Every finding on record at Life Care Center of Coos Bay

Based on interview and record review it was determined the facility failed to keep a resident free from physical restraint for 1 of 1 sampled resident (#6) reviewed for physical restraints. This placed residents at risk for potential abuse or neglect. Findings include:Resident 6 was admitted to the facility in 11/2025 with diagnoses including Alzheimer's disease. A 11/25/25 admission MDS indicated Resident 6 was severely impaired and rarely made decisions, had disorganized thinking, and altered level of consciousness. The facility's 12/8/25 investigation documented that Resident 6 had been found in bed with blankets tucked in on both sides of her/his body, restricting movement. The investigation concluded that abuse and neglect had not been substantiated, but the rolled blankets had limited the resident's movement, and staff had significantly deviated from resident-rights standards and facility policy. The investigation included the following written staff statements:-Staff 3 (CNA) reported Staff 3 and Staff 4 found Resident 6 in a praying position, lying sideways on the bed. Staff 3 and 4 assisted Resident 6 back into the center of the bed. Two subsequent times, staff found Resident 6 in a weird position, though not on the floor. Staff 3 and Staff 4 folded blankets and placed them on both sides of Resident 6 to keep the resident in a safe position in bed.-Staff 4 (CNA) documented during resident rounds she had seen Resident 6 lying sideways in a weird position. Staff 3 asked about using pillows, and Staff 11 (RN) stated it was okay. No pillows were available, so blankets were rolled up and placed under the resident on each side, with a sheet tucked in at the foot of the bed. -Staff 11 (RN) reported Resident 6 was hard of hearing and very wiggly. Staff had found the resident in weird positions at night, with her/his head on one side of the bed and feet off the other side, but not on the floor. Staff 3 had suggested using pillows, but none were available, so staff had tucked blankets under the mattress at the foot of the bed. On 4/15/26 at 9:13 AM, Staff 4 confirmed her written statement was accurate. Staff 4 stated she would never place blankets under a resident on that way again because it was considered a restraint, and Resident 6 could not exit the bed if she/he wanted to. On 4/16/26 at 7:55 AM, Staff 3 confirmed her written witness statement was accurate. Staff 3 stated she and Staff 4 were unable to find pillows, so they used blankets rolled up. Staff 3 stated she was educated and now knows it was not permitted to roll blankets as it was a restraint for Resident 6. On 4/16/25 at 8:41 AM, Staff 5 (CNA) stated when she entered Resident 6's room on 12/8/25, the resident grasped her arm and had a concerned expression. Usually, Resident 6 smiled when Staff 5 entered the room. Staff 5 stated she observed blankets waded at both sides of Resident 6 and a sheet wrapped over the top of her/him and tucked under the blankets in a manner which restricted the resident's movement. On 4/16/26 at 12:38 PM, Staff 2 (DNS) confirmed Staff 3 and Staff 4 should not have placed blankets under Resident 6 restricting her/his movement.

Based on interview and record review, it was determined the facility failed to provide a safe and orderly discharge for 1 of 3 sampled residents (#5) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings included:Resident 5 was admitted to the facility in 3/2026 with diagnoses including multiple sclerosis (MS) (an autoimmune disease that affects the central nervous system, leading to damage of the nerve fibers, resulting in a range of physical and cognitive symptoms). A 3/18/26 MDS indicated Resident 5 was cognitively intact. A 3/17/26 Event Note indicated Staff 20 (Assistant DNS) was notified Resident 5 had marijuana in her/his room. Resident 5 stated her/his friend brought it in. Staff 20 educated Resident 5 on the importance and side effects with medication. Resident 5 informed Staff 20 she/he would have her/his friend pick up and remove the marijuana from the facility. Staff 20 documented Resident 5's friend removed the marijuana from the facility. Psychosocial Notes dated 3/18/26 indicated Staff 19 (Social Services Director) stated Resident 5 told Staff 20 she/he had marijuana and a pipe in her/his room on 3/18/26 and used the marijuana. Staff 19 documented staff members smelled the marijuana in her/his room. Staff 19 went into Resident 5's room with Staff 21 (Medical Records Director) and informed Resident 5 the facility could no longer continue care and would discharge her/him home on 3/18/26 because she/he had used marijuana, which violated facility policy. Resident 5 became upset, yelled, and kicked a table. Staff 22 (LPN Unit Care Coordinator) entered the room and informed Resident 5 the facility was federally funded and could no longer keep her/him. Staff 22 explained that smoking combined with aggressive behavior meant she/he was not in the right facility. Resident 5 yelled and cursed, stating she/he would not leave. Staff 20, Staff 7 (LPN), and Staff 33 (LPN) also entered the room. A 3/18/26 Care Management Note indicated Staff 22 heard Resident 5 yelling, berating staff, throwing items, and kicking the bedside table. Resident 5 had smoked marijuana in the facility. Staff discussed the policy forbidding indoor smoking. Marijuana was not allowed and was confiscated by Staff 20 on 3/17/26. Reports of continued use were received on 3/18/26. Discharge was warranted, and physician orders were obtained. Staff attempted to discuss discharge options; Resident 5 continued to scream, curse, and verbally insult Staff 22. Resident 5 refused to leave. Staff 22 stated safe discharge education was needed; Resident 5 responded, I'm not going anywhere. Local law enforcement was contacted to assist. Review of Resident 5's clinical round found a Notice of Involuntary Transfer dated 3/18/26 and was issued due to resident's behaviors created a serious and immediate threat. A 3/18/26 Discharge Summary indicated Resident 5 discharged to home or community reason for discharge was non-compliance with facility policy. Resident required one person with stand pivot transfers, dressing and bed mobility. Home health services was not checked. On 4/13/26 at 8:18 AM and 4/15/26 at 8:45 AM, Resident 5 stated staff searched her/his room without consent. Staff 20 entered with a bag and stated she/he could not have it. Resident 5 stated she/he did not know the contents. Resident 5 explained that a friend brought it and he/she was unaware. With multiple sclerosis, Resident 5 stated she/he had difficulty with emotions from raging to crying to laughing. Resident 5 stated five staff members were in her/his room, and it felt overwhelming. Resident 5 felt attacked upon learning of the discharge. With no alternatives, she/he blew a fuse. Resident 5 stated she/he never smoked the marijuana and did not touch the marijuana. On 4/16/26 at 9:53 AM, Staff 19 stated in a 3/18/26 staff meeting she had been informed the facility would discharge Resident 5 for using marijuana and that Staff 20 stated Resident 5 had smoked the marijuana. On 4/16/26 at 10:17 AM, Staff 22 stated Resident 5 smoked over the weekend of 3/14/26 which was reported through the 24 hour report. She explained they could not safely provide care due to threats to staff. On 4/16/26 at 10:25 AM, Staff 20 stated he had found Resident 5's marijuana in her/his room. Staff 20 stated Resident 5's friend came and got the marijuana. Staff stated that Resident 5 told him they had not used any of the marijuana and was upset about being discharged . Staff 20 did not hear from other staff Resident 5 had smoked in the facility. On 4/16/26 at 10:31 AM, Staff 21 stated during staff meeting on 3/18/26 he was informed Resident 5 had been caught smoking marijuana, and it was confiscated and was caught a second time. Staff 20 confiscated the marijuana and Resident 5 was caught a second time. On 4/16/26 at 12:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated on 3/17/26 Resident 5 had marijuana in her/his room and it was removed. The next morning Resident 5 was smoking in her/his room. Staff 1 thought Staff 20 had seen her/him smoking. Staff 1 stated Resident 5 had made the decision to leave. Staff 1 put in a form for involuntary transfer and thought she had completed one for a 30-day and one for an immediate transfer.

Based on interview and record review it was determined the facility failed to make prompt efforts to resolve resident grievances for 1 of 1 facility reviewed for grievances. This placed residents at risk for unresolved grievances. Findings include:The facility's 1/7/25 Grievance Program policy detailed expectations for a prompt effort to resolve grievances and maintain a recordkeeping system with grievance receipt date, grievance summary statement, investigation steps, pertinent findings or conclusions, whether grievance was confirmed or not confirmed, and decision date. A review of facility grievances from 7/2025, 8/2025, 9/2025, 10/2025, and 11/2025 revealed six grievance forms with incomplete documentation to indicate the grievances were resolved. On 12/18/2025 at 1:39 PM Staff 1 (Administrator) said the process for addressing grievances was to fill out a Concern and Comment card, submit the card to the Social Services Director, complete an investigation, then once all steps toward resolution were finished the Administrator signed off on the card. Staff 1 said once her signature was on the card the investigation was considered closed. Staff 1 reviewed the six incomplete grievances and confirmed documentation toward resolution was incomplete.

Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 1 of 1 dining room reviewed for dining. This placed residents at risk for cross contamination. Findings include:The 10/28/25 Hand Hygiene Policy and Procedure indicates the facility must establish and maintain an infection prevention and control program designed to maintain to provide as a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Procedure:2. Associates perform hand hygiene (even if gloves are used) in the following situations:a. Before and after contact with the resident;b. After contact with blood, body fluids or visibly contaminated surfaces;c. After contact with objects and surfaces in the resident's environment;On 12/18/25 at 12:11 PM Staff 20 (CNA) was observed in the dining room delivering a lunch tray to a resident. Staff 20 removed lids from the bowls and cut up items on the plate for the resident. Staff 20 touched the resident's shoulder and asked if she/he needed anything else. Staff 20 touched her face, twirled her hair and adjusted her clothing while waiting for another lunch tray to be prepared by the dietary staff. Staff 20 retrieved another lunch tray and delivered the tray to a resident.On 12/18/25 at 12:20 PM Staff 20 stated she was uncertain when she was supposed to complete hand hygiene. Staff 20 acknowledged she did not sanitize her hands between delivery of the lunch trays and touching of other surfaces.On 12/18/25 at 12:40 PM Staff 2 (DNS) stated she expected staff to complete hand hygiene before they entered and left a room, in the dining room, in between handing out trays and when staff were in contact with the residents or their environment.

