Every finding on record at Keizer Nursing and Rehabilitation

Based on observation and interview the facility failed to ensure resident meals were prepared in a sanitary manner for 1 or 1 kitchens reviewed for sanitation. This placed residents at risk for foodborne illnesses. Findings include:On 12/16/25 at 10:01 AM, Staff 7 (Cook) stated the residents were given meal tickets to complete each day and those tickets were tallied and utilized by the facility during meal planning and plating. During observations on 12/16/25 at 12:10 PM, Staff 7 picked up resident tickets with gloved hands, then picked up bread rolls and placed them on lunch plates with the same gloved hands. This pattern repeated throughout the meal service. During observations on 12/16/25 at 12:20 PM, Staff 9 (Dietary Aide) picked up meal tickets and then touched resident plates, silverware, desserts, and condiments for service to residents. On 12/16/25 at 12:42 PM, Staff 7, 8 (Dietary Manager), and 9 acknowledged meal tickets were an unclean surface. Staff 8 stated she previously had concerns about the use of resident-completed meal tickets on the tray line. On 12/26/25 at 1:30 PM, Staff 1 (Administrator) stated he agreed resident-completed meal tickets were an unclean surface and food, dishes and other clean surfaces should not be touched after touching an unclean meal ticket.

Based on observation and interview it was determined the facility failed to ensure the resident food refrigerator was free of outdated food items for 1 of 1 refrigerator. This placed residents at risk for consuming spoiled food. Findings include: On 12/16/25 at 12:58 PM, the resident food refrigerator was observed with food containers dated 11/9/25 and 11/20/25, take-out food dated 11/15/25 and 11/29/25, and a jar of soup with no date.The freezer section was observed with two opened and partially used ice cream containers with no open date. Some of the containers did not identify which resident room the food belonged to. Staff 8 (Dietary Manager) stated it was her responsibility to monitor foods in the resident refrigerator and she had not done it recently. She stated foods should be removed after 3 days unless unopened and unexpired and marked with resident room numbers. Staff 2 (DNS) stated staff should be marking foods with the room number of the resident.

Based on interview and record reviewed it was determined the facility failed to follow physician orders for 1 of 2 residents (# 302) reviewed for medication. This placed residents at risk for unmet needs. Findings include:Resident 302 was admitted to the facility in 8/2025 with diagnoses including spinal stenosis, (a condition in which the spine becomes too narrow and presses on the nerves) and pain. An 8/25/25 physician's order instructed staff to administer tizanidine HCI 2 mg tablets three times a day for muscle spasms. Another 8/25/25 physician's order instructed staff to administer tizanidine HCI 2 mg tablets every eight hours PRN for muscle spasms. A 9/26/25 Significant Change in Status MDS indicated Resident 302 was cognitively intact. A 10/22/25 physician order indicated staff were to administer oxycodone 5 mg every four hours PRN for pain or discomfort. The 11/11/25 MAR indicated at 10:30 PM Resident 302's tizanidine was not administered and directed staff to see progress note. The 11/12/25 at 1:08 AM, progress note indicated the facility was out of Resident 302's tizanidine medication. The 11/12/25 MAR indicated at 9:30 AM indicated tizanidine was not available. The 11/12/25 at 10:43 AM, progress noted indicated staff notified the pharmacy and requested Resident 302's tizanidine. The 11/12/25 MAR indicated Resident 302's pain was a 10 out of 10 and her/his oxycodone was ineffective. A 11/12/25 at 11:45 AM, progress note indicated Resident 302 had break through pain due to tizanidine not being available. A 11/12/25 physician order indicated staff were to administer oxycodone 5 mg tablet PRN for pain until tizanidine arrived. On 12/4/25 a public complaint was received which alleged the facility failed to administer residents' medications as ordered. On 12/16/25 at 9:29 AM, Resident 302 stated several weeks prior, the facility did not order her/his muscle relaxant in a timely manner, resulting in the medication running out. Resident 302 reported having increased pain during that time. Resident 302 further stated when her/his medication are not given on time she/he becomes a rolling mess. On 12/16/25 at 10:34 AM, Staff 3 (Agency RN) confirmed Resident 302's muscle relaxant was not ordered in a timely manner and was unavailable. Staff 3 stated Resident 302 had increased pain, and she contacted the physician and requested a one-time authorization to increase her/his oxycodone for breakthrough pain. Staff 3 also contacted the pharmacy to refill the resident's muscle relaxant. On 12/16/25 at 2:40 PM, Staff 4 (LPN) confirmed Resident 302's medication was not ordered in a timely manner. Staff 4 reported there had been ongoing issues with medications not being ordered on time, particularly non-narcotic medications. Staff 4 explained that nurses were responsible for reordering medications timely, but she was unsure who monitored to ensure this occurred. Staff 4 further stated agency staff were also expected to reorder medications timely but often did not. On 12/16/25 at 3:30 PM, Staff 5 (Agency LPN) stated 11/11/25 was her first day working at the facility. Staff 5 stated she believed Resident 302's muscle relaxant had already been ordered and she did not check with the pharmacy. She became aware later the resident had not received her/his muscle relaxant, and she/he was in a lot of pain. Staff 5 stated both the resident and her/his family were upset about the situation. On 12/17/25 at 11:24 AM, Staff 6 (Pharmacist) confirmed Resident 302 had two separate orders for tizanidine: a scheduled order for 2 mg three times a day for muscle spasms, and a PRN order for 2 mg every eight hours for muscle spasms. Staff 6 reviewed the facility's refill record and confirmed on 10/24/25, a refill was requested for the resident. Staff 6 stated the facility called again on 11/12/25 and requested the refill. Staff 6 confirmed the resident ran out of medication before the facility placed the refill request. On 12/17/25 at 12:12 PM, Staff 2 (DNS) confirmed staff were expected to reorder medications timely.

Based on observation interview and record review it was determined the facility failed to ensure a resident with history of trauma received trauma informed care for 1 of 1 sample resident (#23) reviewed for mood and behavior. This placed residents at risk for lack of psychosocial needs and a potential decline in their quality of life. Findings include: Resident 23 was admitted to the facility in 2024 with diagnoses including altered mental status with auditory hallucinations, anxiety, and PTSD (Post-Traumatic Stress Disorder). The 3/29/24 Preadmission-Admission Screening/Resident Review (PASRR) Level I, indicated serious mental illness. Sections II and III of the form were not completed, and no documentation was provided to support further assessment. The 4/9/25 Resident Review Screening for Mental Illness confirmed the need for specialized services. Part B of the form was not completed within the required seven-day timeframe, and there was no documentation of staff follow-up regarding the referral. The 4/14/25 care plan revealed increased hallucinations, delusions and mistrust towards caregivers. The 4/21/25 care plan indicated PTSD but did not document the resident's trauma history or identify individual triggers. Interventions noted a psychiatric consult. The care plan did not include person-centered details related to her/his triggers. The 4/22/25 Psychiatric Admission Note indicated Resident 23 had a complex psychiatric history including depression, anxiety, chronic pain syndrome, cognitive communication deficits, and a past history of auditory hallucinations. Resident 23 had a history of sexual abuse and traumatic physical injury. The 4/27/25 Significant Change in Status MDS revealed Resident 23's BIMS score was seven which indicated severe cognitive impairment. The cognitive, behavioral, mood state, and psychosocial well-being CAAs did not reference or reflect trauma informed care planning. The 4/29/25 Social Services Psychosocial Evaluation did not document the resident's trauma history or demonstrate a psychosocial assessment which incorporated PTSD related concerns. There was no evidence of a trauma informed, person centered care plan. On 5/7/25 at 10:36 AM, Staff 14 (CNA) stated Resident 23 would spontaneously reference past traumas while receiving assistance with personal care a couple times a month. During these episodes, the resident reportedly described being raped by multiple individuals, tied up, and drugged. Staff 14 stated Resident 23 at times appeared to re-experience past events, demonstrating behaviors and making statements such as, you shouldn't be doing this because . On 5/8/25 at 9:51 AM, Staff 6 (RN) reported long-term familiarity with the resident and noted frequent hallucinations and delusions, often triggered by loud noises, unfamiliar staff and lack of sleep. Staff 6 stated Resident 23 consistently expressed the belief others were trying to harm her/him and often became verbally aggressive towards new staff members because she/he did not trust them. Staff 6 stated loud noises, particularly during mealtimes, where especially upsetting for the resident. Staff 6 recalled an incident the previous week in which the resident placed a chair in front of her/his door to prevent staff from coming in her/his room during lunch because she/he was overwhelmed and needed to calm down. On 5/9/25 at 9:36 AM, Staff 1 (Administrator) and Staff 13 (Regional Director of Clinical Services) acknowledged there was not appropriate follow up related to Resident 23's PASRR, along with incomplete documentation. Staff 1 and Staff 13 acknowledged the need for Resident 23 to have triggers identified for her/his PTSD diagnosis to reduce triggers and prevent re-traumatization. Staff 1 and Staff 13 confirmed the care plan and CAAs did not reflect trauma or person-centered care.

