift daily. A Progress Note on 9/14/19 at 6:25 AM, by Staff 8 (LPN) revealed Resident 23 had her/his irrigation for catheter clamped at 1:30 AM. Due to extenuating circumstances resident was not unclamped until 4:00 AM when resident woke from sleep. Resident 23's blood pressure was not able to be read on the machine. The emergency system was called and Resident 23 was sent to the hospital. The 9/14/19 Admission Hospital Records revealed Resident 23 presented with [MEDICAL CONDITION] (abnormally low blood pressure) due to autonomic dysreflexia (sudden onset of excessively high blood pressure) in the setting of the bladder, her/his catheter was clamped more than two hours following routine irrigation. On 9/16./19 a Hospital Physician reported Resident 23 had a UTI, [MEDICAL CONDITION](abnormal heart rate), [MEDICAL CONDITION] and autonomic dysreflexia which was due to the catheter clamped more than two hours following routine irrigation at the facility. A Physician Note on 9/18/19 revelead Resident 23 was prone to autonomic dysreflexia due to her/his [MEDICAL CONDITION]. Resident 23 was hosptalized on [DATE] with possible complicated UTI and [MEDICAL CONDITION] due to autonomic dysregultion (dysfunction of the nerves that regulate non voluntary body functions) in the setting of increased bladder pressure with the catheter clamped over two hours. A 9/28/19 Provider Progress Note by Staff 12 (Nurse Practitioner) revealed Resident 23 had been recently hospitalized for [REDACTED]. Resident 23 developed [MEDICAL CONDITIONS] diaphoresis (sweating). Resident 23 was found to have been in a-fib (irregular heart beat) and had been admitted to the hospital with [REDACTED]. During an interview on 10/7/19 at 4:50 PM, Resident 23 described the event on 9/14/19. Resident 23 reported Staff 8 (LPN) had clamped her/his catheter tube at about 1:30 AM. Resident 23 fell asleep, woke at about 4:00 AM in a pool of urine, severely sweating and heart rate low. Resident 23 thought she/he might die and yelled for help. Staff Resident 23 stated she/he was admitted to the hospital with [REDACTED]. Resident 23 stated this event continued to be very scary, as her/his heart was the one thing still working good. When Resident 23 said it scared her/him, she/he was visibly shaken with change of voice tone and fearful facial expression. Resident 23 advocated for the irrigation of the catheter to happen on the day shift so she/he would be awake and the facility had changed to day shift. On 10/8/19 at 6:37 AM, Staff 15 (RN) was observed to clamp and irrigate Resident 23's suprapubic catheter daily with 30 ML acetic acid 0.25%, Staff 15 was observed to set an alarm on the cell phone in her pocket. Staff 15 returned to Resident 23's room and was observed to unclamp the suprapubic catheter tube at 7:13 AM. No concerns were made during the observation. On 10/8/19 at 6:23 AM, Staff 16 (LPN) reported she was aware of the order for irrigation of the catheter for Resident 23. Staff 16 reported she did not recall the incident of the catheter tube left clamped for an extended amount of time other than on 9/14/19. On 10/8/19 at 6:44 AM, Staff 15 reported she had a routine to set her cell phone alarm. Staff 15 was aware of the 9/14/19 incident of Residents 23's catheter tube clamped past the 30 minutes. She was not aware of any other incidents. During a phone interview on 10/8/19 at 1:59 PM, Staff 8 confirmed she was a float nurse who had been to the facility a few times. Staff 8 stated she wrote Resident 23's Progress Note on 9/14/19 at the end of her shift, which was about 6:30 AM. Staff 8 did not recall the physician order [REDACTED]. On 10/10/19 at 10:45 AM, Staff 2 (Interim DNS) stated she would expect nursing staff to follow the physician order [REDACTED].

Based on interview and record review it was determined the facility failed to ensure a timely response to a resident's change in condition and physician's orders [REDACTED].#s 3 and 4) reviewed for changes in condition. Resident 3 was unresponsive, transported to the hospital and subsequently passed away. Findings include: 1. Resident 3 was a long term resident of the facility with [DIAGNOSES REDACTED]. a. A public complaint was received on 8/26/15 which indicated the resident had an extremely high fever and was left for an extended period before staff were aware she/he was unresponsive. Witness 5 (Complainant) stated the resident was eventually taken to the hospital and passed away. The resident's care plan dated 2/2/15 indicated the resident was alert, oriented and directed her/his own care. The resident was noted to be inconsistently compliant with physician orders, treatments, positioning and refused some care. The resident's quarterly MDS dated [DATE] indicated the resident had no behaviors, [MEDICAL CONDITION] and no cognitive deficits. The resident was noted to have a brief interview for mental status score of 15 out of 15, which indicated the resident had no cognitive impairments. A physician assessment dated [DATE] indicated the resident's pressure wound had suspected osteo[DIAGNOSES REDACTED] (bone infection). The resident was being considered for surgical intervention of the wound and infection. The resident's Vitals Report indicated the resident had a temperature ranging from 103.8 to 105.0 degrees on 3/25/15. On 3/26/15 at 2:25 am the resident's temperature was 102.1; at 5:48 am the resident's temperature was noted at 98.4 degrees. Nurse's Notes (NNs) dated 3/25/15 at 8:52 am indicated a review of unprocessed orders showed a sticky note r/t (related to) this Resident's L (left) lateral and medial thigh bright red. Reviewed PN (Progress Notes) and saw no mention of this. After discovery of the sticky note the resident was then assessed to have redness on the thigh which was hot to the touch, potential [MEDICAL CONDITION]. The resident's RNCM was notified for follow up with the physician. NNs dated 3/25/15 at 12:26 pm indicated the resident's right hip and lateral thigh area was red, firm and very warm to the touch. No temperature was noted. The inflammation was noted in the same location as an infection earlier this month. The resident's physician was faxed an update. No additional information was noted regarding a physician response. A fax was sent to the physician on 3/25/15 at 12:18 pm which indicated the resident's left upper thigh was inflamed, very red, firm and warm to the touch. The resident started [MEDICATION NAME] (antibiotic) on 3/9/15 100 mg twice a day for seven days but redness has returned. NNs dated 3/25/15 at 10:00 pm indicated the resident was visibly shivering and stated was not feeling well. Vital signs were stable except a temperature of 103.8 degrees. Area of hot/redness to left thigh, possible [MEDICAL CONDITION] has extended to beyond the left thigh around the lower back and lateral aspect of the right thigh. The perimeter of the red area was marked to determine growth. The on call physician was contacted and an order to give [MEDICATION NAME] (antibiotic) 2 grams intramuscular injection now and start [MEDICATION NAME] 300 mg (antibiotic) in the morning. The resident remained alert and able to state her/his needs at this time. NNs dated 3/26/15 at 12:20 am indicated the resident's temperature increased to 104.9 at 10 pm. The resident refused transport to the emergency room for evaluation and treatment due to the dangerously high fever. Multiple staff members approached the resident but she/he refused all requests for transport to the hospital. At 11:30 pm the resident's temperature was 105.0. The resident continued to refuse transport. At approximately 12:00 am EMTs were contacted and arrived at the facility but the resident refused EMT transport. At 12:00 am the resident's temperature was 103.7 degrees, other vital signs were noted as stable. Resident continued to remain alert, able to state needs and follow commands given. The resident stated she/he felt a little better. Frequent monitoring for the resident's change in condition continued. NNs dated 3/26/15 at 6:06 am indicated the resident's fever began to decrease at approximately 3:00 am; recorded as 102.1 degrees with Tylenol given as ordered. Resident declined to go to the hospital and declined to have family contacted multiple times. At 6:00 am the resident's temperature decreased to 98.4 and the resident appeared to be resting comfortably. NNs dated 3/26/15 at 10:45 am indicated report received at shift change the resident refused transport to the hospital for an elevated temperature of 104.9 degrees. At 9:30 am the resident was unresponsive with unstable vitals. After several unsuccessful attempts to wake the resident 911 was