Based on interview and record review it was determined the facility failed to provide information regarding the risks and benefits for the use of psychotropic medications prior to administration for 2 of 5 sampled residents (#s 5 and 24) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include:1. Resident 5 was admitted to the facility in 3/2025 with a diagnosis of fibromyalgia (widespread chronic pain). Resident 5's 9/16/25 Quarterly MDS indicated the resident was cognitively intact with a BIMS score of 13. Resident 5's 10/2025 physician orders included amitriptyline (antidepressant) 50 mg once daily at bedtime, started on 10/21/25. There was no evidence in Resident 5's health record to indicate the resident was informed of the risks, benefits, and side effects of amitriptyline prior to administration. On 12/17/25 at 9:12 AM, Resident 5 was unable to recall details of her/his medications. On 12/18/25 at 3:02 PM, Staff 4 (LPN Resident Care Manager) reviewed Resident 5's health record and confirmed there was no evidence Resident 5 was provided the risks and benefits for the amitriptyline. 2. Resident 24 admitted to the facility in 9/2024 with diagnoses including anxiety and diabetes. A 6/5/25 physician order included sertraline 50 MG (used to treat anxiety) one time daily and a 9/16/25 physician order included trazodone 25 MG (used to treat anxiety and insomnia) at bedtime. Resident 24's 6/2025 through 12/2025 MARs revealed the resident received sertraline 50 MG daily since 6/6/25. Resident 24's 9/2025 through 12/2025 MARs revealed the resident received trazodone 25 MG nightly since 9/16/25. A review of Resident 24's medical record revealed no documentation that Resident 24 was informed of the risks and benefits for use of sertraline and trazodone prior to administration. On 12/19/25 at 8:36 AM Staff 2 (DNS) confirmed Resident 24 was not provided with the risk and benefits for use of sertraline and trazodone.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse were reported to the State Agency within two hours for 1 of 2 sampled residents (#52) reviewed for abuse. This placed residents at risk for continued abuse. Findings include:Resident 52 admitted to the facility in 11/2024 with diagnoses including anxiety and adult failure to thrive.An 11/4/25 Annual MDS revealed a BIMS score of 14 which indicated the resident had no cognitive impairment.Resident 52 passed away in the facility on 11/25/25.On 12/18/25 at 9:51 AM and at 1:49 PM Staff 16 (CNA) stated she witnessed Staff 17 (CNA) showing pictures of Resident 52's genitals to Staff 18 (CNA) on Staff 17's personal cell phone. Staff 16 stated the incident occurred in 11/2025, and she reported it to Staff 1 (Administrator) the following Monday.No evidence was found to indicate the incident was reported to the State Agency.On 12/18/25 at 11:27 AM Staff 1 and Staff 2 (DNS) stated they were unaware of any allegations of abuse related to Resident 52. Staff 1 stated she spoke with Staff 16 recently regarding a separate incident but was not told about an incident regarding Resident 52.On 12/18/25 at 2:15 PM Staff 1 and Staff 2 stated they just learned Staff 19 (Staffing Coordinator) was aware of the allegation of abuse involving Resident 52 in 11/2025 and it was not reported to the State Agency.On 12/18/25 at 2:28 PM Staff 19 stated on 12/8/25 in the morning before 8:30 AM, Staff 16 told her about an incident that occurred over the weekend that was already reported to Staff 1 and proceeded to tell Staff 19 about a different incident that involved Staff 17, Staff 18, and Resident 52 that occurred in 11/2025. Staff 19 stated she told Staff 16 to go report that incident to Staff 1 immediately. Staff 19 stated she did not follow up with Staff 1 to confirm the allegation of abuse was reported.On 12/18/25 at 5:33 PM Staff 2 stated she expected all staff to report any allegations of abuse immediately to their supervisor so the State Agency could be notified timely.

Based on interview and record review it was determined the facility failed to notify the resident in writing of the reason for transfer to the hospital for 2 of 2 sampled residents (#s 8 and 66) reviewed for hospitalization. This place residents at risk for lack of information related to transfer. Findings include:1. Resident 8 admitted to the facility in 5/2024 with diagnoses including bipolar disorder and diabetes. A review of Resident 8's medical record revealed she/he was transferred to the hospital on [DATE] due to confusion and unrelieved pain. Resident 8 re-admitted to the facility from the hospital on [DATE] with a diagnosis of septic arthritis in the right hip. A review of Resident 8's medical record revealed no indication the resident was notified in writing of the reason she/he was transferred to the hospital. On 12/18/25 at 4:34 PM Staff 2 (DNS) stated Resident 8 was not notified in writing of the reason she/he went to the hospital. 2. Resident 66 admitted to the facility in 9/5/25 with a diagnosis of pneumonia. A 10/9/25 Progress Note revealed Resident 66 experienced a change of condition and was sent to the hospital. A review of the medical record revealed no indication a written Notice of Transfer was issues to Resident 66 or her/his resident representative. On 12/18/25 at 4:53 PM Staff 24 (LPN) stated she did not issue a written Notice of Transfer to Resident 66 when she sent her/him to the hospital and was not aware it was required.

Based on interview and record review it was determined the facility failed to ensure residents received restorative therapies for 1 of 1 sampled resident (#1) reviewed for rehab services and falls. This placed residents at risk for a decline in ADLs and falls. Findings include:Resident 1 was admitted to the facility in 9/2025 with diagnoses including right leg fracture and sepsis (life-threatening medical emergency caused by the body's overwhelming response to an infection).A 9/23/25 admission MDS revealed a BIMS score of 15 which indicated the resident had no cognitive impairment.On 12/15/25 at 12:47 PM Resident 1 stated she/he was supposed to receive restorative services after skilled therapy ended, but staff had not walked or done any exercises with her/him in several weeks. On 12/16/25 at 1:20 PM Staff 21 (CNA) stated the facility had two RAs (Restorative Aides) and they completed all the restorative therapies for the residents. Staff 21 stated she did not do any exercises or ambulation with Resident 1. On 12/17/25 at 9:28 AM Staff 22 (CNA) stated there were RAs who completed all the restorative programs for the residents.On 12/17/25 at 1:43 PM Staff 4 (LPN, Unit Care Coordinator) stated Resident 1's restorative program was completed by the CNAs and there were no RAs in the facility. On 12/18/25 at 12:44 PM Staff 2 (DNS) Staff 2 stated she expected CNAs to read the care plan before each shift and follow the care plan related to the restorative program.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 7 sampled residents (#s 24 and 45) reviewed for medications and skin. This placed residents at risk for worsening wounds and unmet medical needs. Findings include: Resident 24 admitted to the facility in 9/2024 with diagnoses including chronic pulmonary embolism (when blood clots in the lung arteries don't dissolve leading to blocked blood flow) and diabetes. A review of the 12/2025 MAR revealed a 6/5/25 physician order for Eliquis (an anticoagulant) 5 MG one tablet by mouth two times a day for chronic pulmonary embolism. The 12/11/25, 12/12/25, and 12/13/25 MAR indicated the 8 AM dose was not given to Resident 24 and coded as, Other/See Progress Note by Staff 21 (LPN). A review of Resident 24's progress notes for 12/11/25, 12/12/25, and 12/13/25 revealed Eliquis 5 MG tablet was on order. No further information was documented. On 12/17/25 at 1:30 PM and on 12/18/25 at 4:49 PM Staff 21 stated if a resident was out of a medication the pharmacy and physician was notified, and she checked the Omnicell machine (an automated medication management system to securely store, track, dispense, and manage pharmaceuticals) to see if the medication was on hand. Staff 21 stated if she notified the physician and pharmacy, she would have made a progress note in the resident's chart. Staff 21 stated she did not recall if she checked the Omnicell on 12/11/25, 12/12/25, and 12/13/25 for Resident 24's Eliquis medication. On 12/18/25 at 5:28 PM Staff 2 (DNS) stated if a resident was out of a medication the nurse was to verify it was re-ordered and check if the medication was available in the Omnicell. If the medication was not available, the nurse was to call the pharmacy to satellite the order, notify the physician of a missed dose of medication and the nurse on-call was to be notified. Staff 2 stated Eliquis 5 MG tablet was a medication available in the Omnicell and stated she was the nurse on-call during the weekday. Staff 2 stated she was not notified by Staff 21 that Resident 24 missed a dose of Eliquis on 12/11/25, 12/12/25, and 12/13/25. On 12/19/25 at 8:36 AM Staff 2 provided an Omnicell Transaction by Item, Eliquis 5 MG tablet 1 each, report for a date range of 12/7/25 through 12/13/25. This report revealed the following two transactions: -12/12/25 at 7:43 PM one Eliquis 5 MG tablet was dispensed from the Omnicell for Resident 24 and there was a total of eight Eliquis 5 MG tablets on hand in the Omnicell. -12/13/25 at 7:30 PM one Eliquis 5 MG tablet was dispensed from the Omnicell for Resident 24 and there was a total of seven Eliquis 5 MG tablets on hand in the Omnicell. On 12/19/25 at 11:25 AM Staff 2 confirmed Eliquis 5 MG tablet was available in the Omnicell and should have been given to Resident 24 on 12/11/25, 12/12/25, and 12/13/25 per the physician order. 2. Resident 45 admitted to the facility in 7/2024 with a diagnosis of diabetes. A 12/3/25 physician order revealed Resident 45 was to receive wound care on her/his right shin every three days. The 12/2025 MAR revealed Resident 45 was documented to have received wound care on her/his right shin on 12/12/25 by Staff 21 (LPN) and on 12/15/25 by Staff 25 (LPN). On 12/15/25 at 4:24 PM Resident 45's right shin was observed with a dressing in place with 12/8 written on it. On 12/16/25 at 10:27 AM Resident 45's right shin was observed with a dressing in place with 12/8 written on it. Resident 45 stated her/his wound was last changed on whatever date was written on the dressing. On 12/16/25 at 10:31 AM Staff 25 confirmed Resident 45's wound care was scheduled to be completed every three days and the current dressing on her/his right shin was dated 12/8. Staff 25 stated Resident 45's wound care needed to be completed. On 12/18/25 at 12:55 PM Staff 21 stated she did not recall if she changed Resident 45's right shin dressing as scheduled on 12/12/25, but if she did, she would have signed and dated the dressing. On 12/18/25 at 3:00 PM Staff 2 (DNS) stated Resident 45's dressing was expected to be changed as scheduled and when the nurse changed dressings they were to sign and date the dressing. On 12/18/25 at 4:13 PM Staff 25 stated she saw Resident 45's 12/15/25 wound care was not completed and stated she if she signed the wound care as complete, she would have intended to complete the task but did not get to it. Staff 25 stated she did not recall if she asked another nurse to do Resident 45's 12/15/25 wound care.