Based on observation, interview, and record review it was determined the facility failed to ensure a dependent resident received required assistance with ADLs for 1 of 1 sampled resident (#17) reviewed for mobility and positioning. This placed residents at risk for unmet needs. Findings include: Resident 17 was admitted to the facility in 4/2022 with diagnoses including diabetes and osteoarthritis (a degenerative joint disease). A review of Resident 17's clinical record revealed an order for fingernail care every day shift every Friday, which started on 3/10/23 and was discontinued on 5/25/23. No additional documentation was located for diabetic nail care in Resident 17's clinical record in 4/2025 and 5/2025. A 4/27/25 revised care plan indicated Resident 17 had fragile skin, decreased mobility, and cognitive deficits. Resident 17 was forgetful of events at times and time of day. Interventions included keeping Resident 17's fingernails short and allowing her/him time to think and respond to her/his needs. On 5/6/25 at 12:03 PM and 5/9/25 at 7:50 AM, Resident 17 was observed to have fingernails approximately a half an inch long. Resident 17 stated her/his fingernails were too long and she/he was concerned they would poke into her/his hands and cause a cut as they were jagged. Resident 17 wanted her/his nails trimmed. On 5/9/25 at 7:58 AM, Staff 5 (CNA) was in Resident 17's room and verified her/his fingernails were long. On 5/9/25 at 7:59 AM, Staff 6 (RN) stated she found no documentation regarding Resident 17's nail care in the clinical record. On 5/9/25 at 10:22 AM, Staff 1 (Administrator) stated when a resident was diabetic, nurses were expected to provide nail care and documentation was to be completed in the residents clinical record.

Based on interview and record review it was determined the facility failed to report a fall with major injury to the State Survey Agency within 24 hours for 1 of 1 sampled resident (#25) reviewed for dialysis. This placed residents at risk for neglect. Findings include: The Oregon Department of Human Services Nursing FRI form revised 4/2023 indicated alleged violations (an occurrence not yet investigated and, if verified, could be noncompliance with Federal requirements) not involving abuse or resulting in serious bodily injury must be reported to the state agency no later than 24 hours after the allegation was made. Resident 25 was admitted to the facility in 12/2023 with diagnoses including diabetes and kidney failure. Review of a facility incident report investigation closed 8/5/24 indicated Resident 25 sustained a fall on 7/24/24 while working with physical therapy. The report indicated the resident complained of pain and x-rays of her/his right leg and foot were ordered by the provider. A 7/25/24 progress note indicated the provider ordered Resident 25 be sent out to the hospital for further evaluation. Review of the 7/25/24 hospital report indicated Resident 25's right leg was fractured in multiple places. On 5/8/25 at 10:24 AM, Staff 9 (Former DNS) stated she did not file a FRI regarding Resident 25's fall on 7/24/25. She stated a FRI was not necessary because Resident 25's injuries were not serious bodily injuries as defined on the FRI form, and the FRI form was only needed if serious bodily injury occurred. On 5/9/25 at 12:04 PM, Staff 2 (DNS) acknowledged a FRI was not submitted for Resident 25's fall with major injury on 7/24/25.

Based on interview and record review, it was determined the facility failed to notify the physician regarding weight changes for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for lack of physician involvement. Findings include: Resident 7 was admitted to the facility in 1/2025 with diagnoses including chronic heart failure, hypertension (abnormally high blood pressure), and a pacemaker (a small device implanted in the chest to help control the heartbeat). A 4/13/25 physician order indicated staff were to complete daily weights and notify the physician of a weight gain of three or more pounds in 24 hours or above 283 pounds for weight monitoring. A review of Resident 7's 4/2025 TAR revealed the following weights in pounds: -4/2/25: 283 -4/3/25: 287 -4/4/25: 286 -4/5/25: 290 -4/9/25: 287 -4/10/25: 290 -4/11/25: 279 -4/12/25: 288 No documentation was found in Resident 7's clinical record to indicate the physician was notified of three or more pounds weight gain or weight over 283 pounds. On 5/8/25 at 10:31 AM, Staff 4 (LPN) stated she could not recall if she notified the physician of Resident 7's weight gains in 4/2025. Staff 4 stated she should have documented the information in the resident's chart when the physician was notified. On 5/9/25 at 10:26 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to implement the physician's order and notify the physician of the increased weight changes.

Based on observation, interview, and record review it was determined the facility failed to ensure resident medications were not expired for 1 of 1 medication storage room and 1 of 4 medication carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: During an observation of the medication storage room on 5/6/25 at 12:31 PM, the following were found: - Three bottles of Pro Stat AWC liquid (nutritional supplement) with an expiration date of 4/3/25. - One bottle of ASA (aspirin) 325 mg tablets with an expiration date of 4/2025. - 33 boxes of bisacodyl (laxative) 10 mg suppositories with an expiration date of 4/2025. On 5/6/25 at 12:47 PM, Staff 7 (LPN) stated the expectation for expired medications was for them to be destroyed and replaced. During an observation of medication cart number 2 on 5/6/25 at 12:55 PM, the following was found: - One bottle of ASA 325 mg tablets with an expiration date of 4/2025. On 5/6/25 at 1:01 PM, Staff 8 (LPN) stated the expectation for expired medications was for them to be removed from the medication cart. On 5/9/25 at 12:04 PM, Staff 2 (DNS) acknowledged expired medications were found in the medication storage room and medication cart number 2. She stated the expectation for expired medications was for them to be removed from circulation and destroyed.

Based on observation, interview and record review the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) form was in a prominent place, readily accessible to residents and visitors for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for lack of awareness of nurse staffing levels. Findings include: Random observations from 2/13/24 through 2/16/24 and 2/26/24 through 2/27/24 revealed the DCSDR form was attached to a clipboard and placed inside an opaque file folder. The opaque file folder was mounted to the wall across from the nurses station. The DCSDR was not easily identifiable, and as a result, residents and visitors were unable to view the census or the number of staff working during each shift. On 2/27/24 at 9:15 AM Staff 1 (Administrator) acknowledged the DCSDR was not located in a prominent place.

Based on observation, interview, and record review it was determined the facility failed to ensure food was stored appropriately in the refrigerator, temperatures were maintained, and staff utilized beverage thickener in a sanitary manner for 1 of 1 kitchen reviewed for safe food handling. This placed residents at risk for food borne illness. Findings include: 1. The facility's Food Safety Policy, dated ,d+[DATE], indicated refrigerated foods must be labeled and dated, stored below 41 degrees F unless otherwise specified by law, and temperatures would be monitored. On [DATE] at 9:40 AM the ,d+[DATE] Temperature Log for the resident refrigerator, located in the dining room was reviewed. The log indicated a temperature was to be recorded twice a day. The log revealed a total of seven days recorded in ,d+[DATE] and five of the seven days were over the minimum temperature of 41 degrees F. On [DATE] at 9:43 AM during observations of the locked resident refrigerator in the dining room the following was noted: -One container of salad with a date of [DATE]. -One pre-packaged bag of apple slices, expired [DATE]. -Three containers of salad with a date of [DATE]. A sign taped on the outside of the resident unit refrigerator stated, Resident food only. Put an open date on anything open. Only keep up to 3 days worth of food per resident. On [DATE] at 12:58 PM Staff 21 (Infection Preventionist Unit Manager) acknowledged the above observations. She confirmed the refrigerator temperatures were not monitored appropriately and acknowledged the five days over the minimum temperature of 41 degrees F. Staff 21 stated the night shift nurses were expected to check the unit refrigerator and dispose of any outdated items. Staff 21 stated she was unsure how many days food items could be left in the resident refrigerator. On [DATE] at 2:09 PM Staff 1 (Administrator) stated the facility's policy for food items in the resident unit refrigerator was to discard the item after three days. 36494 2. Random observations from [DATE] through [DATE] during lunch meals from 12:00 PM through 12:30 PM revealed multiple CNAs prepared beverages for residents in the main dining area. Staff were observed to use a scoop for the thickening mix with either a glove or bare hand. The staff would grab a small blue scooper, scoop out the thickener powder, and then place the blue scoop back in the container. On [DATE] at 12:26 PM Staff 15 (CNA) stated staff were to use a glove to scoop out the thickener from the container. Staff 15 stated she placed the scoop back into the container and closed the lid. On [DATE] at 12:53 PM Staff 13 (CNA) stated she did not wear gloves when reaching into the container to scoop out the thickener. On [DATE] at 1:39 PM Staff 6 (Dietary Manager) stated staff were expected to sanitize their hands and put gloves on before scooping out the thickener from the container. Staff 6 stated the scoop was not to be left inside the container.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 9, 10, 13 and 15) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: Annual training hours were requested on 2/22/24 related to 12 hours of in-service training completed for Staff 9, Staff 10, Staff 13 and Staff 15. Staff 1 (Administrator) was unable to produce the documentation. On 2/27/24 at 9:15 AM Staff 1 acknowledged Staff 9, Staff 10, Staff 13, and Staff 15's in-service trainings were not completed.