called. The resident left the facility for the hospital at 10:00 am. No additional documentation was located regarding resident monitoring, vitals and responsiveness between 6:00 am and 9:30 am. The resident was admitted to the hospital and passed away on 3/28/15. Emergency Transportation Dispatch notes dated 3/26/15 indicated emergency personnel were contacted at 9:37 am, enroute to the facility at 9:40 am, arrived at the facility at 9:43 am, with the resident at 9:46 am and left with the resident at 10:10 am. The resident's care was transferred to staff at the hospital at 10:19 am. Hospital critical care notes dated 3/27/15 indicated the the resident was admitted comatose 24 hours after extremely high fever of 105.7 degrees. The resident was unresponsive, intubated and connected to a ventilator. The resident's pupils were fixed and unresponsive with no voluntary body movements observed. Septic shock likely due to pneumonia also has chronic sacral ulcer. Possible concern for meningitis due to change in mental status and high fevers. A hospital discharge summary dated 3/28/15 indicated the resident's admission and discharge [DIAGNOSES REDACTED]. The resident was placed on comfort care, removed from the ventilator and passed away shortly thereafter. Interview on 11/9/15 at 11:43 am Witness 5 (Complainant) stated the resident had a 105 degree fever that the family was not made aware of. The resident went all night before she/he was sent to the hospital. Witness 5 stated they were told the resident was unresponsive. The resident was not checked frequently and it was several hours between the last time the resident was able to respond and when the resident was sent to the hospital. Witness 5 indicated they were told the resident refused to go to the hospital. Witness 5 stated family would have easily been able to get the resident to go to the hospital but they were not informed of the fever. Witness 5 further indicated she doubted the resident could make a proper decision with a fever of a 105 in the first place. Interview on 11/10/15 at 11:38 am Witness 6 (Family) indicated the resident developed an extremely high fever of 105 degrees. The facility did not notify them of the fever or that the resident was unresponsive until an hour after the resident was already at the hospital. Witness 6 stated she was told the resident refused to go to the hospital but she would have been able to convince the resident to go. Witness 6 indicated the resident had refused the hospital in the past but she was able to convince her/him to go. Witness 6 further indicated when she was told the resident was found unresponsive she was told it had been a few hours since the resident was last checked. Witness 6 believed the resident's death could have been prevented if she/he had been watched closer and made it to the hospital sooner, the resident was only [AGE] years old. Interview on 11/16/15 at 1:25 pm Witness 1 (Former Facility RN) indicated the resident was alert, oriented and directed her/his own care. On 3/25/15 the resident's temperature was high and continued to increase throughout the evening with a high of 105 degrees. Witness 1 tried to get the resident to go to the hospital but she/he refused multiple times. Witness 1 additionally had other nurses and CNAs attempt to convince the resident without success. The resident refused to have her/his family called as well. The resident was coherent and conversive throughout the evening even with the temperature. Witness 1 stated she contacted paramedics in a hope the resident would agree to go to the hospital without success. Witness 1 stated she believed the resident's death maybe could have been prevented if (she/he) would have gone to the hospital sooner. The resident was monitored frequently throughout the night at around 4:00 or 5:00 am her/his temperature was normal. The resident had received a hefty dose of antibiotic earlier in the night which likely helped with the temperature. Witness 1 indicated a temperature that high does not just go away. She reported to the oncoming shift what had occurred and to watch the resident closely. Witness 1 further indicated she made it clear to the next nurse the resident needed to go to the hospital for evaluation and should be reapproached frequently to gain agreement. The resident needed to be checked on often to ensure the temperature did not return and ensure vital signs were stable. Interview on 11/16/15 at 11:50 am Witness 2 (Former Facility RN) indicated he was told in report the resident had very high fever and refused transport to the hospital. He stated the assigned CNA checked the resident's vitals throughout the shift; he believes every 30 minutes or so. A few hours into the shift the resident was unresponsive and was sent to the hospital. Witness 2 stated he did not have any verbal interactions or discussions about a hospital evaluation with the resident on 3/26/15. He did not see or evaluate the resident on 3/26/15, until the resident was unresponsive. Interview on 11/18/15 at 2:40 pm Staff 13 (CNA) indicated the resident was normally very easy to wake up, alert, directed her/his own care. She received report at the start of the shift regarding the resident's high fever and refusals to go to the hospital. Staff 13 was told the resident needed close monitoring and to be checked out by the hospital. Staff 13 went to do her vitals around 6:45 am, the shift started at 6:00 am. The resident's vitals were not within in her/his normal limits and the resident was not responsive. Staff 13 stated the resident was breathing but would not wake up or respond to her when normally the resident was very easy to wake. After a few attempts to wake the resident Staff 13 reported to the nurse; the nurse went down little bit later and tried to wake but no luck. Staff 13 further indicated the resident was taken to the hospital sometime after breakfast. She did not go back to check on the resident again once the nurse took over. Staff 13 stated she did not see the resident or interact with her/him on 3/26/15 before she went to do her first rounds and vitals near 7:00 am. Interview on 11/18/15 at 3:15 pm Witness 4 (Former Regional Nurse Consultant) indicated he was acting DNS on 3/25/15 and 3/26/15. He was contacted by the nurse on 3/25/15 and told of the resident's high fever and refusals to go to the hospital. Witness 4 stated he was told the resident was alert, oriented, verbal and very clear she/he did not want to go to the hospital. The staff called EMTs but the resident still refused. The staff knew the resident was risking her/his life but couldn't get her/him to the hospital. Witness 4 received a phone call early in the morning on 3/26/15 not long after change of shift, 6:00 am or 7:00 am, and was told the resident was unresponsive. Witness 4 could not speak to the NNs which indicated a 10:00 am departure for the resident, he could not imagine the resident waited at the facility for hours before going to the hospital. The hospital was only a mile from the facility. Interview on 11/18/15 at 3:15 pm Witness 3 (Former Facility RN) indicated on 3/25/15 she discovered a sticky note that mentioned cherry red inflammation on the leg and a high temperature. She did not recall the specific temperature at this time but it warranted an immediate physician contact not a sticky note. There was no information in the resident's progress notes about any issue with thigh redness. Witness 3 stated the resident had a recent history of [MEDICAL CONDITION] as well as a long term unstageable wound with possible bone infection. The resident was at high risk for complications from infections so any infection needed to be responded to promptly. Witness 3 instructed the assigned nurse and the resident's RNCM to contact the resident's physician immediately for orders. Witness 3 was told the physician was contacted, but she discovered only a fax was sent, as a result the physician did not respond right away. Witness 3 was in the building around 9:00 am or so on 3/26/15 but not directly involved with the resident. Witness 3 received reports about the temperature, a lack of monitoring of the resident and staff concerns. Interview on 11/10/15 at 3:15 pm Staff 1 (Administrator) and Staff 2 (DNS) were not employees of the facility at the time of the resident's change in condition. Staff 1 and Staff 2 had no additional information or documentation to provide. b. A physician's orders [REDACTED]. The resident's March 2015 MAR showed the 3/26/15 [MEDICATION NAME] 8:00 am dose was not administered as ordered. The resident discharged to the hospital due to unresponsiveness at 10:00 am. Interview on 11/10/15 at 3:15 pm Staff 2 (DNS) had no additional information regarding the missed medication. 