Based on interview and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for antibiotic resistant organisms and unresolved infections. Findings include:The facility's 7/22/25 Antibiotic Stewardship Policy indicated the facility should follow the McGeer Criteria for assessment of residents suspected of having an infection prior to initiation of antibiotics. According to Revised McGeer Criteria for Infection Surveillance, UTI without indwelling catheter must fulfill at least one sign or symptom on a checklist. The symptoms include discomfort, fever, leukocytosis, hematuria, and/or increase in incontinence, urgency, or frequency.Resident 5 was admitted to the facility in 3/2025 with diagnoses including fibromyalgia (widespread chronic pain). Resident 5's 11/15/25-12/1/25 progress notes revealed no urinary complaints including discomfort, fever, leukocytosis, hematuria, or increased urgency/frequency/incontinence.Resident 5's health record demonstrated a UA collection occurred on 12/1/25. Resident 5's health record revealed no corresponding physician order for the UA.A 12/1/25 UA Final Result report reflected positive results for leukocytes, nitrites, protein, blood, and two or more types of bacteria. There was no evidence in the resident record to support a sensitivity was completed to identify an appropriate antibiotic to treat the UTI.A 12/4/25 Physician Order included Nitrofurantoin (antibiotic) 100 mg, one capsule by mouth twice daily for 10 days for UTI.On 12/18/25 at 4:45 PM, Staff 15 (Medical Director) reviewed the 12/1/25 UA report and confirmed it reflected positive results which supported the need for a culture and sensitivity test. Staff 15 indicated the importance of starting residents on an accurate antibiotic to eliminate bacteria causing a UTI.On 12/19/25 at 10:46 AM, Staff 2 (DNS) confirmed Resident 5's health record lacked documentation of any urinary complaints leading up to the 12/1/25 UA and acknowledged the lack of a physician order for the UA test. Staff 2 stated Resident 5's 12/1/25 UA results were indicative a culture and sensitivity should have been carried out to ensure the appropriate antibiotic was administered.

Based on interview and record review it was determined the facility failed to ensure lab services were provided when ordered for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for unnecessary blood draws. Findings include:Resident 24 admitted to the facility in 9/2024 with diagnoses including diabetes and anxiety.A 12/4/25 pharmacy recommendation revealed Resident 24 received a thyroid replacement medication but a TSH (Thyroid-Stimulating Hormone) laboratory test within the last year was not located in the resident's medical record.A 12/10/25 physician order revealed an order for a fasting lipid panel, TSH and serum magnesium concentration laboratory test scheduled for 12/10/25.A review of the 12/2025 TAR revealed the task to draw labs for a fasting lipid panel, TSH and serum magnesium concentration was completed on 12/10/25 at 5:34 AM.A review of the 12/11/25 lab results revealed results to the lipid panel and magnesium tests, but no indication of results for the TSH lab test.A review of Resident 24's record revealed no indication of the TSH lab results.On 12/18/25 at 4:15 PM Staff 4 (LPN Unit Care Coordinator) confirmed the TSH lab was not drawn for Resident 24 and should have been drawn on 12/10/25 with the lipid panel and magnesium. Staff 4 stated she expected staff to ensure lab services were provided when ordered.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from accidents and update care plans after accidents for 3 of 4 sampled residents (#s 21, 36 and 48) reviewed for accidents and non-pressure wounds. Resident 21 fell from a mechanical lift resulting in a left arm fracture and hospitalization . Findings include: 1. Resident 21 admitted to the facility in 2018 with diagnoses including left side paralysis and depression. A FRI and associated investigation dated 6/8/24 revealed Staff 43 (CNA) and Staff 44 (CNA) transferred Resident 21 using a mechanical lift that did not have required safety clips attached. As a result the left leg strap of the lift sling came off the arm of the mechanical lift and Resident 21 fell and landed on her/his left arm. Resident 21 was transferred to a local hospital and was identified to have a fractured arm. A 9/6/24 quarterly MDS indicated Resident 21 had moderate cognitive impairment. On 9/23/24 at 2:46 PM Resident 21 was interviewed and confirmed she/he fell out of the mechanical lift and went to the hospital. Resident 21 was not able to recall the specific details of her/his fall or injury, however the resident remembered the fall and stated, I fell out of the [mechanical lift] and broke my arm. On 9/25/24 at 10:19 AM Staff 10 (CNA) stated mechanical lift training was provided in CNA school, but no updated training was provided at the facility. She recalled when Resident 21 fell on [DATE] and broke her/his arm because of CNAs' failure to properly and safely operate the mechanical lift. On 9/25/24 at 2:17 PM Staff 2 (DNS) confirmed Resident 21's accident on 6/8/24 occurred because of CNAs' error in using the mechanical lift. From 9/23/24 through 9/27/24 Staff 43 and Staff 44 did not respond to multiple attempts to interview. 26991 2. Resident 36 was admitted to the facility in 4/2023 with a diagnosis of Parkinson's disease. An 4/19/24 annual MDS revealed Resident 36 had impaired mobility and was at risk for falls. A care plan initiated 4/20/23 revealed Resident 36 was at risk for falls. Interventions to prevent falls included staff were to keep her/his wheel chair within reach and to ensure brakes were locked. Staff were also to provide toileting after meals and before bed. Staff were to encourage the resident to use her/his call light and to ensure frequently used items were within reach. a. On 9/26/24 at 8:28 AM Resident 36 was in bed, her/his wheelchair was not within reach, and the wheelchair brakes were not locked. Resident 36 was observed to have a wrist call light. On 9/26/24 at 8:29 AM Staff 36 (CNA) verified Resident 36's wheelchair was not locked and not within reach. On 9/26/24 at 10:29 AM Staff 2 (DNS) stated Resident 36's wheel chair was to be locked and within reach. b. Un-witnessed Fall investigations dated 7/22/24, 7/30/24, 8/1/24, 8/2/24, 8/10/24, 8/18/24, 8/31/24, 9/24/24 and 9/26/24 revealed the following: -7/22/24 at 3:53 PM Resident 36 was found on the floor in front of the bathroom. The investigation did not include when Resident 36 was last visualized, when she/he was toileted, and where her/his wheelchair was located at the time of the fall. New interventions included staff were to ensure frequently used items were within reach (this was not a new intervention). - 7/30/24 at 5:45 AM Resident 36 was found on the floor near her/his window. Resident 36 requested to use the bathroom when staff found the resident. The investigation did not indicate when the resident was last visualized or toileted. New interventions included the resident was to use a wrist call light. The care plan was not updated to include a wrist call light. -8/1/24 at 8:00 PM Resident 36 was found at the side of her/his bed. Resident 36 reported she/he had to use the bathroom. New intervention to be implemented included for staff to remind Resident 36 to use her/his call light (this was not a new intervention). -8/2/24 at 8:00 PM Resident 36 was found on the floor near her/his bed and wheelchair. The investigation indicated Resident 36 was last checked on 10 minutes prior to the fall but did not specify if the resident was assisted with toileting. New interventions included staff were to ensure frequently used items were to be within reach (this was not a new intervention). -8/10/24 at 9:21 PM Resident was found on the floor. The resident was last observed and incontinent check done at 8:55 PM. New interventions to be implemented included keeping frequently used items within reach (this was not a new intervention). -8/18/24 at 7:10 AM Resident 36 was observed on the floor with her/his unlocked wheelchair in front of her/him. New interventions to prevent falls included to have frequently used items within reach (this was not a new intervention). -8/31/24 at 5:56 AM Resident 36 was observed between her/his bed and window. The investigation did not include when Resident 36 was last assisted. New interventions to prevent falls included to have frequently used items within reach (this was not a new intervention). -9/24/24 at 8:50 PM Resident 36 was observed on the floor near her/his bathroom. The investigation did not indicate when Resident 36 was last assisted. On 9/26/24 at 10:32 AM Staff 2 (DNS) acknowledged Resident 36's investigations did not always include information to ensure care plan interventions were followed and new interventions identified to prevent falls were already in place. c. Resident 36's post fall Neurological Check List forms (assessment for head injury: assessments were to be done every 15 minutes for one hour, every 30 minutes for two hours, every two hours for eight hours, every eight hours for 32 hours) revealed the following neurological checks: - For a 7/22/24 fall: on 7/22/24 at 3:50 PM, 4:05 PM, 4:35 PM, 5:05 PM and 6:00 PM, on 7/23/24 at 4:45 PM and 8:45 PM, and on 7/24/24 at 4:45 AM and 7:25 AM. -For a 8/18/24 fall: on 8/18/24 at 3:30 AM and 5:30 AM, on 8/19/24 at 9:30 AM and 1:30 PM, and on 8/20/24 at 1:30 PM. -For a 8/31/24 fall: on 8/31/24 at 11:30 PM, on 9/1/24 at 1:30 AM and 11:30 PM, and on 9/2/24 at 1:30 AM and 5:30 AM. -For a 9/11/24 fall: on 9/12/24 at 4:00 AM and 8:15 PM, and on 9/13/24 at 8:15 PM. -For a 9/24/24 fall: on 9/2/24 at 1:45 AM, and on 9/25/24 at 5:45 AM. On 9/27/24 at 5:08 PM Staff 2 (DNS) stated she would provide neurological assessments for the above missing dates and times. No additional information was provided. 50930 3. Resident 48 admitted to the facility in 2024 with diagnoses including chemical imbalance affecting the brain and repeated falls. An Admission MDS dated [DATE] indicated Resident 48 was cognitively intact. The MDS also revealed Resident 48 had a history of falls. Review of progress notes revealed Resident 48 had a falls on 7/12/24 and 8/10/24, and two falls on 9/21/24. Review of fall investigations and progress notes revealed staff were to place fall mats on both sides of Resident 48's bed, keep the bed in the lowest position, and keep all frequently used items within the resident's reach. A 9/23/24 review of the resident's care plan revealed the risk for falls area was not updated with the most recent falls, and no new interventions were created after any of her/his falls. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged Resident 48's care plan did not contain the interventions mentioned in the fall investigations and progress notes.