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 4 of 6 sampled residents (#s 9, 21, 31 and 290) reviewed for call light wait times and staffing. This placed residents at risk for delayed ADL care needs. Findings include: 1. On 2/20/24 the facility provided lists of residents who: -Required assistance with eating: 3 -Required two-person assistance: 20 -Required assistance with dressing: 39 -Required assistance with bathing: 39 -Required assistance with toileting: 12 -Residents who were incontinent: 25 -Had wandering behaviors: 13 -Had behavioral healthcare needs: 3 -Had bariatric healthcare needs: 4 On 10/11/23 a public complaint was received which indicated the facility was short staffed on all shifts due to a former resident, Resident 40's need for a one to one CNA every shift since 8/2023. Interviews with residents revealed the following concerns: On 2/20/24 at 11:57 AM Resident 9 stated the facility was short staffed all the time. Resident 9 stated the facility utilized agency staff and call light response times were up to 30 minutes and often occurred during the afternoon. On 2/20/24 at 12:04 PM Witness 1 (Family Member) stated she visited Resident 7 daily in the late afternoon and evening. Witness 1 stated the facility did not have enough staff in the building to assist all residents timely. Witness 1 stated call light response times were long. Witness 1 stated residents waited up to an hour just to go to bed because of staff shortages. Witness 1 stated she observed on multiple occasions there were no staff to be found on the floor. Witness 1 further stated the facility utilized agency staff often and they did not know the residents. On 2/20/24 at 12:07 PM Resident 290 stated call light response times varied and were 15 minutes or longer. Resident 290 stated, 15 minutes can be a long time. Interviews with staff revealed the following concerns: On 2/20/24 at 4:05 PM Staff 23 (CNA) stated due to required a one to one CNA every shift, the facility was short staffed. Staff 23 stated CNAs were often late providing care or answering call lights for other residents, and this occurred on both day and evening shifts. On 2/21/24 at 9:29 AM Staff 12 (CNA) stated the facility struggled with staff shortages since 9/2023. Staff 12 stated there was high acuity residents in the facility including bariatric residents and it was difficult to assist residents timely. Staff 12 stated call light response times could be long and she tried to answer the call lights as quickly as possible. Staff 12 stated residents complained of long call light response times and usually it was related to residents wanting to go to bed or the residents needed their brief changed. On 2/22/24 at 10:36 AM Staff 13 (CNA) stated the facility often ran short on CNAs for each shift because a former resident required a one to one CNA. Staff 13 stated she often did not receive her breaks. Staff 13 further stated other residents did not receive care timely and had lengthy call light times. On 2/22/24 at 10:56 AM Staff 11 (CNA) stated the facility experienced occasional staffing shortages and relied on agency staff. Staff 11 stated she responded to call lights as quickly as possible, but residents frequently complained about extended call light response times. Staff 11 stated staff members turned off a resident's call light and indicated they would be right back, but never returned. Staff 11 stated the issue seemed to be related to residents requesting assistance with brushing their teeth or just needing a fresh cup of coffee. On 2/22/24 at 2:33 PM and 2/24/24 at 2:46 AM Staff 18 (CNA) stated the facility experienced staffing shortages consistently since 9/2023. Staff 18 stated call light response times could be greater than 15 minutes, especially on evening shift. Staff 18 stated they had a lot of high acuity residents requiring assistance from two staff which resulted in long call light response times. On 2/23/24 at 10:04 AM Staff 9 (CNA) stated the facility was short staffed consistently since 9/2023. Staff 9 stated the facility had a lot of high acuity residents including bariatric residents, residents who required two-person assistance with all ADL care needs and requiared mechanical lifts for transfers. Staff 9 stated call light response times were long at times. On 2/23/24 at 10:50 AM Staff 15 (CNA) stated the facility had several residents with a high acuity. The day shift often ran short on CNAs due to a former resident which required one to one supervision from a CNA. On 2/23/24 at 2:46 PM Staff 10 (CNA) stated on several occurrences she had to wait for another CNA to complete resident care as the facility was short staffed. The CNA who provided one to one care for a former resident was not able to help with other resident's care as she/he required supervision for increased behaviors. On 2/24/24 at 1:43 AM Staff 32 (CNA) stated the facility struggled with staffing shortages. Staff 32 stated many residents required two-person assistance or were totally dependent on staff for help. On 2/24/24 at 2:02 AM Staff 8 (LPN) stated the facility was consistently short staffed and with high acuity residents in the building call lights were difficult to answer timely. Staff 8 stated weekends were consistently short staffed. On 2/26/24 at 11:03 AM Staff 7 (LPN) stated the facility was consistently short staffed on the weekends. Staff 7 stated on 2/25/24 the facility had four CNAs but were suppose to have five on the floor, and residents might wait longer to receive ADL care. On 2/26/24 at 11:26 AM and 1:55 PM Staff 5 (Staffing Coordinator) stated she created the staff schedule based off the facility's current census and required one additional CNA due to having bariatric residents. Staff 5 stated the facility had difficulty meeting the state minimum CNA staffing ratios and at times it was difficult to find CNA coverage when a former resident required one to one supervision. Staff 5 further stated this was an on-going issue. On 2/27/24 at 9:15 AM Staff 1 (Administrator) stated there was a staffing crisis and acknowledged the facility struggled with meeting the state minimum CNA staffing ratios. Staff 1 stated she expected call lights to be answered timely, but indicated there was not a specific time range a call light was to be answered.

Based on interview and record review it was determined the facility failed to provide timely treatment for a worsening surgical site infection for 1 of 2 sampled residents (#8) reviewed for hospitalization . This placed residents at risk for untreated infections. Findings include: Resident 8 was admitted to the facility in 5/2023 with diagnoses including fracture of the right femur (thighbone) with an external fixator (stabilizing frame to hold broken bones in the proper position). The 10/23/23 Significant Change Pressure Ulcer/Injury CAA indicated Resident 8 had a surgical intervention to her/his right lower extremity and had an external fixator present. The resident was noted to be at risk for pressure ulcer/injury due to the external fixator and indicated nursing staff were to monitor the site. Resident 8's 12/4/23 Weekly Total Body Skin Assessment indicated the resident's skin color, temperature and condition were normal and there were no new wounds. The 12/5/23 Provider Note indicated Resident 8's external fixator to her/his right leg had redness, edema (swelling) and scant (minimal) drainage to the right thigh around the pin sites. Staff were to continue to monitor for worsening signs and symptoms and notify the provider as needed. Antibiotics were ordered. The 12/2023 MAR indicated Resident 8 did not receive the first dose of the antibiotics, which were ordered on 12/5/23, until 12/8/23. A Nursing Progress Note dated 12/6/23 at 9:25 PM indicated the resident reported a pain level of 10 (worse pain possible) to her/his right leg. The resident described the pain as constant, burning, shooting pain. A Nursing Progress Note dated 12/7/23 at 5:14 AM revealed Resident 8 reported thigh pain, burning, and muscle spasms in her/his right leg. The resident was tearful from the pain and rated her/his pain as a 10. The skin around the external fixator was assessed to be red in color and there was drainage from the leg which had an odor. The redness and odor from the drainage were not previously present. The resident screamed out in pain to a light touch of her/his skin. No documentation was found in Resident 8's clinical record to indicate the physician was notified of the change in condition and no new treatments for the worsening infection were initiated until 12/9/23. A Nursing Progress Note dated 12/9/23 at 6:37 PM revealed Resident 8 reported burning and pain in her/his right leg. Assessment of the right leg revealed the resident had redness from the insertion site to the right hip area. The resident's right leg had taut (stretched tight) skin. Review of Resident 8's December 2023 MAR indicated the following: - From 12/1/23 through 12/5/23 the resident did not rate her/his pain at a 10. - From 12/6/23 through 12/9/23 the resident's pain ranged from 6-10 and on seven occasions was rated a 10. Resident 8's Hospital After Visit Summary dated 12/15/23 indicated the resident was hospitalized on [DATE], diagnosed with cellulitis and infected hardware in her/his right lower extremity, and was started on IV antibiotics. On 2/21/24 at 9:23 AM the surveyor asked Resident 8 about her/his hospitalization and pain in 12/2023, but the resident did not want to discuss it. On 2/23/24 at 11:49 AM Staff 16 (LPN) stated when a resident had a change in condition her process was to assess the resident, notify the physician of the assessment findings and implement any new physician orders. Staff 16 reported when a resident had a change in condition the resident was placed on Alert Charting and documented on every shift. Staff 16 stated she provided wound care for Resident 8's external fixator on 12/7/23 and 12/8/23; the resident had drainage from the pin sites which had a little odor and the skin around the pins had light redness. On 2/26/23 at 10:20 AM Staff 4 (RNCM) stated she was not aware of Resident 8's change in condition until she/he was sent to the hospital. Staff 4 acknowledged there was no indication the physician was notified and no treatment put in place when Resident 8's condition worsened on 12/7/24. Staff 4 stated she expected the nurse to assess the resident and contact the physician to report a change in condition. Staff 4 further stated her expectation was for the resident to be placed on Alert Charting and assessed and monitored frequently for signs and symptoms of infection.