2. Resident 4 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. a. Skilled Nursing Facility Transfer Orders dated 4/1/15 showed an order for [REDACTED]. [MEDICATION NAME] is a non-steroidal anti-[MEDICAL CONDITION] drug used to treat mild to moderate pain. The resident's April 2015 TAR reflected application of [MEDICATION NAME] ointment to both knees four times a day. The treatment was not documented as completed on 33 occasions. b. Skilled Nursing Facility Transfer Orders dated 4/1/15 showed an order for [REDACTED]. The resident's April 2015 TAR reflected the order but the treatment was not documented as completed on 15 occasions. A new order was received on 4/7/15 and noted on the April 2015 TAR for [MEDICATION NAME] to be applied to the pannus, under the breasts and to the groin twice a day. The treatment was not documented as completed on seven occasions. c. A signed fax dated 4/9/15 indicated the resident was to receive Miracle Mouthwash, swish and swallow every four hours. The resident's April 2015 MAR did not reflect the new order until 4/13/15. d. Hospital emergency room discharge orders dated 4/10/15 indicated A & D ointment was to be applied daily to the resident's lip [MEDICAL CONDITION]. The order was not reflected on the April 2015 MAR. e. An order dated 4/7/15 indicated Iodine swab to the Left foot, 2nd digit blackened toenail every day. The April 2015 TAR reflected the Iodine order but the treatment was not documented as completed on three occasions. f. The facility bowel care protocol indicated: residents who did not have a bowel movement in three days would receive Milk of Magnesia (MOM) at bedtime. If no bowel movement by the following day shift (the fourth day) a [MEDICATION NAME] suppository is given. If a resident continued without bowel movements a Fleets enema would be given during evening shift of the fourth day. Residents who are noted as having small bowel movements will be assessed for constipation. If the resident exceeds for days without a bowel movement the physician will be notified for further orders. Review of the resident's April 2015 bowel records showed the resident had no bowel movement from 4/4/15 through 4/7/15. The resident was noted to have two small bowel movements on 4/8/15, no bowel movement on 4/9/15 and 4/10/15. The April 2015 MAR and TAR showed the resident received no suppository in April 2015. The resident's MAR showed MOM was given on 4/1/15 and 4/9/15. NNs dated 4/1/15 through 4/10/15 showed no assessment of the resident for constipation. The resident was sent to the hospital on [DATE] for abdominal and right sided pain and coccyx ulcer evaluation. The resident returned with a new [DIAGNOSES REDACTED]. An emergency department encounter note dated 4/10/15 indicated abdominal pain seemed to result from constipation and a stimulatory laxative would be added to the resident's medication profile. g. A fax to the physician was sent on 4/1/15 which indicated the resident's was a new admission and requested multiple orders for skin treatment related to yeast rashes, blackened toenail and tip of left foot 2nd toe, a non-blanchable purple area to the right buttocks near coccyx and a referral to a wound care specialist. Review of NNs dated 4/1/15 through 4/6/15 showed no response from the physician, no new orders from the requested items on admission and no follow up with the physician regarding the original order requests. Interview on 11/10/15 at 4:10 pm Staff 2 (DNS) indicated she had no additional information to provide regarding any of the missing documentation or incomplete orders.

Based on interview and record review it was determined the facility failed to ensure a pressure ulcer was properly assessed, monitored and treated to prevent worsening of the ulcer for 1 of 3 sampled residents (#4) reviewed for pressure ulcers. Resident 4's wound significantly worsened with minimal expectation for healing and the resident was hospitalized . Findings include: A public complaint was received on 9/15/15 which indicated the resident developed a pressure ulcer that was not properly cared for. Witness 7 (Complainant) stated she was concerned the facility did not turn, treat or care for the resident's wound. Resident 4 was admitted to the facility in April 2015 with [DIAGNOSES REDACTED]. Hospital Emergency Department notes and a Hospital History and Physical dated 3/30/15 indicated the resident was found down by assisted living facility staff and was unable to speak. The resident had right sided face and arm weakness. The resident's skin was noted with no significant rashes. The resident was alert but unable to speak, able to shake/nod head for yes/no. A Hospital Discharge Summary dated 4/1/15 indicated the resident was admitted due to right sided weakness with likely stroke. The resident's physical exam contained no information regarding any skin wounds or ulcers. The resident's extremities were noted to have no [MEDICAL CONDITION]. Skilled Nursing Facility Transfer Orders dated 4/1/15 indicated the resident had [MEDICAL CONDITION] of the toe of the left foot and an unrepaired right [MEDICAL CONDITION]. Noted in the section labeled Wound/Skin Care was: follow current recommendations of the wound team for treatment. Follow standard nursing protocols for wound care. physician's orders [REDACTED]. The resident's Admission Nursing Database dated 4/1/15 indicated the resident required the assistance of 1-2 two staff for all ADL care. The resident was noted as alert with right sided flaccidity status [REDACTED]. The 4/1/15 admission nursing assessment indicated the resident had actual skin impairment. The resident's skin conditions were documented as 17 different individual areas which included the following: -1.3 cm x 2.0 cm non-blanchable, purple area on the right buttocks near the coccyx -2.7 cm x 2.4 cm redness of the left foot on second toe, surrounding 0.7 cm x 0.5 cm blackened thick scab -1.4 cm x 1.6 cm blackened toenail and tip of the toe -bilateral heels soft but blanchable A fax to the physician was sent on 4/1/15 at 9:18 pm which indicated the resident was a new admission and orders were requested for [MEDICATION NAME] cream to yeast areas under the breasts, abdomen and groin; Iodine swab every day to blackened areas to the toes on the left foot; and no sting barrier film every day to a non blanchable purple area on the buttocks and a referral to the hospital wound care specialist. No response was received from the physician regarding the requested orders until 4/7/15. There was no documentation in the resident's record to indicate any followup was completed between 4/1/15 and 4/7/15. physician's orders [REDACTED]. The resident's In Room Care Plan dated 4/3/15 indicated the resident required two person extensive assistance for transfers and one person extensive assistance for bed mobility. The resident was noted to be at moderate risk for skin breakdown and it was noted wound care per protocol. The resident's Preliminary Care Plan dated 4/3/15 indicated multiple areas of actual skin breakdown. No other information regarding the resident's skin was noted. The resident's care plan dated 4/9/15 contained no information regarding the resident's multiple skin issues, skin breakdown risk or interventions to help maintain the resident's skin. Nurse's Notes (NNs) dated 4/1/15 through 4/9/15 indicated the resident was alert and oriented with possible confusion. The resident was difficult to understand but answered with one word responses appropriately a majority of the time. The resident remained in bed most of the day and pain appeared to be well controlled with current narcotic medications. On 4/4/15 it was noted the sore on the coccyx area was intact with no drainage, [MEDICATION NAME] (ointment) was applied per orders. On 4/5/15 it was noted the resident had an open sore to the right hip area. The area was cleaned and ointment and dressing were applied. The site on the coccyx was darkened in color, skin intact no drainage; [MEDICATION NAME] was applied and left open to the air. There was no additional documentation regarding the resident's skin condition or interventions in place. NNs dated 4/10/15 indicated the resident refused to eat, complained of increased pain even after medicated for pain. The dressing to the resident's coccyx was changed and the resident was turned every two hours. At 8:00 pm the resident returned from the hospital with orders to inspect sacral pressure sore, cleanse and change dressing daily. Wound check to left toe every three days and daily A&D ointment to lip [MEDICAL CONDITION]. There