Based on observation, interview and record review it was determined the facility failed to ensure residents received appropriate pain management for 2 of 2 sampled residents (#s 41 and 52) reviewed for pain. Resident 41 was not administered pain medication for five days resulting in unresolved severe pain which limited her/his usual activities. Findings include: 1. Resident 41 was admitted to the facility in 2024 with diagnoses including pressure ulcer of the sacrum and chronic pain syndrome. A 5/2024 MAR revealed Resident 41 took oxycodone (narcotic pain medication) twice daily from 5/1/24 through 5/23/24. From 5/24/24 through 5/28/24 Resident 41 was not administered oxycodone. A quarterly MDS dated [DATE] confirmed Resident 41 was assessed to be cognitively intact. On 9/25/24 at 2:26 PM Staff 43 (CMA) stated she was frustrated the facility failed to order medications in a timely manner for Resident 41, and stated it consistently happened to other residents twice a month. She stated there was never an excuse for running out of medications, and stated if a physician was on vacation, there was an on-call physician available, and an order could be called in by the on-call physician to the pharmacy. The pharmacy provided the facility with a code to access the locked emergency medication cart. Staff 43 confirmed there was no code given to access the emergency supply of medication for Resident 41. Staff 43 confirmed from 5/24/24 through 5/28/24 Resident 41 did not receive her/his oxycodone that was ordered to be administered one tablet by mouth every four hours as needed and prior to wound care. On average Resident 41's pain level prior to receiving oxycodone was between seven and eight on a pain scale from one to 10. This constituted unresolved severe pain that prevented Resident 41 from doing her/his usual daily activities. On 9/26/24 at 9:28 AM Resident 41 stated from 5/24/24 through 5/28/24 (five days) the pain was unbearable because she/he was not given her/his usual pain medication (oxycodone) twice daily. She/he described the pain as burning, stabbing pain that was constant. Resident 41 stated her/his sacral pressure ulcer was the most painful, she/he could not get comfortable in bed, and she/he refrained from usual activity because of the severe pain. Resident 41 stated she/he laid down and waited until Tuesday until they could get a code to get into the emergency supply. Resident 41 stated on 5/28/24 it took a couple of hours before the medication relieved the pain and it was two days before baseline pain level was achieved. On 9/27/24 at 11:10 AM Staff 2 (DNS) confirmed the emergency kit for medications was not accessed over the memorial weekend. 26991 2. Resident 52 admitted to the facility on [DATE] after spinal surgery. 8/13/24 hospital admission orders revealed Resident 36 was to be administered oxycodone (narcotic pain medication) every eight hours PRN. An 8/2024 MAR revealed on 8/14/24 (day of admission) staff did not administer oxycodone to Resident 52. On 8/14/24 Resident 52 reported severe pain. Progress Notes revealed no documentation related to resident 52's pain medication. An 8/16/24 admission MDS indicated Resident 52 was cognitively intact. On 9/25/24 at 3:10 PM Resident 52 stated she/he was always in pain related to her/his surgery. On 9/25/24 at 3:19 PM Witness 9 (Pharmacy Technician) stated on 8/14/24 the pharmacy authorized facility staff to remove three doses of oxycodone from the emergency supply. On 9/25/24 at 3:35 PM and 9/26/24 at 10:36 AM Staff 2 (DNS) stated the staff had authorization to pull the oxycodone from the emergency kit but did not. Staff 2 stated Resident 52 was sent to the emergency room for pain medication and returned. Staff 2 acknowledged there was no documentation in Resident 52's record related to Resident 52's transfer to the hospital and the rationale for not administering the pain medication.

Based on observation, interview and record review it was determined the facility failed to ensure the staffing information was posted in a location easily accessible to residents and visitors. The facility also failed to post accurate and complete staffing information for 4 of 46 days reviewed for staffing. This placed residents and visitors at risk for incomplete, inaccessible, and inaccurate information. Findings include: On 9/23/24 at 11:00 AM the Direct Care Staff Daily Report was observed to be posted above standing eye level on a wall behind the nurse's station counter. On 9/24/24 at 3:12 PM the Direct Care Staff Daily Report was not filled out for the evening (2:00 PM to 10:00 PM) shift. On 9/26/2024 at 8:40 AM the Direct Care Staff Daily Report was posted without any data. Review of the Direct Care Staff Daily Reports for 8/12/24 through 9/26/24 revealed missing census data for 8/31/24 evening shift and missing nursing hours for the night shift on 9/16/24. On 9/26/24 at 12:25 PM Staff 34 (Staffing Coordinator/Admissions Coordinator) stated the staffing sheet was always posted in the observed location, and acknowledged it was hard to see from outside the nurse's station. She also acknowledged the missing data for the identified dates.

Based on observation, interview and record review it was determined the facility failed to implement enhanced barrier precautions (EBP; requires staff to wear gown and gloves with resident contact) and transmission based precautions for 2 of 3 sampled residents (#s 3 and 9) reviewed for pressure and non-pressure ulcers. This placed residents at risk for cross-contamination. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. On 9/23/24 at 12:02 PM Resident 3 was observed to have scabs and a wound dressing on her/his right shin. Resident 3's room was not identified to require EBP. On 9/24/24 at 7:50 AM Staff 25 (LPN) stated each day staff were provided a list of residents who required EBP. Staff stated Resident 3 was not on the list. On 9/24/24 at 8:15 AM Staff 2 (DNS) stated residents who had wound care should be on EBP. 2. Resident 9 admitted to the facility in 7/2024 with a diagnosis of a leg fracture. On 9/25/24 at 8:32 AM Resident 9 was observed to have a sign on the door indicating EBP and droplet precautions (mask required) when staff entered the resident's room. Staff 27 (PT) was observed standing by Resident 9 with gloves on but no mask or gown. On 9/25/24 at 9:04 AM Staff 2 (DNS) stated staff were to wear a mask when they entered Resident 9's room, and if they had contact with her/him they were to don gloves and a gown. On 9/25/24 at 9:04 AM Staff 27 stated he was not notified Resident 9 was on droplet precautions and he did not see the new sign posted by Resident 9's door for droplet precautions.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 5 of 6 staff members (#s 11, 18, 38, 39 and 40) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 5/25/18, had 10 hours and 46 minutes of documented training from 9/26/23 through 9/26/24 -Staff 18 (CNA), hired 5/18/22, had five hours and 36 minutes of documented training from 9/26/23 through 9/26/24 -Staff 38 (CNA), hired 8/2/23, had no documented training from 9/26/23 through 9/26/24 -Staff 39 (CNA), hired 3/29/18, had five hours and 52 minutes of documented training from 9/26/23 through 9/26/24 -Staff 40 (CNA), hired 4/13/22, had four hours and 41 minutes of documented training from 9/26/23 through 9/26/24 On 9/26/24 at 4:58 PM Staff 2 (DNS) stated all CNA staff were given competency evaluations upon hire and annually in March of each year. She stated in-service training was completed for CNA staff during staff meetings and via internet-based services. On 9/27/24 at 11:36 AM Staff 2 (DNS) acknowledged the identified CNA staff records did not show 12 hours of annual in-service training.