Based on interview and record review it was determined the facility failed to notify a physician of a resident's change in condition for 1 of 3 sampled residents (#8) reviewed for hospitalization . This placed residents at risk for delayed treatment. Findings include: Resident 8 was admitted to the facility in 5/2023 with diagnoses including fracture of the right femur (thighbone) with an external fixator (stabilizing frame to hold broken bones in proper position). Resident 8's 12/2023 TAR indicated a surgical wound on the resident's right lower extremity. Staff were to monitor the wound, change the resident's dressing daily, and notify the wound nurse and physician if there were signs or symptoms of infection. A Nursing Progress Note dated 12/7/23 at 5:14 AM revealed Resident 8 reported thigh pain, burning, and muscle spasms in her/his right leg. The resident was tearful from the pain and rated her/his pain as a 10 (worse pain possible). The skin around the external fixator was assessed to be red in color and there was drainage from the leg which had an odor. The redness and odor from the drainage were not previously present. The resident screamed out in pain to a light touch of her/his skin. Review of Resident 8's clinical record revealed no evidence the physician was notified of the resident's change in condition. On 2/23/24 at 11:49 AM Staff 16 (LPN) stated when a resident had a change in condition her process was to assess the resident, notify the physician of the assessment findings and implement any new physician orders. On 2/26/23 at 10:20 AM Staff 4 (RNCM) acknowledged there waso indication the physician was notified when Resident 8's condition worsened on 12/7/23. Staff 4 stated she expected all nurses to assess and contact the physician to report residents changes in condition. Refer to F684.

Based on observation, interview and record review it was determined the facility failed to implement the plan of care related to communication needs for 1 of 1 sampled resident (#35) reviewed for communication. This placed residents at risk for communication barriers. Findings include: Resident 35 was admitted to the facility in 1/2024 with diagnoses including stroke and aphasia (difficulty speaking). The resident's primary language was Spanish. Resident 35's comprehensive care plan dated 1/23/24, indicated a Speech/Language Therapist was to evaluate Resident 35 to provide effective communication to allow the resident to express her/his wishes and coordinate with therapy for possible alternative communication devices as indicated. According to record review and observation, Resident 35 was able to point and verbalize yes/no. The Speech/Language evaluation dated 1/23/24 did not address speech, language, or communication. The evaluation reviewed the resident's history and recommended the resident continue with NPO (nothing by mouth) status due to severe dysphagia (difficulty swallowing). The evaluation also revealed the resident was not alert or able to participate in the evaluation and indicated patient non-verbal and did not rouse during session. During random observations from 2/20/24 through 2/22/24 staff did not introduce themselves, communicate or interact while they provided ADL care for Resident 35. In an interview on 2/23/24 at 12:30 PM Staff 26 (LPN) stated she did not feel comfortable communicating with the resident because she didn't speak Spanish. On 2/23/24 at 12:43 PM Staff 4 (RN Resident Care Manager) stated she was not familiar with the Speech/Language evaluation and stated she could have requested a second evaluation to address communication.

Based on observation, interview and record review it was determined the facility failed to implement appropriate adaptive dining equipment for 1 of 3 sampled residents (#31) reviewed for food. This placed residents at risk for decreased food intake and an undignified dining experience: Findings include: Resident 31 was admitted to the facility in 3/2022 with diagnoses including anoxic brain injury (complete lack of oxygen to the brain) and dysphagia (difficulty swallowing). Resident 31's care plan for ADL self care performance deficit with eating, last revised 12/2/23, included the intervention to use weighted silverware and a scoop plate (an adaptive meal plate with a high, curved rim which enables food to be rolled back onto the spoon to minimize spillage) and to provide one-to-one staff assistance for meals. On 2/20/24 at 9:25 AM Staff 6 (Dietary Manager) stated the facility's kitchen was being repaired after the ice storm (1/2024) due to pipes bursting in the kitchen. Staff 6 stated all residents were served their meals in a Styrofoam container and plasticware was provided because the kitchen was not functioning. They facility used a food truck with equipment to cook all meals for the residents. Resident 31's meal ticket form on 2/20/24 included the following: - mildly thickened liquids - adaptive equipment to include a scoop plate, weighted fork, weighted spoon and two handled cup. Observations of Resident 31 were conducted from 2/20/24 through 2/23/24 between the hours of 12:00 PM through 12:30 PM. Resident 31 was observed in her/his wheelchair in the main dining for lunch. For the meals observed, Resident 31's food was served in a Styrofoam container. Resident 31 was provided with plastic utensils and attempted to utilize the plasticware to eat. Whenever the resident attempted to use her/his fork her/his hand would have uncontrollable tremors. On one occasion Resident 31 unsuccessfully attempted to gather the food onto her/his plastic fork from the Styrofoam container. As a result, with the help of a CNA, the resident attempted to bring the food to her/his mouth and one ended up on her/his lap. On 2/22/24 at 2:33 PM Staff 10 (CNA) stated Resident 7 required adaptive silverware for all her/his meals and was to recieve a one-person assistance with meals. Staff 10 stated the resident needed assistance because of her/his tremors and to ensure the resident did not choke. On 2/22/24 at 3:52 PM Staff 17 (LPN) stated Resident 7 needed assistance with all her/his meals due to her/his hands shaking. Staff 17 stated the resident was to be provided with weighted silverware to help reduce her/his hand tremors and staff were to sit and assist her/him at meals. Staff 17 stated the resident was able to feed herself/himself but became frustrated due to her/his tremors. On 2/23/24 at 9:52 AM Staff 9 (CNA) stated Resident 7 needed one staff to assist her/him with meals and required weighted silverware because of her/his tremors. On 2/26/24 at 9:16 AM Staff 4 (RN Resident Care Manager) stated staff were expected to implement and follow the care plan. Staff 4 stated Resident 31 required weighted silverware and one-person assistance with meals.

Based on observation, interview and record review it was determined the facility failed to obtain lab samples for 1 of 1 sampled residents (# 25) reviewed for laboratory services. This placed residents at risk for lack of timely stool sample. Findings include: Resident 25 was admitted to the facility in 4/2023 with diagnoses including diarrhea and GERD (Gastro-esophageal reflux disease). A 2/18/24 Progress Note at 10:02 AM indicated Staff 33 (LPN) notified the provider regarding Resident 25 and her/his multiple loose stools, complaints of hurting and a burning on her/his behind and loose stools associated with foul odor and mucus. On 2/18/24 at 10:16 AM an order was obtained from the provider for a stool sample to be obtained and sent to the lab. No evidence was found in the resident's clinical record to indicate the stool sample was collected. On 2/22/24 at 11:31 AM Staff 27 (Agency CNA) stated she provided incontinence care for Resident 25 and noticed a foul smell and stated she would let the nurse know. On 2/26/24 at 12:49 PM Staff 29 (LPN) stated, This was a one time order and it should have been completed. The facility had the supplies to collect the stool sample. On 2/26/24 at 1:26 PM Staff 4 (RN Resident Care Manager) verified the stool sample was not collected. She stated the stool sample could have been collected on 2/20/24. The staff had plenty of opportunities to collect the stool sample. Staff 4 stated she expected staff to collect the stool sample within a couple of days of the order and if the resident did not have a stool to sample then the provider was to be notified.

Based on interview and record review it was determined the facility failed to obtain medications timely for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include: Resident 9 admitted to the facility in 5/2023 with diagnoses including depression. A review of Resident 9's 2/21/24 physician orders revealed an order for bupropion 50mg twice daily with a start date of 12/15/23. A review of Resident 9's 12/2023 MAR revealed the facility did not receive the medication from the pharmacy until 12/19/23 (four days after the order). Records revealed no communication between the facility and the pharmacy during the identified date range. On 2/26/24 at 4:16 PM Staff 22 (LPN Resident Care Manager) stated the expectation was for the nurse on duty to call the pharmacy for the medication to be sent to the facility on a rush order if the facility did not have the medication in the CUBEX (an automated medication dispensing machine with a limited inventory of medications). Staff 22 stated she expected nursing staff to notify the resident's physician of the pharmacy delay. Staff 22 acknowledged there was no documentation to indicate the pharmacy was called or the physician was notified. She acknowledged Resident 9 did not receive the scheduled medication for four days.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 2 of 5 randomly selected CNA staff (#s 9 and 13) reviewed for staffing. This placed residents at risk for lessened quality of care. Findings include: Performance reviews were requested on 2/22/24 for Staff 9 and Staff 13. Staff 1 (Administrator) was unable to produce the documentation. On 2/27/24 at 9:15 AM Staff 1 acknowledged Staff 9 and Staff 13's annual performance reviews were not completed.