was no additional information regarding the specifics of the pressure sore. Hospital Emergency Department notes dated 4/10/15 indicated the resident had increased right sided and abdominal pain. The resident had many areas of skin breakdown, sides of mouth, neck, inguinal folds and under breasts are reddening .also has 3 areas bandaged on (her/his) right hip and coccyx. The Emergency Department notes further indicated the resident's abdominal pain seemed to result from constipation with laxatives added to medication profile. The sacral decubitus ulcer was concerning and required daily wound care and dressings. NNs dated 4/11/15 indicated the pressure sore on the coccyx was now open with drainage present. The area was cleaned, treated per orders and the dressing was changed. There was no other information noted regarding specifics of the pressure sore. NNs dated 4/12/15 indicated dressing changed to the coccyx, resident tolerated well. The dark area (eschar) appeared smaller and was open with drainage present. The dressing on the resident's hip was replaced, area remained red with slight drainage. NNs dated 4/13/15 indicated the resident's physician was in and requested transport of the resident to the hospital. The resident's family had stayed over night due to a fear of leaving the resident and belief the resident was not getting properly taken care of. The resident was noted to have increased pain when moving; the scheduled pain medication did not appear to help with the resident's pain. The resident was noted to be cooperative with cares and allowed staff to turn her/him every two hours. A Hospital History and Physical dated 4/13/15 indicated the resident was admitted for comfort care measures related to multiple medical problems and deterioration at the nursing facility. The resident was noted to have a 5.0 cm decubitus ulcer of the sacral region noted as a stage 3 with necrotic tissue. The corners of the resident's mouth were noted with severe inflammation, cracking and chapping. A red rash was noted on the right side of the resident's neck with sharp borders consistent with a fungal infection. There was a significant amount of macerated red skin in the folds of her/his breasts and also her/his pannus. Physician's Progress Notes dated 4/14/15 indicated the resident had a rapidly enlarging, foul smelling and necrotic ulcer. The resident had severe pain which could be related in part to the resident's previous stroke, pressure ulcer and a [MEDICAL CONDITION]. The resident was admitted to hospice care for pain control and comfort. The resident later discharged home with hospice and passed away. The resident's April 2015 TAR reflected the following orders/treatments: -0.7 cm x 0.5 cm blackened scab surrounded by 2.7 cm x 2.4 cm redness on the left foot, second toe. Cleanse with iodine swab and let air dry every day. The order was dated 4/1/15. The treatment was not provided as ordered on nine occasions. -A second order for an iodine swab to the left foot, second digit blackened toe nail every day dated 4/7/15 was noted on the TAR. The treatment was not provided as ordered on three occasions between 4/7/15 and 4/12/15. -1.3 cm x 2.0 cm non-blanchable purple area on the right buttocks near coccyx. Apply no sting barrier film every day. The order had no date. The treatment was documented as completed on three occasions between 4/1/15 and 4/12/15. -A second order for an iodine swab to the right buttock every day and no sting barrier film dated 4/7/15 was noted on the TAR. The no sting barrier was documented as completed on one occasion and the iodine swab was documented as completed three times between 4/7/15 and 4/12/15. -Bilateral heels soft but blanchable. Apply no sting barrier film every day. The order had no date. The treatment was documented as completed one time between 4/1/15 and 4/12/15. -Weekly skin checks were to be completed once a day on Sunday with an order date of 4/1/15. No weekly skin checks were documented. The resident's record contained no pressure related skin tracking sheets or non pressure related skin tracking sheets for any of the resident's skin issues. There was no ongoing documentation of the wounds size, depth, appearance, odor or drainage noted in the record. Interview on 11/9/15 at 12:15 pm Witness 7 (Complainant) stated as far as she was aware the resident had no wounds to her/his bottom when she/he left the hospital and was admitted to the facility. The resident was only at the facility a week or so before Witness 7 discovered the resident had a pressure ulcer on her/his bottom and back. The resident seemed very painful without relief. Witness 7 helped on several occasions to turn the resident because staff were not doing it. The resident did not have an air mattress on the bed and care was very inconsistent. The resident's family was there daily all day and evening long and the staff rarely came in to turn or provide care. Witness 7 was taken aside by an unknown facility staff and told about the resident's wound. The staff member additionally stated the resident was not being cared for and the facility was short staffed. Witness 7 stated they immediately had the resident taken to the hospital for evaluation. The resident additionally had yeast sores in her/his mouth that had spread down the neck and outside the mouth. The resident was not eating due to the mouth pain as well. Witness 7 stated the resident returned to the facility after the emergency roiagnom on [DATE]. The resident's primary care physician (Witness 12) came to see the resident on 4/13/15 and had the resident sent back to the hospital due to the condition of the wound. Witness 7 was told the wound ate inwards and was not something the resident could recover from. Witness 7 indicated prior to the hospital visit on 4/10/15 she nor family members saw any dressing changes being completed. Four interview attempts were made between 11/17/15 and 12/7/15 to reach Witness 11 (Former Facility RN) with three voicemails left. On 11/28/15 at 9:34 am Witness 11 answered and stated she would return my call in the afternoon after some rest from a long shift. No return call was received. Interview on 11/10/15 at 2:27 pm Witness 8 (Family) indicated prior to 4/13/15 she saw only pieces of the wound when she would help turn the resident for toileting care. The wound was very large went all across the resident's bottom and up to lower back. On 4/13/15 Witness 8 saw the wound which was over the tailbone, top of the resident's right butt cheek and was an irregular shape. The area was open with black skin and very foul smelling with skin peeling off. Witness 8 stated the resident's bottom did not have any dressing until 4/10/15 when they took the resident to the hospital. The first few days of the resident's stay the staff were barely in the room and did not consistently turn the resident. The resident did not have an air bed or any other device to help her/his skin while in bed. The resident did not get out of bed too often due to pain. Witness 8 stated they were told by the physician the wound was not a recovery situation anymore but comfort was the only goal. Witness 8 stated during the toileting care that was provided by staff the family usually stepped out to allow privacy; so they did not see the resident's bottom before they were told something was wrong on 4/10/15. The facility did not tell them anything prior to 4/10/15. Witness 8 stated a family member was at the facility all day and into the evening prior to the discovery of the wound and stayed 24/7 after that due to a fear the resident would receive no care. Interview on 11/13/15 at 2:10 pm Staff 6 (RN) indicated she did not remember the resident but was the admitting nurse. Staff 6 stated with new admissions she would get the nursing assessment done as a priority. The completion of TARs and skin sheets would be completed next or passed to the next shift depending on how busy she was. The RNCM would then look at the assessments when back in the facility and take any additional actions. Staff 6 stated at the time there was some back-and-forth on who was responsible for completing skin sheets, but she could not remember who should have completed at that time. Interview on 11/10/15 at 2:00 pm Staff 10 (RNCM) stated at the time the resident was at the facility she was a floor nurse not the RNCM. Staff 10 indicated she did not remember the resident. Staff 10 stated there should be information on the TAR related to each skin issue whether treatment required or just monitoring. Additionally, there should be skin sheets completed for all skin issues both pressure and non pressure related. Staff 