Based on interview and record review it was determined the facility failed to ensure residents were included in care planning for 1 of 2 sampled residents (#31) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 31 was admitted to the facility in 7/2022 with diagnosis including autism. A review of Resident 31's profile sheet revealed Witness 2 (Family Member) was Resident 31's responsible party and guardian. A review of Psychosocial Notes from 7/31/23 through 7/17/24 revealed the following: -10/26/23 Quarterly care conference held with Witness 2 via phone. -5/6/23 note did not indicate the meeting was a care conference and attendance did not include Witness 2. No documentation Witness 2 was invited to a care conference meeting. -7/17/24 late entry for 7/11/14 note did not indicate the meeting was a care conference meeting and did not include documentation Witness 2 was in attendance or was invited. No additional documentation was found in Resident 31's clinical record which indicated Witness 2 was invited or attended a care conference since 10/26/23. On 9/24/24 at 7:51 AM Witness 2 stated he was not invited or attended to a care conference for quite some time. Witness 2 stated it was before Staff 4 (Social Services Director) started working at the facility. A review of the facility's staff list revealed Staff 4 was hired on 4/23/24. On 9/26/24 at 12:56 PM Staff 2 (DNS) Staff 3 (Regional [NAME] President) and Staff 29 (Regional Nurse) stated they would look for additional information for care plan conferences. No additional documentation which indicated Witness 2 was invited or attended a care conference meeting since 10/26/23 was provided.

Based on interview and record review it was determined the facility failed to ensure residents' current advance directive information was reflected in clinical records for 3 of 5 sampled residents (#s 3, 45 and 51) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: 1. Resident 3 admitted to the facility in 7/2024 with a diagnosis of rib fractures. A 7/9/24 admission MDS revealed Resident 3 was cognitively intact. A care plan initiated 7/16/24 indicated Resident 3 had an advance directive and staff were to honor her/his wishes. Resident 3's clinical record did not include a copy of her/his advance directive. On 9/25/24 at 10:00 AM Resident 3 stated she/he had an advance directive and her/his medical provider had a copy of the form. On 9/25/24 at 10:10 AM Staff 4 (Social Service Director) stated upon admission a resident was provided information related to advance directives. If a resident stated she/he had an advance directive staff were to follow-up and obtain a copy for the clinical record. Staff 4 acknowledged Resident 3's care plan indicated she/he had an advance directive and her/his clinical record did not include a copy. Staff 3 also stated the hospital clinical record indicated Resident 3 had an advance directive but the hospital also did not have a copy. Staff 3 stated he did not follow-up with Resident 3 to ensure her/his clinical record included a copy of her/his advance directive. On 9/25/24 at 11:16 AM Staff 2 (DNS) stated if a resident's care plan indicated she/he had an advance directive staff were to follow-up and obtain a copy or revise the care plan as needed if the care plan was not accurate. 50930 2. Resident 45 admitted to the facility in 2024 with diagnoses including diabetes and left-sided weakness. Review of Resident 45's medical record revealed no advanced directive. Review of progress notes revealed no information indicating she/he was offered an advanced directive. On 9/26/24 at 12:47 PM Staff 4 (Social Services Director) stated all residents were offered an advanced directive and it was discussed at care conferences. He acknowledged Resident 45 had no advanced directive and no documentation of one being offered or refused. 3. Resident 51 admitted to the facility in 2024 with diagnoses including chronic obstructive pulmonary disease and surgical amputation of her/his left leg above the knee. Review of Resident 51's medical chart revealed no advanced directive. An undated facility Conference/DC Planning form revealed Resident 51 was provided information regarding an advanced directive. Review of progress notes revealed no follow up information for the advanced directive. On 9/26/24 at 12:47 PM Staff 4 (Social Services Director) stated all residents were offered an advanced directive and it was discussed at care conferences. He acknowledged Resident 51 had no advanced directive and there was no follow up documentation for the advanced directive previously offered.

Based on interview and record review it was determined the facility failed to ensure a resident representative was notified of hospitalization s for 1 of 2 sampled residents (#33) reviewed for notification. This placed resident representatives at risk for lack of care decisions. Findings include: Resident 33 admitted to the facility in 4/2023 with a diagnosis of dementia. Resident 33's clinical record indicated Witness 6 (Family Member) was Resident 33's first emergency contact. On 9/23/24 at 3:52 PM Witness 6 stated in the recent past she/he was not notified when Resident 33 was admitted to the hospital. Progress Notes revealed on 8/17/24 Resident 33 had a change of condition and was transported to the hospital for evaluation and treatment. There was no indication Witness 6 was notified. On 9/25/24 at 1:58 PM a request was made to Staff 24 (LPN IP) to provide documentation Witness 6 was notified of Resident 33's hospitalization . No additional information was received.

Based on interview and record review it was determined the facility failed to provide written notification regarding a change in coverage for 1 of 3 sampled residents (#9) reviewed for Medicare notification of non-coverage. This placed residents and their representatives at risk for unknown financial liabilities. Findings include: Resident 25 was admitted to the facility in 7/2024 with diagnosis including fracture of the left leg. A review of the 7/16/24 Admission MDS indicated Resident 9's BIMS was 9 which indicated moderate cognitive impact. A NOMNC (Notice of Medicare Non-Coverage) form was signed by Resident 9 on 7/22/24. It was not documented if her/his responsible party was contacted or made aware of the form and the effective date Medicare would no longer pay for skilled nursing services, which was 7/25/24, or how to appeal the decision if they disagreed. On 9/26/24 at 10:39 AM Witness 1 (Family Member) stated she was Resident 9's responsible party and she/he was able to understand the NOMNC form. Witness 1 stated the facility did not contact her regarding the NOMNC form, and she wondered why as the facility knew she was Resident 9's responsible party. On 9/26/24 at 10:59 AM and 11:58 AM Staff 21 (Social Services Director) and Staff 27 (Business Office) stated the protocol for the NOMNC form for a cognitively impaired resident was to notify and have the family representative present during the signing of the form. Staff 21 stated he would review a resident's BIMS score and if the resident was their own responsible party. Staff 27 stated she had Resident 9 sign the NOMNC form and she did not review Resident 9's clinical record for a responsible party. In an interview on 9/26/24 at 12:52 PM Staff 2 (DNS), Staff 3 (Regional [NAME] President) and Staff 29 (Regional Nurse) stated the expectation of staff was residents who were cognitively intact signed the NOMNC and/or a resident's representative.

Based on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were appropriately assessed and care planned interventions were implemented for 1 of 2 sampled residents (#37) reviewed for pressure ulcers. Resident 37 experienced a worsening of a Stage 3 pressure ulcer. Findings include: Resident 37 admitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 1/23/19 History and Physical indicated Resident 37 had an unspecified open wound to the right elbow that was present for approximately one month. The wound measured 0.5 cm x 0.5 cm x 0.1 cm. There was no exudate (drainage from the wound), the wound base had 100% pink granulation (new tissue). The skin around the wound was hyperpigmented (darkening of the skin). Resident 37 had no reported pain or discomfort. The Admission/Readmission Collection Tool dated 2/5/19 indicated Resident 37 had a Stage 3 pressure ulcer to the right elbow. A 2/5/19 physician order [REDACTED]. Staff were to apply [MEDICATION NAME] AG (anti-microbial dressing) to the Stage 3 pressure ulcer and secure with [MEDICATION NAME] (a border foam dressing). The order indicated wound treatments to occur every other day on day shift and staff were to off load the right elbow at all times. The 2/5/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 3 mm x 4 mm x less than 0.1 cm (0.3 cm (length) x 0.4 cm (width) x less than 0.1 cm (depth)). No odor was present, the wound was pink with granulating tissue and no tunneling noted. The assessment indicated necrotic (dead) tissue measuring 1 mm x .2 mm of black eschar (dead tissue). The assessment did not include an assessment of pain or if the response to treatment resulted in improvement or deterioration. The 2/12/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 3.8 cm x 3.0 cm x 0.1 cm. No odor was present, the wound was pink with granulating tissue and no tunneling noted. The assessment did not include an assessment of pain or if the wound response to treatment was improved or deteriorated. The 2/18/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 0.6 cm x 1.0 cm x 0.1 cm. A scant amount of drainage was noted with no odor present. The assessment did not include an assessment of the wound bed appearance, pain, or if the response to treatment had improved or deteriorated. The 2/20/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 0.2 cm x 0.4 cm x 0.1 cm. The wound was noted to improve with pink [MEDICATION NAME] tissue and granulating (beefy red) tissue was present. The wound had serous (yellow fluid with small amounts of blood) drainage present. The current treatment plan indicated to clean the wound with wound cleanser, rinse with saline and pat dry with gauze. Staff were to apply [MEDICATION NAME] AG to the ulcer and secure with [MEDICATION NAME] border foam dressing. Staff were to off-load (to remove all pressure to the affected area) pressure at all times. The assessment did not include an assessment of infection or if pain was present. The 2/28/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 0.5 cm x 1.8 cm x 0.2 cm. The wound had [MEDICATION NAME] tissue with serous drainage present. The wound had worsened with signs and symptoms of infection including generalized [MEDICAL CONDITION] to the right elbow. Resident 37 had no indication of pain and there was no change to the current wound treatment. The assessment did not indicate the physician was notified. The 3/6/19 Pressure Ulcer Status Record indicated a Stage 3 right elbow pressure ulcer measuring 1.5 cm x 1.5 cm x 0.1 cm. The wound was unchanged and had [MEDICATION NAME] tissues with serous drainage present. Signs and symptoms of infection were present including generalized [MEDICAL CONDITION] to the right elbow. Resident 37 had no indication of pain and no change to the current wound treatment. The assessment did not indicate if the physician had been notified. A review of the comprehensive care plan dated 2/19/19 revealed no information or interventions were in place regarding Resident 37's right elbow. A review of Resident 37's in room care plan (used by CNAs for resident care needs) directed staff to elevate the right elbow at all times. Random observations from 3/4/19 through 3/7/19 revealed Resident 37 was up in her/his wheelchair on multiple occasions and her/his right elbow was not off-loaded. An interview on 3/5/19 at 1:49 PM Witness 3 (Family Member) indicated Resident 37 had a wound on her/his right elbow and stated the resident had an elbow pad but could not remember if the resident ever had it on in the facility. Witness 3 further stated he thought the wound had worsened due to not having an elbow pad over the area. In an interview on 3/7/19 at 10:14 AM Staff 21 (CNA) stated Resident 37 was an extensive assist and was hard to reposition due to having a sore right elbow. She indicated when the resident was up in her/his wheelchair she would ensure Resident 37 had her/his leg foot rest in place and the resident liked to be covered with a blanket. During an interview on 3/8/19 at 10:53 AM and an observation at 12:18 PM Staff 11 (LPN) revealed the wound bed was pink with slight drainage, and she was not sure of the wound status because she had only completed the wound treatment one other time a few weeks back. The RN surveyor indicated the wound was roughly 1.0 cm x 1.5 cm and the wound bed was pale pink. During interviews on 3/7/19 at 4:20 PM and on 3/8/19 at 2:14 PM Staff 3 (RNCM) acknowledged there was no information or interventions in place for Resident 37's Stage 3 pressure ulcer to the right elbow on the comprehensive care plan. She indicated she could not speak to any of the assessments completed because she was not involved with the wound treatments. When asked what her expectations were when a wound was not improving she stated if the wound was growing in size or had drainage the physician should be notified right away. She further indicated she could not find any information that the physician was notified of the wound worsening or any new orders were put into place since the resident's admission on 2/5/19.