Based on interview and record review it was determined the facility failed to provide services to prevent a fall for 1 of 2 sampled residents (#2) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 2 was admitted to the facility in 9/2022 with diagnoses including dementia and weakness. Resident 2's 9/26/23 Quarterly BIMS Evaluation indicated a score of an eight which indicated moderate cognitive impairment. The 11/17/23 Quarterly Fall Risk Evaluation indicated Resident 2 was at risk for falls as she/he was non-ambulatory. Review of Resident 2's 10/24/23 Care Plan revealed the resident required extensive assistance of two staff with a Hoyer (mechanical lift) for transfers. Review of an incident report dated 12/21/23 revealed Staff 31 (CNA) attempted to transfer Resident 2 to her/his wheelchair without additional staff assistance and without a Hoyer. The resident was unable to bear weight to transfer and was assisted by Staff 31 to the floor. Staff 31 reported she was unaware of the resident's transfer status. On 2/26/24 at 1:16 PM Staff 16 (LPN) stated on 12/21/23 Resident 2 was on the floor after Staff 31 attempted to transfer the resident without a Hoyer. Staff 16 stated she assessed the resident who denied injury and the resident was not injured from the incident. On 2/26/24 at 1:00 PM Staff 4 (RNCM) acknowledged Resident 2 was care planned for two-person staff assistance with a Hoyer for transfers and the care plan was not followed on 12/21/23.

Based on observation, interview and record review it was determined the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 2 sampled residents (#s 18 and 19) reviewed for nutrition. As a result Resident 19 had a severe weight loss of 10.50% in 38 days. This placed residents at risk for further weight loss. Findings include: 1. Resident 19 readmitted to the facility in 2022 with diagnoses including failure to thrive, stroke and dementia. The 1/9/23 Care Plan indicated Resident 19 had a nutritional problem and had right sided hemiparesis (paralysis to one side of the body). The RD was to evaluate and make diet change recommendations PRN. The 2/1/23 physician order indicated Resident 19 was to receive a house supplement 118 ml. one time daily. The order indicated the start date was 1/25/22. The Weight Summary from 1/20/23 through 2/27/23 indicated the following: -1/20/23 221.9 lbs -2/1/23 212.0 lbs. -2/13/23 202.5 lbs. -2/27/23 198.6 lbs. Resident 19 had a severe weight loss of 23.3 lbs. (10.50%) in 38 days. The 2/1/23 Nutrition At Risk (NAR) note indicated the following: -Resident 19's weight fluctuated and she/he weighed 221.9 lbs on 1/20/23 and 212 lbs on 2/1/23. -It was believed the incorrect scale was possibly being utilized, will remind staff to use the white Hoyer scale. -Resident 19 regularly does not eat breakfast but she/he does eat lunch and dinner. Family and MD aware. No additional interventions were identified to address the resident's weight loss. The 2/17/23 NAR note indicated the following: -Resident 19 had weight loss and ate 75-100% of meals. -Weight was 202.5 lbs. -Evaluation/plan: reweigh and offer snacks BID. No additional interventions were identified to address the resident's weight loss. No NAR notes were identified in the electronic health record between 2/1/23 and 2/17/23. MARs reviewed for 2/2023 indicated Resident 19 refused the house supplement on nine occasions. Nutrition: Snacks documentation reviewed for 2/2023 and Resident 19 refused snacks 20 out of 27 days. There was no indication what snacks were offered to the resident. Meal monitoring was reviewed for 2/2023 and indicated the following: -48 occasions ate 76-100% -13 occasions ate 51-75% -2 occasions ate 26-50% -1 occasions ate 0-25% -22 occasions refused On 2/22/23 at 12:49 PM Resident 19 was observed to have a meal in front of her/him on the bedside table and was sitting up. The resident repositioned her/himself down to a lying position and did not touch the meal. No staff were present in the room. On 2/22/23 at 12:58 PM Staff 12 (CNA) stated Resident 19 usually did not eat breakfast but usually ate lunch and dinner. Staff 12 stated the resident was picky about her/his food and sometimes accepted alternates. Staff 12 stated nursing staff were responsible for tracking weight and informed CNA staff of weights that needed to be completed. On 2/24/23 at 8:58 AM Staff 26 (CNA) stated Resident 19 usually did not eat breakfast but always ate lunch and dinner. On 2/24/23 at 9:31 AM Staff 8 (LPN) stated Resident 19 received health shakes and resident care managers tracked her/his weights. On 2/27/23 at 9:59 AM Staff 9 (Registered Dietician) acknowledged Resident 19 weighed 221.9 lbs. on 1/20/23 and her/his weight decreased to 202.5 pound on 2/13/23 resulting in an 8.74% loss in 24 days. Staff 9 stated the resident did not eat breakfast and she/he had a health shake added on 1/25/23. Staff 9 stated Resident 19 was supposed to be on weekly NAR. Staff 9 stated she requested a reweigh of Resident 19 after 2/17/23 did not receive the reweigh and the resident was not reviewed at NAR on 2/24/23 and was not reweighed. On 2/27/23 at 10:28 AM Staff 10 (RNCM) stated she did not believe Resident 19's weight of 202 pounds or that she/he had weight loss because she/he is eating too much to have lost that much weight and the scales are not reliable. Staff 10 stated weights were tracked by highlighting who needed a weight on the daily vitals sheets for CNAs and the nurse was expected to follow up and document the weights. On 2/28/23 at 12:22 PM Staff 2 (DNS) acknowledged Resident 19 had a severe weight loss of 23.3 pounds (10.50%) in 38 days. Staff 2 further acknowledged there was no process in place to assess and reweigh the resident, to ensure NAR meetings were completed and to ensure if the snacks were appropriate for the resident in order to prevent further weight loss. 34324 2. Resident 18 admitted to the facility in 2021 with diagnoses including malnutrition. The revised 11/15/22 care plan indicated Resident 18 had a nutritional problem. Interventions included to monitor/record/report to physician any malnutrition and weight loss. Review of Resident 18's weights indicated Resident 18 weighed 145 pounds on 2/22/23 and 152.1 pounds on 1/10/22 a loss of 7.1 pounds (4.6 %). A 1/18/23 physician progress note indicated the resident's current weight was 152.1 pounds and her/his intake was being impacted by deconditioning from a [neck] fracture [suffered on 12/16/22]. The resident's intake was noted to be between 50-75% with improvement over the past week. The plan was to monitor and to consider mirtapazine (appetite stimulant) to help with appetite. A 1/19/23 nutritional note indicated Resident 18 had weight loss with interventions including health shake with meals and medication pass TID to prevent further weight loss. Review of Nutrition At Risk (NAR) notes from 1/27/23, 2/10/23 and 2/17/23 indicated Resident 18 had difficulty with eating due to the neck brace and the resident's appetite was less and less. The note indicated the physician was notified. The 2/17/23 NAR note indicated Resident 18 now had a soft collar in place making it easier for the resident to eat her/his meals. There was no indication in the NAR notes the use of mirtapazine was considered. On 2/27/23 at 9:50 AM Staff 9 (Registered Dietician) stated Resident 18's weight loss began in December from suffering a neck fracture. Staff 9 stated the resident wore a hard collared neck brace which contributed to the weight loss due the resident not being able to open her/his mouth wide as she/he was used to. Staff 9 stated she expected Resident 18's appetite to improve due to the current soft collar. Staff 9 stated she was not aware the physician noted the consideration of mirtapazine. Staff 9 stated the possible use of mirtapazine was not discussed in the NAR meetings.

1. Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use for 1 of 4 Staff members (#10) observed for medication administration. This failure, determined to be an immediate jeopardy situation, placed residents at significant risk of blood borne illness. Findings include: The McKesson True Metrix Pro CBG glucometer manufacture guidelines revealed the community use glucometer was to be cleaned and disinfected with Super Sani-Cloth wipes between residents. The undated facility CBG glucometer policy followed the manufacturer's guidelines and instructed staff to clean and sanitize the glucometer with the approved Super Sani-Cloth wipes between residents. The Super Sani-Cloth Germicidal Wipe instructions indicated to disinfect an item, unfold a clean wipe, thoroughly wet the surface, allow the treated surface to remain wet for a full two minutes and let the surface air dry. On 4/8/19 at 11:21 AM Staff 10 (RN) was observed to remove a glucometer from his upper chest pocket, perform a CBG test on Resident 16 and place the glucometer back inside his pocket. Staff 10 walked back to the treatment cart, disposed of the lancet, removed his gloves and did not perform hand hygiene. Staff 10 then completed computer data entry, did not perform hand hygiene, donned new gloves and drew up insulin for Resident 16. Staff 10 walked back to Resident 16's room, administered the insulin, returned to the treatment cart, disposed of the syringe and removed his gloves. No hand hygiene was performed. Staff 16 then took the glucometer out of his pocket, placed the blood test strip inside the glucometer, donned new gloves and began to walk away from the treatment cart. The Surveyor stopped Staff 10 who confirmed he was going to perform a CBG test on another resident. Staff 10 was questioned how often he cleaned and sanitized the glucometer. Staff 10 stated he would occasionally clean the glucometer with alcohol (non-approved cleaning agent) and if he had to guess he would clean it every four to five residents. Staff 10 stated he never used the Super Sani-Cloth wipes unless the glucometer was visibly very soiled. Staff 10 stated the Super Sani-Cloth wipes were in the bottom drawer of the treatment cart which was not convenient for use. Staff 10 then wiped the glucometer with the Super Sani-Cloth wipes (did not use correct technique to clean and sanitize the glucometer), went to Resident 37, performed a CBG test, returned to the treatment cart, removed his gloves and donned new gloves without performing hand hygiene. Staff 10 was asked what the instructions of use were on the approved Super Sani-Cloth wipes. Staff 10 read the instructions and stated he was to wait two minutes after cleaning before the glucometer was used. Staff 10 verified he did not perform hand hygiene between glove changes, kept the glucometer in his pocket and was the only nurse who performed CBG tests for all residents prior to the lunch meal. On 4/8/19, 19 residents were identified to receive CBG tests. On 4/8/19 at 1:11 PM the facility was informed of the immediate jeopardy situation for the improper cleaning and sanitizing of the single, community use glucometer by Staff 10. A plan to abate the immediate jeopardy situation was requested from the facility. On 4/8/19 at 2:05 PM the Abatement Plan was accepted. The plan indicated Staff 10 was suspended until he could prove competency with cleaning and sanitizing the community use glucometer. All licensed nurses would be in-serviced and a competency check completed for glucometer cleaning and sanitizing to prevent blood borne pathogens. All licensed nurses would be in-serviced by 4/9/19 at 6:15 AM with the exception of one LPN who would be in-serviced before returning to the floor on 4/12/19. The DNS or designee would perform no less than two random audits of CBG testing weekly to ensure proper infection control was being followed. The DNS or designee would take the weekly audits to the Quality Assurance committee for review. On 4/9/19 at 8:57 AM Staff 11(LPN) stated she was in-serviced when and how to clean and sanitize the glucometer as well as when to perform hand hygiene. On 4/9/19 at 8:58 AM Staff 8 (LPN) and Staff 6 stated they were in-serviced the prior afternoon the the cleaning and sanitizing of the glucometer. 2. Based on observation, interview and record review it was determined the facility failed to treat a resident with purulent drainage (a sign of infection) for 1 of 1 sampled residents (#34) reviewed for skin. This placed the residents at risk for cross contamination. Findings include: Resident 34 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. The Progress Note for 4/5/19 revealed the resident had an abscess behind her/his right ear. The 4/2019 TAR revealed staff were to cover the abcess if there was drainage. On 4/7/19 at 12:53 PM Resident 34 was sitting in the Fine Dining Room watching TV. There was a large cyst behind her/his right ear and was oozing purulent drainage down her/his neck. There were other residents in the dining room and no staff . At 1:03 PM Staff 11 (LPN) indicated they treated the cyst with a topical antibiotic and warm compresses. The resident refused to leave the dining room for treatment and she proceeded to clean and bandage the wound. On 4/8/19 at 12:06 PM the resident was sitting in the main dining room eating lunch with other residents around. The resident's right side was exposed to the main hallway. The resident's bandage was soiled and dangling off the resident's right side of her/his neck. Several staff passed by and did not address the dangling and soiled bandage. At 12:29 PM Staff 7 (LPN) noticed the bandage and told the resident she would remove the bandage. On 4/10/19 at 8:06 AM and 8:09 AM Staff 2 (DNS) and Staff 3 (LPN Unit Manager) indicated Resident 34's cyst should have been covered if it was oozing.

Based on interview and record review it was determined the facility failed to follow the care plan regarding fall mats for 1 of 3 sampled residents (#2) reviewed for accidents. Resident 2 fell on the floor and was admitted to the hospital with [REDACTED]. Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 1/15/18 Care Plan indicated Resident 2 was a fall risk and was to have non-skid footwear, a low bed and bilateral fall mats in place. On 12/7/18 at 3:38 PM Staff 11 (LPN) stated Staff 6 (CNA) found Resident 2 after her/his fall on 11/13/18 and she was the first nurse to respond to the room. She stated the fall mats were supposed to be in place but were not. She further stated the resident had a large bruise on the right side of her/his face. On 12/12/18 at 7:47 AM Staff 6 stated just before dinner on 11/13/18 she heard Resident 2's roommate yelling when passing by the room. The door was closed and she knocked and entered the room and pulled back Resident 2's curtain and observed her/him lying parallel to the bed on the floor and did not have fall mats in place. She stated the resident was not wearing non-skid socks because she/he rolled them off her/his feet and they were in the bed. Staff 6 further stated Staff 11 assisted her to help Resident 2 back into bed and Resident had redness on the right side of her/his head and a small cut on her/his toe that was slightly bleeding. The 11/13/18 Fall Assessment indicated Resident 2 was found on the floor next to the bed which was in the low position. It further indicated the resident did not have bilateral fall mats in place at the time of the fall. It further indicated the resident had a large 2 inches x 4 inches bruise from just behind the right temple to over the right eye and small skin tear between toes on the left foot. It further indicated the resident was admitted to the hospital with [REDACTED]. On 12/12/18 at 10:31 AM Staff 1 (DNS) stated Resident 2 was care planned for bilateral fall mats which were not in place on the 11/13/18 fall and the resident was admitted to the hospital.