10 reviewed the resident's record and could locate no additional information on the treatments the resident received and no skin sheets were located. Interview on 11/16/15 at 3:15 pm Staff 4 (RN) stated he did not remember the resident. Staff 4 indicated for resident's with skin issues the skin sheets are normally completed within 24 hours of admission. Staff 4 stated whatever he documented in his NNs was all he could speak to because he did not remember the resident. Interview on 11/17/15 at 11:05 am Staff 15 (CNA) stated the resident was very painful and they tried to limit movements as much as possible. Staff 15 indicated she would wait to turn or change the resident until it coincided with the nurses' needs to help minimize the movements. The resident declined pretty fast. Staff 15 stated the resident came with a few skin issues but ended up with some really bad bed sores on her/his bottom. The resident was dependent for care, the staff assisted with all the movements. Staff 15 further indicated they would use pillows to position the resident but the resident could sometimes get back on to her/his back. Interview on 11/18/15 at 2:40 pm Staff 13 (CNA) indicated she was never assigned to the resident but she did assist on several occasions. The resident was in a lot of pain and could not do much on her/his own; the resident was very weak. Staff 13 stated the staff were hesitant to move the resident because of the pain. She never saw the resident make enough movements to get out of whatever position she/he was placed in. In an interview on 11/11/15 at 1:53 pm Witness 12 (Physician) indicated she was the resident's physician prior to admission to the facility and while at the facility. The first time Witness 12 received any information about a wound was an order request on 4/7/15. The orders requested did not indicate the resident had an actual wound present; but requested orders that commonly would be for preventative treatment. Witness 12 stated the family contacted her on 4/10/15 with their concerns and she received notes from the resident's emergency room visit. Witness 12 saw the resident on 4/13/15 and was shocked to see the resident writhing in pain and had a giant decubitis on the sacrum. Witness 12 stated the resident's severity of skin issues were not properly communicated to her prior to her examination of the resident on 4/13/15. Witness 12 indicated the resident absolutely could have recovered from the wound if the area was properly addressed early on. The pressure ulcer would require daily intervention and consistent positioning, a diligent team approach and time would be needed. Interview on 11/10/15 at 4:10 pm Staff 2 (DNS) indicated she was not at the facility when the resident was present. Staff 2 stated there were skin grids/skin sheets for pressure and non pressure related skin issues. The resident should have had initialed and dated orders for all skin issues that required treatment and/or monitoring on the TAR. A skin sheet should have been completed for each of the areas as well. Staff 2 could not locate any additional information related to the resident's treatments, missing orders or missing skin sheets.

1. Based on interviews and record review it was determined the physician's orders for bowel care were not followed and the resident's bowel movements were not monitored for 1 of 3 sampled residents (#1). Resident 1 required hospitalization for a bowel obstruction. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/9/13 physician's orders indicated the resident was to receive MOM 30 cc once a day PRN, [MEDICATION NAME] Laxative Suppository twice a day PRN and a Fleet Enema once a day PRN for bowel care. The facility's December 2010 bowel care protocol indicated the facility's policy was to monitor and provide interventions to ensure routine bowel elimination by residents of the facility. Physician's orders were to be obtained for implementation of the facility bowel care protocol. The facility bowel care procedure indicated the bowel records were to be monitored on a daily basis, residents who did not have a bowel movements in three days (9 shifts) were to be given Milk of Magnesia (MOM) at HS (hour of sleep); if no bowel movement by the following morning (the fourth day, 10 shifts) a [MEDICATION NAME] suppository was to be given. If resident continued without bowel movement, a Fleets enema was to be given the afternoon shift of the fourth day (12 th shift); residents who were noted for having small bowel movements were to be assessed for constipation; residents who were having diarrhea and/or loose stools were to be assessed for constipation/fecal impaction and if the resident exceeded four days without a bowel movement the physician was to be notified for further orders. The Vitals Report indicated the resident had a medium bowel movement on 1/22/13 at 4:29 am. Three days later the resident had a small bowel movement on 1/25/13 at 4:35 am. The January 2013 MAR indicated [REDACTED]. The Vitals Report indicated the resident did not have a bowel movement from 1/26/13 through 1/31/13, a period of five days. The January 2013 MAR indicated [REDACTED]. The documentation indicated no other bowel care medications were provided to the resident The 1/31/13 Progress Notes written at 8:40 pm indicated the resident's appetite was poor, abdomen firm, "distension" and tender. The documentation indicated the resident refused bowel care and stated she/he wanted to wait for MOM to work. The resident stated she/he was passing gas. The 2/1/13 Progress Notes written at 6:03 am indicated the resident's abdomen was very distended and firm to touch. The nursing staff encouraged the resident to accept bowel care and the resident agreed to accept a suppository. The documentation indicated the resident was given a suppository and it was not effective. The nurse offered the resident an enema and to remove the stool digitally. The resident declined the offer of additional bowel care on three occasions. The 2/1/13 Progress Notes written at 10:31 am revealed the physician was notified of the resident's condition and ordered a half a bottle of magnesium [MEDICATION NAME] to be administered immediately and the other ? of the bottle to administered in eight hours. The 2/1/13 Progress Notes indicated a PRN enema was administered with no effect. The 2/1/13 Progress Notes indicated the resident had a bout of emesis and the physician was called at 1:09 pm. The Vitals Report indicated the resident had a large bowel movement on 2/1/13 at 3:20 pm. This represented a total of 10 days or 29 shifts since the resident had a bowel movement larger than a small. There was no documentation the physician was contacted prior to 2/1/13 to inform the physician the resident did not have a bowel movement. The 2/1/13 Progress Notes written at 11:55 pm indicated the resident was confused, had an altered level of consciousness and her/his speech was slurred. The resident complained of dizziness, nausea headache and shortness of breath. The resident was unable to take deep breaths due to pain. The resident's abdomen was distended and the resident had two bouts of large liquid emesis. The physician ordered the resident be evaluated at the local hospital emergency department. The 2/2/13 local hospital report indicated the resident had stool impaction causing partial bowel obstruction. The physician's impression was "stool impaction in the colon, quite massive in scale causing a small bowel obstruction intermittently...." An interview on 2/20/13 at 12:00 pm with Staff 1 (DNS) revealed the facility's bowel care protocol was current and had not been followed for Resident 1. Staff 1 stated after the resident's hospitalization , she inserviced the staff regarding the bowel care protocol and the staff monitored the bowel management sheets daily. An interview on 2/21/13 at 8:02 am with Staff 2 (RNCM) revealed the facility had a bowel protocol and verified the bowel care protocol had not been followed. An interview on 2/21/13 at 9:43 am with Staff 3 (CNA) revealed CNAs documented the bowel movements for each resident in the computer system. Staff 3 stated the CMAs and nurses were responsible to evaluate when bowel care medications were to be provided. 