Based on interview and record review it was determined the facility failed to ensure residents were free from falls with injuries for 2 of 4 sampled residents (#s 28 and 256) reviewed for accidents. Resident 256 experienced a fall that resulted in a fracture. Findings include: 1. Resident 256 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. An 11/20/18 progress note revealed Resident 256 was admitted to the facility after hospitalization for a fall with injuries. A care plan dated 11/20/18 indicated Resident 256 was a fall risk with potential for injury as evidenced by a previous fall related to impaired cognition and gait/balance problems. The care plan listed fall interventions including: keep call light and frequently used items within reach, teach and the remind the resident of fall safety measures and to lock the brakes on the wheelchair before transfers. A fall risk evaluation for Resident 256 was completed on 11/20/18 and indicated the score was 20 (a score above is 10 is considered at risk for falls) and the resident's most recent fall with injuries was 11/16/18. A progress note on 11/23/18 revealed Resident 256 self-transferred to the bathroom without requesting assistance. On 11/24/18 a balance and gait assessment was completed for Resident 256 and the score was 11 (a score less than or equal to 18 is considered at risk of falling). An 11/26/18 progress note revealed Resident 256 ambulated herself/himself to the toilet and did not call for assistance before doing so. On 12/6/18 a progress note indicated Resident 256 was not following directions and standing up in her/his room without assistance. The note revealed a CNA reported the resident went to the bathroom without calling for assistance and was reminded of her/his need for assistance and fall risk status. Resident 256's medical record revealed no evaluation of the effectiveness of fall interventions and the fall interventions were not modified. Resident 256's care plan was not revised regarding her/his self-transfers to the bathroom and lack of ability to remember to use the call light reliably. A 12/7/18 progress note revealed Resident 256 was found on her/his back on the floor between the bathroom and bed. The note indicated the resident was awake but verbally non-responsive and she/he was sent to the emergency department (ED) for evaluation. According to the 12/7/18 hospital report Resident 256 was diagnosed with [REDACTED]. The resident was noted to complain of right-sided pain that correlated with the diagnosed rib fracture while at the ED. A facility investigation on 12/17/18 concluded the the resident's poor cognitive impairment and safety awareness were identified as causes for the fall. An Abuse/Adverse Event Investigation for Resident 256's 12/7/18 injury fall did not include a root cause analysis or describe interventions put in place to prevent reoccurrence. On 3/6/19 at 6:44 PM Witness 1 (Family) stated Resident 256 always wanted to get up out of the wheelchair without help and could not remember to wait for help. Witness 1 further stated the resident wanted to get up to the bathroom and repeated reminders did not help her/him remember to call the staff for assistance. When asked about the resident's [DIAGNOSES REDACTED]. Witness 1 indicated Resident 256 was checked very carefully during her/his four day hospitalization after a fall on 11/16/18 (prior to admission to facility). Witness 1 stated she was certain the physicians or hospital would have informed her if there was a fractured rib at that time. On 3/7/19 Staff 29 (PT) acknowledged Resident 256 was self-transferring and she felt the resident knew it was unsafe but she/he did the transfers anyway. On 3/8/19 at 9:25 AM Staff 3 (RNCM) acknowledged there was no evaluation or modification of fall interventions or revisions to the care plan after the resident continued to self-transfer and did not call staff for assistance for toileting. 2. Resident 28 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. An 8/8/18 Significant Change in Status Assessment indicated Resident 28 was cognitively intact and experienced two non-injury falls since admission in 2/2018. An 8/15/18 Falls CAA revealed the resident's fall risk score was 13 (score above 10 is considered at risk) and she/he had contributing factors for falls including: weakness, swelling in feet and hands, use of diuretic (fluid reducing medication), use of antianxiety medication, pain and history of two falls. A care plan dated 8/15/18 indicated Resident 28 was a fall risk with potential for injury. Fall interventions included the following: keep the call light and other necessary items close by, keep wheelchair at bedside with brakes locked, ensure the resident wears appropriate footwear, frequent visual checks with offers for toileting at specific times and instructions to not leave the resident unattended in the bathroom. A Facility Investigation dated 9/16/18 revealed Resident 28 had an unwitnessed fall and was found in her/his wheelchair with a laceration to the left cheek and skin tears to the left arm, elbow, hand and right hand. Resident 28 was transferred to the emergency department (ED) for evaluation and treatment. The 9/16/18 investigation determined the resident's wheelchair was left at the foot of her/his bed at the time of the incident. There was no evaluation of the effectiveness of fall interventions or documentation of modifications to the interventions. Resident 28's care plan was not revised after the 9/16/18 injury fall including updated fall interventions. A Facility Investigation dated 1/12/19 revealed Resident 28 experienced a fall during a transfer into the shower while a CNA assisted her/him. The resident's injuries included skin tears to both arms and on her/his back. The investigation indicated the CNA failed to use a gait belt (standard of facility care) during the transfer and did not provide appropriate footwear. According to the 1/12/19 investigation, care planned interventions were not implemented by the CNA to ensure the resident's safety. A 1/13/19 progress note revealed the CNA stated the resident lost her/his balance and slipped. The note further revealed after the CNA left the room Resident 28 stated the CNA moved the shower chair because it was in the wrong position during the transfer and that caused her/his fall. Resident 28's care plan was not revised after the 1/12/19 injury fall and there were no modifications to the fall interventions. On 3/5/19 at 10:06 AM Resident 28 revealed she/he had several falls including one near the bed after someone moved the wheelchair away from the side of the bed. The resident stated she/he used the call light and when no one answered she/he got out of bed and slipped, hitting her/his head. Resident 28 stated another fall occurred when a CNA took her/him to the shower room and the shower chair was not in the correct position. Resident 28 said the CNA moved the shower chair during the transfer which caused her/him to fall. The resident stated she/he did not think the falls were her/his fault. On 3/7/19 at 10:42 AM Staff 25 (CNA) indicated Resident 28 was alert and able to participate in transfers. Staff 25 stated the resident had her/his own shower chair and required one-person assist during showers. On 3/7/19 at 4:59 PM Staff 24 (CNA) revealed the resident was prone to self-transferring to her/his bed and was not consistent with using the call light appropriately. On 3/8/19 at 2:49 PM Staff 13 (LPN Unit Nurse) acknowledged there was a lack of documentation to show fall interventions for Resident 28 were evaluated to determine effectiveness and no modifications were made after she/he experienced falls with injuries. Staff 13 further acknowledged fall interventions were not followed regarding the resident's fall in the shower on 1/12/19.