Based on observations, interviews and record review, it was determined that the facility failed to provide necessary care and services regarding assessment and effective treatment of [REDACTED].#s 1, 30, 40 and 79) whose assessments, care plans and provision of care were reviewed. Resident 30 experienced on-going pain and deep frustration secondary to impaired communication ability described by the cognitively intact resident as "verbal pain." Findings include: 1. Resident 30 was admitted to the facility during October 2010 with [DIAGNOSES REDACTED]. The American Pain Foundation has defined a Pain Care Bill of Rights to help people with pain maintain the best possible quality of life. These Rights include: having pain thoroughly assessed and promptly treated; participate actively in decisions about how to manage pain; have pain reassessed regularly and treatment adjusted if pain has not eased; and terminally ill individuals' pain should always be adequately relieved. The 1/27/11 Quarterly MDS indicated the resident received no scheduled pain medication but did receive prn pain medications and non-medication interventions for pain. The resident's pain was rated as moderate, a "2" on a scale of 0-10 with 10 as the worst pain. The pain was noted to make it hard for the resident to sleep at night. The 1/28/11 Pain Assessment revealed the resident had chronic neck/back pain in addition to muscle spasms in his/her back and neck. Resident 30 rated the pain as a 3-4 on a scale of 1-5, with 5 being excruciating. The 2/4/11 History and Physical that noted the resident had "been treated with marijuana in the past for his speech but not at the present time." The resident's 4/28/11 Quarterly MDS revealed the resident had a BIMS score of 14, which reflected the resident was cognitively intact. The MDS indicated the resident received no scheduled pain medication. According to the MDS, the resident experienced moderate pain (2 on a scale of 10) on rare occasions for which he/she received prn pain medications and non-medication interventions. The 4/29/11 Pain Assessment documented the resident as having chronic neck and back pain on a daily basis, usually in the morning. The pain intensity ranged from 1.5 to 4 (moderate) on a scale of 0-10, with 10 being excruciating pain. Rest and medication were documented as interventions that helped the resident's pain. Staff 2 (RNCM) indicated she planned to fax the physician about scheduling pain medications at night. The 7/28/11 Quarterly MDS indicated the resident's BIMS score remained 14. The MDS reflected the resident had started taking scheduled pain medications and still received prn pain medications and non-medication interventions. An 8/2/11 assessment indicated the resident received scheduled narcotic pain medication ([MEDICATION NAME]/APAP 7.5/325) at bedtime and prn which the resident reported were effective. The 8/2/11 Quarterly review indicated the resident had not experienced any changes in pain level. The care plan in the chart, initiated for pain and last reviewed on 8/1/11, noted the resident's pain was to be relieved within one hour through nonchemical interventions and medication if applicable. Interventions included monitoring for signs and symptoms of pain; offer diversional activity/nonchemical interventions such as TV, music; position for comfort; check for toileting, food or fluid needs; alert LN (licensed nurse) if interventions unsuccessful; LN to assess for medication needs and alert physician if medications not successful. The resident's in-room care plan noted pain as a problem but failed to list any interventions for direct care staff to utilize, medication or non-medication related. The care plans did not address what type of activities that decreased the resident's pain. The care plans failed to incorporate that the resident's pain occurred usually in the mornings and did not develop resident specific pain interventions such as whirlpool baths (in the facility's wheelchair accessible soaking tub), hot towels for the resident's neck or massage. On 8/22/11, Resident 30's physician completed the Attending Physician's Statement of the Oregon Medical Marijuana Act Program form which was to be submitted for the resident. The request for the medical marijuana was to treat the debilitating medical condition of malignant neoplasm (cancer). The resident was described as having cachexia (general weight loss and wasting occurring in the course of a chronic disease or emotional disturbance), severe pain and severe nausea. An 8/22/11 Interdisciplinary Progress (IDP) Note reflected the marijuana form was given to the RNCM and a copy placed in the folder. On 10/4/11 at 3:22 pm, Resident 30 stated he/she had used medical marijuana before and it helped. Resident 30 said his/her speech improved 100% with use of medical marijuana. The resident said "I could communicate better." The resident displayed pained facial expressions and some tearfulness during the interview. Resident stated he/she suffered "verbal pain" due to his/her deep frustration with the impaired ability to speak. On 10/4/11 at 3:30 pm, Resident 30 stated he/she would be open to other means of using medical marijuana besides smoking (such as ingestion or oil extraction). On 10/5/11 at 1:55 pm, Staff 2 (RNCM) stated the resident had asked about the medical marijuana about five to six weeks ago. Staff 2 said nothing more had happened. On 10/10/11 at 2:20 pm, Resident 30 said the paperwork has been filled out for the medical marijuana card but had not yet been sent in, The resident stated "I want to get that (medical marijuana) card." According to the resident, the medical marijuana relaxed his/her face and lips so he/she could speak much more fluently. Resident 30 said he/she didn't run his/her words together when using medical marijuana and he/she had a "full vocabulary." The resident stated "I am in pain" when he/she couldn't express him/herself the way he/she wished. According to the resident, the worst was when meeting new people. The resident said because he/she had to put so much energy out, it made it it much more difficult for him/her to be understood. The resident said "it hurts." Resident 30 stated without the medical marijuana, all he/she can say "hi, how are you?" With the marijuana, the resident said he/she can have deep, meaningful conversations. Resident 30 stated "I can not express myself the way I want to" and described the frustration of not being understood as "constant verbal pain." The resident said when using the medical marijuana his/her movements were more fluid and he/she was able to move better. The resident stated he/she had quite a bit of pain in his/her neck due to the spasmodic [DIAGNOSES REDACTED]. Resident 30 said when he/she used the medical marijuana, he/she had no pain. The resident described his/her stomach pain as "like two big hands in my stomach, squeezing." Resident 30 tearfully stated "This is my baseline...It takes all my concentration to keep my pain down." The resident said staff did not have him/her rate the pain on a scale of 1-10 unless he/she asked for prn pain medications. The resident said back rubs, hot baths and hot towels helped decrease the pain but these had not been provided. On 10/11/11 at 2:19 pm, Staff 12 (Social Services) said the medical marijuana was discussed but due to the $150 application fee and family issues, it was put on hold. According to Staff 12, the resident said the application fee and finding a marijuana grower was too overwhelming. The facility was a non-smoking facility and the resident did not want to leave. Staff 12 stated that he stopped working on the medical marijuana at that point. On 10/11/11 at 4:14 pm, Staff 1 (Administrator) stated that they were a non-smoking facility and the resident would have to go off-grounds to smoke the medical marijuana. Staff 1 said "We are not super involved with getting the medical marijuana." Staff 1 stated Staff 2 (RNCM) and Staff 12 (Social Services) had both looked into the issue. On 10/13/11 at 9:57 am, Staff 12 stated that pain had never come up before when he discussed medical marijuana with the resident. Staff 12 was unaware of any other method of using medical marijuana besides smoking it and had not researched the topic. The surveyor offered the DHS (Department of Human Services) medical marijuana website as a resource. The website had information on how to find local growers. The surveyor also noted the resident's application fee for the medical marijuana would be $20. On 10/14/11 at 11:26 am, Staff 2 (RNCM) stated that the resident had a terminal diagnosis. Staff 2 said the resident's pain was assessed by talking to him/her and staff monitoring his/her activity participation. Staff 2 indicated the resident received scheduled and prn [MEDICATION NAME] and that Resident 30 did not want to try use of a [MEDICATION NAME] (narcotic) patch. Staff 2 said medical marijuana was new for the facility staff and the marijuana would be used for easing the resident's throat and making his/her speech clearer. Staff 2 said the resident received whirlpool baths twice a week and heat (such as hot packs) had been offered to the resident and was refused. On 10/14/11 at 11:50 am, Staff 11 (CNA) stated that she showered the resident in his/her bathroom. The Bath Type Detail Report reflected the resident received showers on 9/3/11, 9/6/11, 9/17/11, 9/20/11, 9/25/11 and 9/27/11. There was no documentation of the resident being offered or receiving whirlpool baths. 2. Resident 1 was admitted to the facility during February 2011 and readmitted to the facility from the hospital during August 2011 with [DIAGNOSES REDACTED]. The facility [MEDICAL TREATMENT] information provided to surveyors on 10/4/11 revealed Resident 1 received [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays at 10:45 am. [MEDICAL TREATMENT] is a method of removing toxic substances (impurities or wastes) from the blood when the kidneys are unable to remove these substances. Chart review on 10/11/11 at 1:49 pm revealed a form from the Kidney Care Physicians that included brief information such as the date of the encounter, chief complaint, exam, data, plan, orders and a physician signature section. The form included documentation starting on 8/18/11 and ending on 8/22/11. The chart review on 10/11/11 revealed no documentation of on-going communication to or from the [MEDICAL TREATMENT] center. On 10/11/11 at 4:00 pm, Staff 1 (Administrator) and Staff 2 (RNCM) said that there was not a separate book where documentation of communications with the [MEDICAL TREATMENT] center were kept. Staff 1 and Staff 2 stated that if they wanted anything from the [MEDICAL TREATMENT] center, they had to call and ask for it. Staff 1 said that she would provide a copy of the facility's policies and procedures (P/P) for [MEDICAL TREATMENT]. When asked what the contract with the [MEDICAL TREATMENT] center specified related to the flow of communication, Staff 1 and Staff 2 said they didn't know because the owner took care of that. On 10/12/11 at 9:57 am, Staff 1 (Administrator) stated there was no P/P for [MEDICAL TREATMENT] because it was considered by the facility to be like another physicians' appointment. On 10/12/11 at 1:17 pm, Witness 1 ([MEDICAL TREATMENT] center administrator) stated that the [MEDICAL TREATMENT] center had very good communication with the nursing facility and that the [MEDICAL TREATMENT] center staff routinely called the nursing facility. Witness 1 said the [MEDICAL TREATMENT] center had a contract with Resident 1, but not the nursing facility. On 