2. Based on interviews and record review it was determined the facility failed to obtain a physician's order for wound care and provided wound care without a physician's order; obtain clarification from the physician before reinstituting wound care orders in place prior to hospitalization ; arrange for the resident to be seen by a wound care specialist for an arterial ulcer prior to discharge for 1 of 3 sampled residents (#2). The resident's ulcer increased in size. Findings include: Resident 2 was initially admitted to the facility on [DATE]. The resident was readmitted to the facility on [DATE] from the local hospital with [DIAGNOSES REDACTED]. The local hospital physician's orders indicated the resident's wound was to be treated according to the wound care orders dated 12/26/12. There was no documentation of wound care orders in the resident's chart. The ADL Flowsheet dated 12/28/12 to 1/27/13 included documentation to indicate the resident's right lower leg had a laceration measuring 6 cm by 3 cm with a depth of 0.4 cm. Additionally, the resident had two open areas on the right calf; one area measured 1.2 cm by 1.8 cm with a depth of 0.4 cm and the other area was 2.2 cm by 0.8 cm with a depth of 0.2 cm. The ADL Flowsheet indicated the skin treatment to be provided was "calcium alginate with ABD pad/ Kerlix or Tagederm" (the dressing forms a gel-like consistency as it absorbs exudate to provide a moist healing environment) and was to be changed daily. The documentation on the ADL Flowsheet indicated the dressings were done daily from 12/28/12 to 12/31/12. Another ADL Flowsheet, dated 12/28/12 to 1/27/13, indicated the resident received the dressings from 1/1/13 through 1/9/13. There was a hand-written note of "Duplicate" on the form and the dressings were not documented as being provided. There was no documentation of a physician's order for the wound dressings provided. The TAR labeled as "other skin flowsheet" (for non-pressure ulcer) dated 1/1/13 through 1/31/13 contained the 12/10/12 (date of physician's order) skin treatment for [REDACTED]." The TAR contained documentation the resident received the treatments once a day from 1/1/13 to 1/27/13. The Skin Grid for "all other" skin problems (Skin Assessment) indicated the resident's skin condition was first identified on 12/28/12 as an open lesion on her/his right shin. The lesion measured 6 cm by 3 cm and was 0.4 cm deep. The wound was assessed weekly and on 1/23/13 measured 5.2 cm by 1.5 cm with 80 percent granulation. The wound bed was described as being pink, yellow and white. The Skin Grid for "all other" skin problems indicated the resident had two open sores on the right calf and first identified on 12/28/12. The measurement for one of the sores was 1.2 cm by 1.8 cm with a depth of 0.2 cm. On 1/10/13 the Skin Grid measured the wound as 3 cm long, 2 cm wide and 0.2 cm depth and was described as a scab. On 1/17/13, the wound measured 3 cm by 3 cm and was described as a scab weeping around the edges. On 1/23/13, the wound measured 3.4 cm by 3.0 cm and was 0.2 cm in depth. The wound bed was described as black, pink and yellow. The appearance was described as being 40 percent necrotic, 50 percent granulation and 10 percent slough. A 1/23/13 Progress Note indicated the resident had an arterial ulcer on posterior right lower extremity and slightly increased in size. There was a request for the physician to assess the ulcers for additional treatment orders. The 1/23/13 Residents (sic) Record of (physician's) Office Visit form indicated the physician's plan was for "Pt (patient) needs wound care nurse to see her, debride wounds and advise specific care for her/him. This is for ant. (anterior) and post (posterior) wounds...." The 1/24/13 Residents Record of Office Visit form indicated the physician's assessment was the "R (right) ankle worsening...skin ulcer R) (right) the resident had been seen by the physician regarding follow up regarding the resident's right ankle/shin. The physician's plan indicated the resident was to be seen by "skin care specialist...." The 1/24/13 Progress Note indicated the physician ordered the resident to be seen by the local wound care specialist. The resident's family member was informed of the importance to follow up with the specialist once the resident was transferred to the new facility. The 1/28/13 Progress Note indicated the resident was discharged to a local facility with a referral made to a local home health provider for nursing/PT/OT. The medication and treatment orders were sent to the local facility the resident transferred to. An interview on 2/21/13 at 11:03 am with Staff 1 (DNS) revealed the resident was not seen by the local wound care RN before she/he was discharged from the facility. Staff 1 was asked why the resident was not seen by a wound care specialist and she stated the wound care specialist the facility used was not available. Staff 1 was asked if the information about the need for the resident to be seen by the local wound care nurse had been relayed to the admitted facility. Staff 1 stated the information was sent along at the time of discharge. An interview with Witness 1 (RN of local facility) on 2/20/13 at 11:45 am revealed the facility had not been informed of the resident's skin condition prior to the discharge. Witness 1 stated the facility did not provide current physician's orders to treat the resident's wounds. On 2/25/13, Witness 1 (RN) was asked to provide the physician's orders the local admitting facility received from the local discharging facility for Resident 2. Witness 1 faxed physician orders for the time period of 12/23/12 through 1/23/13. There was 12/10/12 physician's order for treatment of [REDACTED]. Witness 1 provided the 1/28/13 Progress notes to indicate the resident was admitted to the facility at 10:30 am and the resident had a laceration to the anterior shin and an ulcer to the lateral side of her/his right calf. The 1/28/13 Progress Note written at 4:30 pm indicated the wound assessment completed by Witness 1 (RN) indicated the laceration to the resident's right shin measured 5 cm by 2 cm, wound bed covered in yellow slough, with yellow pus drainage, no odor and the resident had no complaints of pain. The pressure ulcer on her/his right lateral calf measured 4 by 4 cm, wound bed was covered with slough, yellow in color with 1.5 by 1.5 cm necrotic tissue in center of wound. The pressure ulcer was assessed to be unstageable at the time. Both wounds were cleaned with normal saline, antibiotic ointment applied, covered with non-adherent pad, wrapped with gauze, secured with tape. Witness 1 (RN) indicated the local home health agency would be contacted for wound care as the wounds required debridement. On 3/7/13 at 2:00 pm, Staff 11 (Medical Records Director) provided a copy of the 12/26/12 wound care order from the local hospital. On 3/7/12 at 3:30 pm Staff 12 (RNCM) was asked to review the resident's chart and indicated the 12/26/12 wound care orders had not been provided by the hospital on the resident's readmission to the facility. The wound care orders were for the resident's left lower extremity wound and there were no wound care orders in the facility system. Staff 12 stated the charge nurse on readmission and Staff 12 did not identify the resident had wound care orders and there was no contact with the local hospital for the orders. Staff 12 stated he contacted the local hospital on [DATE] and obtained a copy of 12/26/12 wound care orders. Staff 12 was asked to review the resident's ADL Flowsheets dated 12/28/12 to 1/27/13. Staff 12 reviewed the documentation of the measurements and treatment of [REDACTED]. Staff 12 stated it was a normal practice for the staff to handwrite an order on the ADL Flowsheet upon admission/readmission before it was entered into the system by the computer. Staff 12 stated he was unable to locate physician's orders for the skin treatments documented on the ADL Flowsheets. Staff 12 stated on 3/7/13, he interviewed with the nurse who readmitted the resident on 12/28/12. The nurse stated the resident had the dressings in place when she/he was readmitted to the facility. The nurse stated she sent a fax to the physician for an order to continue the treatments. Staff 12 stated he reviewed the facility documentation and could not find a fax or any communication sent to the physician regarding wound treatment orders. On 3/7/13, Staff 12 called the physician's office for a copy of the fax or any communication and the physician's office stated there was no documentation of the wound care treatments requested on 12/28/12. Staff 12 provided a copy of the signed physician's orders for the time period of 1/1/13 to 1/31/13 to include the 12/10/12 and 12/21/12 skin treatment orders. Staff 12 confirmed there was no documentation the facility clarified the physician's order after the resident was readmitted to the facility on [DATE]. Staff 12 confirmed the TAR contained the 12/10/12 and 12/21/12 wound treatment orders and documented the resident received the treatments once a day from 1/1/13 to 1/27/13. .