Based on observation, interview and record review it was determined the facility failed to implement policies and procedures to prevent abuse for 1 of 2 sampled residents (#1) reviewed for abuse. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, there was an allegation of sexual abuse to Resident 1 and the facility did not implement their policy to complete a thorough investigation and incident report. Facility's Policy Reporting Alleged Abuse Revised 2/7/17 revealed the following: The five-day report: Facilities must satisfy the federal requirement to report the results of an investigation within five working days from the date of the incident (or knowledge of the incident). Any report after that time will be considered out of compliance with regulation. Resident 1 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. An 10/9/18 Quarterly MDS revealed Resident 1's Brief Interview of Mental Status indicated severe cognitive impairment with a score of five. On 11/2/18 at 9:34 AM Witness 1 (Complainant) stated he heard on 10/27/18 Resident 1 was touched inappropriately by another resident. On 11/2/18 at 10:09 AM Staff 7 (LPN Unit Nurse) stated she spoke to Resident 1 after the incident on 10/27/18 and the resident was distraught, tearful and extremely fidgety. Resident 1 kept cleaning her/his glasses. Staff 7 stated Resident 1 reported she/he did not want to get Resident 9 in trouble. On 11/2/18 at 10:31 AM Resident 1 stated the facility treated her/him well. Resident 1 was asked if she/he felt safe in the facility. Resident 1's facial expression changed and she/he looked anxious and started to twist at her/his shirt over and over. On 11/2/18 at 10:33 AM Staff 1 (Administrator) confirmed she did not completed an investigation and incident report for alleged sexual abuse to Resident 1 on 10/27/18. On 11/2/18 at 12:54 PM Staff 1 and Staff 2 (DNS) were informed of the failure of current measures used by the facility to ensure implementation of the facility's policy to complete an investigation within five working days from date of incident and to report the results. The failure constituted a situation of immediate jeopardy to the health and welfare for residents. A plan of correction was requested to immediately protect residents from harm. On 11/2/18 at 5:18 PM a final immediate plan of correction was received from the facility The facility's immediate plan of correction included: -Complete a formal investigation. -Alleged perpetrator will not visit the facility during investigation. -Interview residents to determine if any were fearful, experienced or observed abuse. -Educate staff on identifying abuse, how to report alleged abuse safeguard residents during investigation and immediately initiating investigation of all alleged abuse. -DNS responsible for assuring compliance. On 11/2/18 at 5:47 PM the plan was verified as implemented removing the immediate risk to residents health and welfare.

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of abuse for 1 of 2 sampled residents (#1) reviewed for abuse. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, there was an allegation of sexual abuse to Resident 1 and the facility failed to report the allegation within the required timeline. Facility's Policy Reporting Alleged Abuse Revised 2/7/2017 Federal requirements mandate that facilities must ensure all allegations of abuse, neglect, exploitation, or mistreatment are reported immediately to their state survey agency. Resident 1 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. An 10/9/18 Quarterly MDS revealed Resident 1's Brief Interview of Mental Status score was a five indicating severe cognitive impairment. On 11/2/18 at 9:34 AM Witness 1 (Complainant) stated he heard Resident 1 was touched inappropriately by another resident. Witness 1 reported the incident happened on 10/27/18. On 11/2/18 at 10:09 AM Staff 7 stated she spoke to Resident 1 after the incident and the resident was distraught, tearful and extremely fidgety. Resident 1 kept cleaning her/his glasses. Staff 7 stated Resident 1 told Staff 7 she/he did not want to get Resident 9 in trouble. On 11/2/18 at 10:33 AM Staff 1 (Administrator) stated after interviewing Resident 1, Resident 9 and Staff 6 she did not believe the incident occurred so did not report the alleged sexual abuse. Staff 1 stated she made some notes but did not complete an incident report. On 11/2/18 at 12:54 PM Staff 1 and Staff 2 (DNS) were informed of the failure of current measures used by the facility to ensure allegations of sexual abuse were reported to the State Survey Agency. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately protect residents from harm. On 11/2/18 at 5:18 PM a final immediate plan of correction was received from the facility The facility's immediate plan of correction included: -Interview residents to determine if any were fearful, experienced or observed abuse. -Alleged perpetrator will not visit the facility during investigation. -Educate staff on identifying abuse and how to report alleged abuse. -DNS responsible for assuring compliance. On 11/2/18 at 5:47 PM the plan was verified as implemented removing the immediate risk to residents health and welfare. On 11/5/18 at 11:29 AM Staff 6 (CNA) stated on 10/27/18 between 1:30 and 1:45 PM she was standing in the hall and heard a ruckus in Resident 1's room. Staff 6 entered the room and observed Resident 9's hand up Resident 1's shirt and Resident 9's other hand on Resident 1's leg. Staff 6 stated Resident 1 was crying. On 11/5/18 at 10:18 AM and 10:37 AM Staff 3 (PT Assistant) stated he left a message regarding the alleged sexual abuse on the National Abuse phone line on 10/27/18 at 4:20 PM and to the State Survey agency on 10/31/18.

Based on interview and record review it was determined the facility failed to investigate alleged sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, there was an allegation of sexual abuse to Resident 1 and the facility did not complete an investigation. Resident 1 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. An 10/9/18 Quarterly MDS revealed Resident 1's Brief Interview of Mental Status score was a five indicating severe cognitive impairment. On 11/2/18 at 9:34 AM Witness 1 (Complainant) stated he heard on 10/27/18 Resident 1 was touched inappropriately by another resident. On 11/2/18 at 10:09 AM Staff 7 stated she spoke to Resident 1 after the incident and the resident was distraught, tearful and extremely fidgety. Resident 1 kept cleaning her/his glasses. Staff 7 stated Resident 1 told Staff 7 she/he did not want to get Resident 9 in trouble. On 11/2/18 at 10:31 AM Resident 1 stated the facility treated her/him well. Resident 1 was asked if she/he felt safe in the facility. Resident 1's facial expression changed and she/he looked anxious and she/he started to twist at her/his shirt repeatedly. On 11/2/18 at 10:33 AM Staff 1 (Administrator) stated after interviewing Resident 1, Resident 9 and Staff 6 she did not believe the incident occurred so did not report the alleged sexual abuse. Staff 1 stated she made some notes but did not complete an incident report. On 11/2/18 at 12:54 PM Staff 1 and Staff 2 (DNS) were informed of the failure of current measures used by the facility to ensure allegations of abuse were timely and thoroughly investigated. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately protect residents from harm. On 11/2/18 at 5:18 PM a final immediate plan of correction was received from the facility The facility's immediate plan of correction included: -Complete a formal investigation -Interview residents to determine if any were fearful, experienced or observed abuse. -Alleged perpetrator will not visit the facility during investigation. -Educate staff on identifying abuse, how to report alleged abuse safeguard residents during investigation, and immediately initiating investigation of all alleged abuse. -DNS responsible for assuring compliance. On 11/2/18 at 5:47 PM the plan was verified as implemented removing the immediate risk to residents health and welfare.

Based on the immediate jeopardy in the areas of Develop/Implement Abuse/Neglect Policies, Reporting of Alleged Violations and Investigate/Prevent/Correct Alleged Violations it was determined the facility was not administered by the management team in an effective and efficient manner. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, there was an allegation of abuse to Resident 1 and the facility did not implement their policies, complete a thorough investigation, and report the allegation in the required timeline. Resident 1 was admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. A 10/9/18 Quarterly MDS revealed Resident 1's Brief Interview of Mental Status was a five indicating severe cognitive impairment. On 11/2/18 at 9:34 AM Witness 1 (Complainant) stated he heard Resident 1 was touched inappropriately by another resident. Witness 1 reported the incident occurred on 10/27/18. On 11/2/18 at 10:09 AM Staff 7 stated she spoke to Resident 1 after the incident and the resident was distraught, tearful and extremely fidgety. Resident 1 kept cleaning her/his glasses. Staff 7 stated Resident 1 told Staff 7 she/he did not want to get Resident 9 in trouble. On 11/2/18 at 10:33 AM Staff 1 (Administrator) stated after interviewing Resident 1, Resident 9 and Staff 6 she did not believe the incident occurred so she did not report the alleged sexual abuse. Staff 1 stated she made some notes but did not complete an incident report or an investigation. Refer to F-607, F-609 and F-610 for additional information.

Based on interviews and record review it was determined the facility failed to ensure a medical appointment was scheduled as ordered and failed to monitor when for 1 of 3 sampled residents (# 3) went to their scheduled appointment. Resident 3's orthopedic appointment was not scheduled as ordered and the resident developed a full-thickness skin loss on her/his right hand. Findings include: Resident 3 was admitted to the facility in September, 2014 with [DIAGNOSES REDACTED]. S/he wore a right forearm and right hand volar splint (a hard surface splint which left the resident's fingertips exposed.) The hospital's Nursing Transfer Summary dated 9/10/14 documented the resident had an unstageable pressure ulcer (full-thickness skin loss) on her/his coccyx and a Stage 2 pressure ulcer (partial-thickness skin loss) on her/his left heel. The summary indicated there were no other pressure ulcers present when the resident was admitted to the facility on [DATE]. The physician's orders [REDACTED]. The Nursing Progress Notes dated 9/12/14 through 9/16/14 indicated the resident was hospitalized for [REDACTED]. The Initial Data Collection Tool dated 9/16/14 documented the resident was readmitted from the hospital on [DATE] with an unstageable pressure ulcer on her/his coccyx and an unstageable pressure ulcer on her/his left heel. An unstageable pressure ulcer is defined as a wound bed on a bony prominence which is covered with either slough (string-like tissue) or eschar (devitalized tissue). The Nursing Progress Notes dated 9/10/14 through 9/21/14 did not indicate the resident was seen by Witness 6 (Orthopedic Physician). The physician progress notes [REDACTED]. The note indicated the PCP requested her staff to make "a follow-up with Witness 6." The Physician's Progress Note dated 10/9/14 indicated Witness 6 documented the x-rays of the resident's right hand showed "significant advanced arthritic changes." The note revealed Witness 6 removed the resident's splint on her/his right upper extremity and he saw a "severe full-thickness skin defect down to flexor tendon sheath of the thumb on the right hand." He described the resident's right hand wound as not showing signs of an infection, bleeding or devitalized tissue. Witness 6 documented the resident's right hand wound was covered with a moist dressing and s/he was referred to the wound clinic and a "hand specialist." The exposed tendon and full-thickness skin loss signified the presence of a Stage 4 pressure ulcer. On 12/17/14 at 2:25 pm Staff 15 (LPN) indicated when a physician's orders [REDACTED]. Staff 15 indicated the orders were reviewed and signed by a facility Licensed Nurse (LN) to be sure the orders were taken care of correctly. On 12/17/14 at 2:35 pm Staff 3 (RNCM) was shown the physician's orders [REDACTED]. She stated the appointment book indicated Resident 3's appointment with Witness 6 occurred on 10/9/14 and there was no documentation which showed the facility tried to make the resident's appointment within two weeks as ordered on [DATE]. On 12/18/14 at 1:55 pm Staff 8 (Ward Clerk) stated when she took a resident's admission physician's orders [REDACTED]. She was informed Resident 3's physician's orders [REDACTED]. She was informed the log book did not show the resident had an appointment with Witness 6 until 10/9/14. Staff 8 indicated the order was not carried out correctly if the facility did not try to schedule the appointment within two weeks. On 12/22/14 at 9:44 am Witness 6 (Orthopedic Physician) stated the resident's splint was removed at his office on 10/9/14 and the splint had been "embedded into the web space between the thumb and first finger. There was no sign of infection, no redness and no weepy drainage even though there was exposed tendon. It was not down to the bone and I'd have sent the resident to the hospital right away if it had looked bad.." On 12/23/14 at 8:40 am Staff 2 (DNS) indicated there was no documentation which showed staff were unsuccessful when they tried to make Resident 3's appointment with Witness 6. On 12/23/14 at 8:45 am Witness 8 (Regional Director of Clinical Services) stated the facility did not make the resident's appointment with (Witness 6) timely and as ordered on [DATE]. She acknowledged Resident 3 developed a full-thickness pressure ulcer on her/his right hand.