10/12/11, review of Resident 1's TARs from 8/16/11 through 10/12/11 revealed no directions to staff regarding monitoring for or managing emergency complications related to [MEDICAL TREATMENT] such as bleeding, hemorrhaging, infection, bacteremia (a serious condition of bacteria in the blood which can rapidly become a life-threatening condition) and septic shock. On 10/13/11 at 10:15 am, Staff 4 (RN/Charge Nurse) said the emergency complications related to [MEDICAL TREATMENT] that he monitored for with Resident 1 included having no blood pressure taken on the left arm (arm with fistula); limiting potassium, [MEDICATION NAME] and calcium in the resident's diet; and checking the thrill on the resident's left side. Staff 4 said he would have to talk to Staff 2 (RNCM) when asked where the monitoring for these types of complications was documented. Staff 4 stated he could not think of anything on the TAR or care plan that would prompt him to look at the things he had referenced monitoring. No further information was provided related to documentation of monitoring for potential complications associated with [MEDICAL TREATMENT]. The Medline Plus Medical Encyclopedia listed the following approaches related to fistula care: check the access site for the "thrill" because it indicated the site was still functioning, not wearing tight clothing around the fistula site or on the arm with the fistula site, avoid placing pressure on the arm with the fistula during sleep, not to use creams or lotions over the fistula site and observing the fistula after [MEDICAL TREATMENT] for swelling, infection or bleeding. The chart care plan listed the resident's [MEDICAL CONDITION] as a problem, noted he/she received [MEDICAL TREATMENT] and documented that the [MEDICAL CONDITION] section had last been reviewed on 7/25/11. Approaches included laboratory testing as ordered by the physician and [MEDICAL TREATMENT] center; urinary output to be monitored for changes; signs and symptoms of dehydration were to be monitored after [MEDICAL TREATMENT]; the shunt was to be monitored for signs and symptoms of infection; and the resident was to be monitored for [MEDICAL CONDITION] or ascites (accumulation of fluid in the abdominal cavity). The chart care plan also listed infection as a problem for the resident. The approaches included following universal precautions. The in-room care plan, dated 8/8/11 and updated on 8/23/11, noted the resident went to [MEDICAL TREATMENT] three times a week. The resident was not to have his/her blood pressure taken on the left arm, vital signs were done per licensed nurse and weights were done at the [MEDICAL TREATMENT] center. The in-room care plan did not include any information regarding infection control measures. On 10/13/11 at 10:51 am, Staff 2 (RNCM) stated the facility usually coordinated care with the [MEDICAL TREATMENT] center by fax. Staff 2 said [MEDICAL TREATMENT] was usually already set when the residents are admitted . Staff 2 indicated if the facility had issues, they contacted the [MEDICAL TREATMENT] center by fax or by phone if the issue was emergent. Staff 2 said the charge nurse should be documenting in the nurses' notes if there were calls to or from the [MEDICAL TREATMENT] center. Staff 2 said in the past the [MEDICAL TREATMENT] center had sent the facility information related to the resident's vital signs and weights. Staff 2 was asked for documentation of the fistula monitoring, directions related to monitoring and care of the fistula, waste handling and emergency complications. No documentation was provided. On 10/13/11 at 10:58 am, Staff 1 (Administrator) verified there was no agreement with the [MEDICAL TREATMENT] center. 3. Resident 40 was admitted to the facility during 2007 with [DIAGNOSES REDACTED]. a. The resident had a 12/8/2007 physician's orders [REDACTED]. The 3/24/11 Significant Change MDS revealed the resident had experienced pain in the last five days and had received both scheduled and PRN (as needed) pain medications. In the Staff Assessment of (the resident's) Pain, it documented staff had not observed or documented signs or symptoms of pain in the last five days. The resident receiving PRN medications during the last five days was inconsistent with the coding reflecting staff had not observed or documented signs or symptoms of pain in the last five days. The frequency of pain indicators section was blank. The 3/24/11 CAAs described the resident as severely demented. The CAAs noted that if the resident was in pain he/she would moan but not ask for assistance. The resident was able to call out to staff when he/she wanted something but could not fully make his/her needs known. According to the CAAs, pain was "not an issue." The 3/25/11 Pain Assessment form documented the resident had displayed no signs, symptoms or behaviors that were indicative of pain. The assessment described the resident's pain medications as effective and no pain noted. Under the recommendations section, Staff 2 (RNCM) indicated she was unable to assess if the resident's calling out was due to pain or anxiety and the resident was receiving appropriate medications that were effective. The 6/23/11 Quarterly MDS revealed the resident was no longer on scheduled pain medications but received PRN pain medications and non-pharmalogical interventions. The resident was noted to exhibit non-verbal sounds that indicated pain with the pain frequency documented as every three to four days. The 6/28/11 Pain Assessment Update reflected the resident received 0.5 ml of [MEDICATION NAME] (narcotic) PRN for discomfort that was expressed by calling out. The medication was described as effective. Review of the MARs for August 2011 through October 1-11, 2011 revealed the resident received PRN [MEDICATION NAME] 22 times during August, 34 times during September and 13 times between October 1-11, 2011. No PRN Tylenol or [MEDICATION NAME] was administered during that time. The 10/4/11 Pain Assessment Update indicated there was no change since the previous (6/28/11) assessment. There was no evidence the resident's pain levels had been evaluated after the scheduled pain medication was discontinued. There was no documentation the monthly increases in the use of PRN [MEDICATION NAME] that began in August 2011 had been identified. There was no evidence the effectiveness of the current pain management approach had been assessed regarding the resident's need for frequent PRN [MEDICATION NAME] for pain. On 10/10/11 at 12:28 pm, the resident was observed in his/her bed yelling out. The resident's bedroom was at the opposite end of the hallway from the nursing station. The resident's yelling was audible at the nursing station. Staff were observed not to enter the resident's room to check on him/her. The October 2011 MAR indicated [REDACTED]. On 10/11/11 at 1:34 pm, Staff 16 (CNA) stated Resident 40 "hollers out" when he/she has pain. Staff 16 said the resident's body and face will get tense and the resident will tense up when moved. On 10/11/11 at 4:51 pm, the resident was observed in bed and yelling out. Staff were observed not to come to the room to check on the resident. The October 2011 MAR indicated [REDACTED]. On 10/12/11 at 11:02 am, the resident was observed in bed. The resident's facial expression was a grimace and the resident's shoulders appeared tense and drawn up toward the resident's head. On 10/12/11 at 4:51 pm, the resident was observed in in bed with his/her brow furrowed. The October 2011 MAR indicated [REDACTED]. On 10/14/11 at 9:26 am, Staff 2 stated Resident 40 was taking a lot of prn [MEDICATION NAME]. Staff 2 said the resident expressed pain by calling out and facial expressions. Staff 2 said the resident had a pain scale in the closet. The observations on 10/10/11 and 10/11/11 when the resident's yelling out went unnoticed and on 10/12/11 when the resident's facial grimacing and tense body posture were unaddressed were shared with Staff 2. Staff 2 said that the resident would get lonely and that was part of the calling out behavior. Staff 2 stated that she had considered scheduling the [MEDICATION NAME] but wanted to balance it with maintaining the resident's alertness. Staff 2 said that she would contact the physician and ask for the [MEDICATION NAME] to be scheduled but at a lower dose. Staff 2 said that the increased use of the PRNs just started over the last month. b. Record review revealed a 6/24/11 physician's orders [REDACTED]. The chart did not contain evidence the evaluation for splinting/padding for the resident's right hand contracture had occurred. Observation of Resident 40 on 10/5/11 at 10:00 am revealed the resident was in bed, had a right hand contracture and no hand roll or splint. Observation of the resident on 10/10/11 at 11:34 am revealed the resident's right contracted hand was visible and no hand roll or splint was present. On 10/10/11 at 4:39 pm, the resident was observed with no hand roll or splint on the right hand contracture. On 10/11/11 at 9:03 am Witness 4 (Certified Occupational Therapy Assistant-COTA) stated therapy had just received the request for evaluation of the resident' s contracted hand. Witness 4 said the evaluation had not been done but she had given a CNA a palm protector for the resident until the evaluation was completed. On 10/11/11 at 9:30 am, the resident was observed to be in bed with no palm protector on his/her contracted right hand. On 10/11/11 at 11:05 am, the resident was observed in bed with no palm protector. On 10/11/11 at 12:47 pm, the resident was observed in bed without a palm protector. On 10/11/11 at 1:34 pm, Staff 16 (CNA) said that cleaning the resident's contracted hand was painful for the resident. Staff 16 said the resident received pain medication before the cleaning but it was still painful for the resident. Staff 16 stated the resident "guards" the contracture even when she/he is not moving. Staff 16 indicated staff try to do ROM with the contracted hand to loosen it up so they can clean the hand but it's more like massage. On 10/14/11 at 9:26 am, Staff 2 (RNCM) said that the 6/24/11 order showed up in her box last week and that someone had misplaced the order. Staff 2 said she gave it to Witness 4 (COTA). According to Staff 2, Witness 4 waited until the physician came in last Tuesday (10/11/11) to get a new order. Staff 2 said the contracture had not changed during the last year. Staff 2 said CNAs can hold the resident's affected hand, rub it with lotion and clean it. 4. Resident 79 was readmitted to the facility during August 2011 with a [DIAGNOSES REDACTED]. a. The hospital transfer records contained an order for [REDACTED]. The resident's clinical record lacked documentation that the 8/8/11 INR was done. The missing 8/8/11 INR documentation was shared with Staff 2 on 10/14/11 at 9:16 am. Staff 2 (RNCM) said she would look for documentation related to the 8/8/11 INR. b. A 9/2/11 (Friday) physician's orders [REDACTED]. The resident's INR on that date was 2.0. (The usual target range is between 2.0 and 3.0.) The September 2011 MAR indicated [REDACTED]. A 9/9/11 physician's note revealed the facility had administered the wrong dose of [MEDICATION NAME] the prior week. The resident was to receive 2 mg of [MEDICATION NAME] on Sunday, Tuesday, Wednesday and Saturday and 1 mg on Monday and Friday. The resident's 9/9/11 INR was 1.4 On 10/14/11 at 9:16 am, Staff 2 (RNCM) was asked for evidence the facility investigated the cause for the [MEDICATION NAME] medication error. Staff 2 (RNCM) said she would look for documentation. No documentation was provided.