Based on interview and record review it was determined that the facility failed to proved the necessary supervision for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a left hip fracture. Findings include: Resident 1 was admitted to the facility in late January 2011. Admitting [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-inflammatory agents) for polymyalgia rheumatica and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in lowest position and floor mats on both sides of the bed. Review of the resident's clinical record revealed a history of a fall from her/his wheelchair. The care plan was revised on 6/24/11 and included, "Do not leave the resident alone when up in the W/C (wheelchair)." An IR (Incident Report) on 7/15/11 revealed the resident was placed in a shower chair and taken to the shower area in the bathroom in her/his room by Staff 2, CNA. Staff 2 noticed a puddle of urine just outside the bathroom door. The IR revealed Staff 2 reached for paper towels and placed them on the urine outside of the bathroom and wiped the floor with her foot. Staff 2 reported she heard a thump and found the resident on the floor against the shower wall and on her/his left side. The documented conclusion of the facility investigation related to the incident revealed, "Aide made an error in judgment by turning away to wipe up fluid on the floor when with high risk patient." The IR revealed Staff 4, RN, assessed the resident and the resident was transported to a local hospital ER. Hospital reports revealed the resident had a surgical repair of the left hip fracture on 7/15/11. In interview on 7/26/11 at 11:10 am, Staff 2, stated she was aware the resident was at high risk for falls. A re-enactment of the event was done with Staff 2. She stood in the doorframe of the bathroom and stated it was at that point the resident was no longer in view and not within arms reach. "I was aware I should have kept (her/him) in view and in close contact at all times." In interview on 7/26/11 at 11:25 am, Staff 3, CNA, stated she assisted in the transfer of the resident to the shower chair on 7/15/11. She reported the resident was placed as far back as possible in the shower chair as she/he was such a high fall risk. In interview on 7/26/11 at 11:50 am, Staff 4. RN, stated he was summoned to the resident's room at approximately 10:00 am on 7/15/11. He stated he observed the resident on the floor in the shower. Staff 4 stated the resident's left leg was pronated and a large hematoma of the left hip had formed in approximately 10 minutes. He stated the resident did not complain of any pain. The EMS was activated and the resident was transported to a local hospital ER. He stated, "The aide cleaned up a spill and placed the resident at risk to do so." The 7/21/11 the hospital discharge summary revealed the resident had passed away. The report indicated the resident did well with the hip surgery but in days following the surgery she/he slowly but steadily deteriorated. The report revealed, "The reason for (her/his) expiration is felt to be a combination of (her/his) recent hip fracture, significant dementia, congestive heart failure and possible underlying lung disease." This is a repeat citation that involved Resident 1.

Based on interview and record review it was determined that the facility failed to follow professional standards for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 sustained a left [MEDICAL CONDITION]. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] (6) (d) Follow the care plan as directed by the licensed nurse; (f) Tasks associated with safety; (B) Apply preventive/supportive/protective strategies or devices when working with a person with dementia. Conduct Unbecoming a Nursing Assistant [PHONE NUMBER] (2) (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant. Resident 1 was admitted to the facility in late January 2011 with [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-[MEDICAL CONDITION] agents) for polymyalgia rheumatica and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in lowest position and mats on both sides of the bed. Review of the resident's clinical record revealed a history of falls from her/his wheelchair. The care plan was updated on 6/24/11 and included, "Do not leave the resident alone when in the W/C (wheelchair)." An IR (Incident Report) on 7/15/11 revealed the resident was placed in a shower chair and taken to the shower area in the bathroom in her/his room by Staff 2, CNA. Staff 2 noticed a puddle of urine just outside the bathroom door. The IR revealed Staff 2 reached for paper towels and placed them on the urine and wiped the floor with her foot. Staff 2 reported she heard a thump and noted the resident was against the wall on her/his left side, hit her/his head on the wall and had slid to the floor. The conclusion of the investigation revealed, "Aide made an error in judgment by turning away to wipe up fluid on the floor when with high risk patient." The resident was transported to a local hospital ER and found to have sustained a left [MEDICAL CONDITION]. The hospital reports revealed the resident had a surgical repair of the fracture on 7/15/11. In interview on 7/26/11 at 11:10 am, Staff 2, stated she was aware the resident was at high risk for falls. A re-enactment of the event was done with Staff 2. She stood in the doorframe of the bathroom and stated it was at that point the resident was no longer in view and not within arms reach. "I was aware I should have kept (her/him) in view and in close contact at all times." In interview on 7/26/11 at 11:25 am, Staff 3, CNA, stated she assisted in the transfer of the resident to the shower chair on 7/15/11. She reported the resident was placed as far back as possible in the shower chair as she/he was such a high fall risk. In interview on 7/26/11 at 11:50 am, Staff 4, RN, stated he was summoned to the resident's room at approximately 10:00 am on 7/15/11. He stated he observed the resident on the floor in the shower. Staff 4 stated the resident's left leg was pronated and a large hematoma of the left hip had formed in approximately 10 minutes. He stated the resident did not complain of any pain. The EMS was activated and the resident was transported to a local hospital ER. He stated, "The aide cleaned up a spill and placed the resident at risk to do so." The 7/21/11 hospital discharge summary revealed the resident had passed away. The report revealed, "The reason for (her/his) expiration is felt to be a combination of (her/his) recent [MEDICAL CONDITION], significant dementia, [MEDICAL CONDITION] and possible underlying lung disease." Refer to F 323

Based on interview and record review it was determined that the facility failed to provide the necessary supervision for 1 of 4 sampled residents (#1) who experienced falls. Resident 1 sustained two lacerations of the forehead and a skin tear of the left arm. Resident 1 was treated at the local hospital ER. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-inflammatory agents) and as a result had fragile skin and a tendency to bruise easily. The 5/1/11 Quarterly MDS revealed the resident required extensive assistance to perform ADLs and required a 1-2 person pivot transfer. The assessment included the resident enjoyed sitting in her/his recliner or to lie in bed to relax and watch television. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in the lowest position and mats on both sides of the bed. An IR (Incident Report) revealed on 6/12/11 at 4:35 pm, the resident was found on the floor in her/his room in front of the wheelchair. The resident sustained [REDACTED]. In less than 24 hours a bruise started to form around the resident's right eye. The IR revealed the resident wanted to sit in her/his wheelchair. It was determined she/he leaned forward and fell from the wheelchair. The report included the resident will attempt to self transfer. The care plan was followed but did not include to supervise the resident when she/he was in the wheelchair. The care plan was revised and included to keep the resident in high traffic areas when sitting in the wheelchair. On the exterior of the resident's closet door an orange sign with bold black writing revealed, "Safety-Place in high traffic area." The sign was dated 6/14/11. On 6/24/11 at 9:30 am, an IR revealed the resident was found face down on the floor in her/his room. The resident sustained [REDACTED]. The IR revealed the resident had been in the wheelchair, unattended in her/his room and apparently fell forward onto the floor. The resident was sent to the ER and returned with orders for wound care of the lacerations of the forehead. The care plan was revised to include, "Do not leave resident alone when up in WC." NN revealed the resident complained of a headache and "pain all over" when she/he returned from the ER. The resident required the administration of pain medication. During hourly observations on 6/27/11 the resident was noted to have a bandage on her/his forehead and a large bandage on both forearms. When the bandage of the forehead was removed by staff, two dime size lacerations were noted. Both eyes had periorbital bruising and swelling. Multiple bruises were noted on the resident's arms. The resident had on a short sleeved garment and was not care planned to wear protective sleeves. The resident slept frequently but was easily aroused and would answer yes or no questions appropriately. In interview on 6/27/11 at 11:20 am, Staff 2, CNA, stated the resident was a two person pivot transfer. She stated two staff members performed the transfers as a precaution due to the resident's fall history and tendency to bruise easily. Staff 2 stated the resident did not wear any sleeves to protect her/his arms. The resident had not refused to be in high traffic areas during her care. "(She/he) likes to be in the recliner." In interview on 6/27/11 at 4:00 pm, Staff 1, RNCM, stated the resident had refused at times to be in high traffic areas. There was not an alternate plan to ensure the resident's safety during those times. Staff 1 stated the resident's Haldol (antipsychotic) had been reduced on 5/20/11 and increased confusion and agitation had been noted. In interview on 6/29/11 at 9:20 am, Staff 4, CNA stated she was the resident's caregiver on 6/24/11 when the fall occurred. She stated she was aware the resident was to be in high traffic areas when up in the wheelchair. Staff 4 reported the resident wanted to stay in her/his room and not at the nurse's station. "I wanted to put (her/him) back to bed and I couldn't find anyone to help." She stated she looked for help for 15 minutes. When she could not find assistance she reported she went on a break. Staff 4 stated she told Staff 7, RN that she was going on a break but did not tell anyone the resident was sitting in the wheelchair, in her room, unsupervised. In interview on 6/30/11 at 8:30 am, Staff 4 stated she asked Staff 8, RN to assist her in returning the resident to bed. She stated Staff 8 replied she was too busy to assist her. "I told her I was going on a break." Staff 4 stated she left the resident as it was her time to go on a break. In interview on 6/30/11 at 9:15 am, Staff 8 stated on 6/24/11 she had changed the resident's dressings while she/he was in the wheelchair. She reported during that time Staff 4 was changing the linens on the resident's bed. Staff 8 stated Staff 4 did not ask for assistance to transfer the resident to the bed. "She did not tell me she was going on a break. I had no idea she left the resident alone."

Based on interview and record review it was determined that the facility failed to follow professional standards for 1 of 4 sampled residents (#1) who experienced falls. Resident 1 sustained two lacerations of the forehead and a skin tear of the left arm. Resident 1 was treated at the local hospital ER. Findings include: The Oregon State Board of Nursing (OSBN) Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] (6) (d) Follow the care plan as directed by the licensed nurse; (f) Tasks associated with safety; (B) Apply preventive/supportive/protective strategies or devices when working with a person with dementia. Conduct Unbecoming a Nursing Assistant [PHONE NUMBER] (2) (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's history and physical revealed long term use of steroids and aspirin (both anti-[MEDICAL CONDITION] agents) and as a result had fragile skin and a tendency to bruise easily. The 5/11/11 Quarterly MDS revealed the resident required extensive assistance with ADLs and required a 1-2 person pivot transfer. The resident was assessed at high risk for falls related to a history of multiple falls, cognitive impairment, poor safety awareness and decreased functional status. Care planned interventions included a wheelchair and bed pad alarm, bed in the lowest position and mats on both sides of the bed. An IR (Incident Report) revealed on 6/12/11 at 4:35 pm the resident was found on the floor in her/his room in front of the wheelchair. The report included the resident will attempt to self transfer. The care plan was followed but did not include to supervise the resident when she/he was in the wheelchair. The care plan was revised and included to keep the resident in high traffic areas when sitting in the wheelchair. On the exterior of the resident's closet door an orange sign with bold black writing revealed, "Safety-Place in high traffic area." The sign was dated 6/14/11. On 6/24/11 at 9:30 am, an IR revealed the resident was found face down on the floor in her/his room. The resident sustained [REDACTED]. The IR revealed the resident had been in the wheelchair, unattended in her/his room and apparently fell face forward onto the floor. The resident was transported to a local hospital ER and returned with wound care orders. The care plan was revised to include, "Do not leave resident alone when up in WC." NN revealed the resident complained of a headache and "pain all over" when she/he returned from the ER. The resident required the administration of pain medication. During observations of the resident on 6/27/11 two dime size lacerations of the forehead were noted. Both eyes had periorbital bruising and swelling. Multiple bruises were noted on the resident's arms. In interview on 6/29/11 at 9:20 am, Staff 4, CNA, stated she was the resident's caregiver on 6/24/11 when the fall occurred. She stated she was aware the resident was to be in high traffic areas when up in the wheelchair. Staff 4 reported the resident wanted to stay in her/his room and not at the nurse's station. I wanted to put (her/him) back to bed and I couldn't find anyone to help." She stated she looked for help for 15 minutes. When she could not find assistance she stated she went on a break. Staff 4 stated she told Staff 7, RN that she was going on a break but did not tell anyone the resident was sitting in the wheelchair, in her/his room, unsupervised. In interview on 6/30/11 at 8:30 am, Staff 4 stated she asked Staff 8, RN to assist her in returning the resident to bed. She stated Staff 8 replied she was too busy to assist her. "I told her I was going on a break." Staff 4 stated she left the resident as it was time to go on a break. In interview on 6/30/11 at 9:15 am, Staff 8 stated on 6/24/11 she had changed the resident's dressings while she/he was in the wheelchair. She reported during that time Staff 4 was changing the linens on the resident's bed. Staff 8 stated Staff 4 did not ask for assistance to transfer the resident to bed. "She did not tell me she was going on a break. I had no idea she left the resident alone." Refer to F-323