Based on observation, interview and record review it was determined the facility failed to prevent dehydration and to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (#21) who was reviewed for tube feeding. As a result of the facility's failure to monitor weights and re-evaluate the impact of interventions the resident experienced severe (greater than 5% in one month) weight loss and dehydration. Findings include: Resident 21 was admitted to the facility 5/8/14 with [DIAGNOSES REDACTED]. The goal of the Temporary Care Plan dated 5/8/14 was to minimize potential for dehydration and maintain or gain weight. The Nutritional Status CAA in the Admission RAI dated 5/22/14 indicated Resident 21 had experienced a 60 pound weight loss in the past 1-2 years. The resident had a poor appetite and a PEG tube (a tube surgically inserted directly into the stomach to provide nutrition and hydration) was being considered. NN dated 5/12/14 identified Resident 21 weighed 133 pounds. Day Surgery Prep Instructions indicated Resident 21 was NPO after midnight 5/14/14 for PEG tube insertion scheduled 5/15/14. NN dated Thursday 5/15/14 identified Resident 21 returned to the facility with a PEG tube and unclear tube feeding orders. The on-call physician gave orders to keep the resident NPO until the attending physician could be contacted during office hours the following day. On Friday 5/16/14 at 3:17 pm a Resident at Risk (RAR) Dietary Note was entered by Staff 25 (Registered Dietician) and Staff 3 (RNCM). The note indicated Resident 21 was eating 89% of most meals and weighed 139 pounds. This contradicted physician orders [REDACTED]. There was no evidence in the medical record a re-weigh was done on Friday 5/16/14. NN did not indicate the facility attempted to contact the attending physician to obtain clarification for tube feeding orders on the same date. NN dated Saturday 5/17/14 at 7:23 pm identified Resident 21 had abdominal distention, pain and had vomited. The on-call physician said to call the surgeon. The on-call surgeon ordered to keep the resident NPO until the attending physician was back in the office Monday 5/19/14. NN dated Sunday 5/18/14 at 9:21 am identified Resident 21 had less abdominal distention and pain. "Chief concern this morning is risk of dehydration." The on-call physician was contacted and ordered an evaluation by a speech therapist that morning. On 5/18/14 at 10:13 am NN indicated Resident 21 was evaluated and found to be safe drinking honey-thick liquids by mouth. No nutrition was ordered via PEG tube or PO. On 5/18/14 the Weight History indicated Resident 21 weighed 123 pounds. This represented a 10 pound weight loss in six days. NN dated Monday 5/19/14 at 3:00 pm indicated the attending physician was out of the office until 5/21/14 and the surgeon was not available until 5/29/14. Witness 5 was concerned about the resident's nutritional/protein intake so the nurse gave the resident healthshakes despite not having a physician's orders [REDACTED]. On Wednesday 5/21/14 at 12:23 am NN indicated Resident 21 had returned from the appointment with the surgeon with unclear tube feeding orders. The on-call physician refused to clarify and ordered staff to wait until the attending physician was available in the morning. The resident had a low grade fever and was confused regarding the time of day. There was no evidence in the medical record the facility had attempted to contact Staff 27 (Medical Director) to obtain clarification of tube feeding orders or discuss possible intravenous fluid to prevent dehydration. NN on 5/21/14 at 2:26 pm indicated the resident was at Bay Area Hospital to confirm PEG tube placement and for a repeat swallow study. No tube feeding clarification had been obtained. NN on 5/21/14 at 11:14 pm indicated Resident 21 had returned to the facility earlier at 6:00 pm with concentrated urine and exhaustion to the point of needing a two-person assist to get to bed, instead of one. The attending physician reported the resident had failed the swallow study and was NPO. Tube feeding (TF) could be started the next morning at 10 ml/hour and staff were to call him 5/22/14 at 3:00 pm with an update. physician's orders [REDACTED]. If tolerated, increase the rate to 83 ml/hour x 18 hours on the second day. NN indicated the progression of the resident's tube feeding: -5/22/14 TF tolerated at 10 ml/hour -5/22/14 at 2:30 pm TF increased to 40 ml/ hour -5/23/14 at 2:57 pm the tube feeding was noted at 10 ml/hr and was increased to 40 ml/hr (should have been 83 ml/hour) -5/23/14 at 9:00 pm tube feeding running at 83 ml/hour -5/24/14 at 10:51 am tube feeding running at 40 ml/hour and increased to 60 ml/hour (should have been 83 ml/hour) -5/24/14 at 2:00 pm tube feeding running at 60 ml/hour and increased to 83 ml/hour (should have been 83 ml/hour). A 5/23/14 RAR Dietary Note written by Staff 3 (RNCM) identified the resident weighed 123 pounds, was on tube feeding at 40 ml/hour and was receiving water boluses. It failed to note the resident had lost 16 pounds from the previous RAR note and failed to assess and evaluate the past week's lack of hydration and nutrition and how it impacted the resident. On 5/25/14 the Weight History indicated Resident 21's weight was 138 pounds. There was no evidence a re-weigh was done despite a 15 pound gain from a week prior. The 5/29/14 RAR Dietary Note identified, "If this weight is up it is probably (due to her/his) having been dehydrated." The admit weight of 131 pounds and current weight of 138 pounds "this week" were mentioned; however, the weight of 123 pounds mentioned in the RAR Note one week earlier was not identified. By 6/2/14 the attending physician ordered daily weights for Resident 21. On 6/6/14 Staff 25 (Registered Dietician) recommended increasing Resident 21's tube feeding to 90 ml/hour for 23 hours/day due to a current weight of 122 pounds. This represented a weight loss of 16 pounds in 11 days. On 7/1/14 at 12:07 pm Witness 5 stated she was frustrated because Resident 21 was admitted to the facility to gain weight and get strong and instead the resident lost weight. Witness 5 stated it was hard to tell how much weight was lost because the resident wasn't being weighed everyday, some weights were obvious errors, and staff recorded the weights in several different places. "They got 131 to 123 pounds and it seems like it should have raised some eyebrows but it didn't, and this is a (person) who was here because (she/he) was basically starving (her/himself) to death." According to Witness 5, Resident 21 became incontinent during that time and was exhausted and difficult to arouse one morning. Staff 25 was interviewed on 7/1/14 at 4:45 pm. She stated the "transition" was difficult because Resident 21 was suddenly NPO, it was difficult to get a hold of the doctor and it was the weekend. On 7/1/14 at 5:50 pm Resident 21 was observed to be gaunt while receiving tube feeding and consuming oral fluids. The resident's diet had just been upgraded to nectar thick fluids. Staff 27 (Medical Director) was interviewed on 7/2/14 at 2:29 pm. He was unaware of Resident 21's significant weight loss in one week and the facility's difficulty obtaining orders from surgeons, attending physicians and on-call physicians. He confirmed the facility could have monitored weights more and stated it was standard to do three daily weights upon admission. Staff 27 often recommended daily weights for a week then three times weekly. He stated adequate hydration was important. Staff 2 (DNS) was interviewed on 7/2/14 at 2:51 pm. She stated the facility's protocol for weighing residents included a weight on admission, daily weights x 3 days, then weekly on Sundays, then monthly once stable as determined by the RAR committee. Staff reweighed residents if a 3 pound gain/loss was noted. Staff 2 stated she reviewed weights on Mondays and asked for reweights if it had not already done. When asked about Resident 21's weight history she read weights aloud from the Resident at Risk notes: -5/8/14 = 131 pounds -5/16/14 = 139 pounds -5/23/14 = 123 pounds -5/29/14 = 138 pounds "It doesn't sound right," she stated. She was unable to determine from the chart if re-weighs had been done. The May 2014 Dietary Monthly Flow Report for Resident 21 was provided by the facility on 7/2/14 at 5:56 pm. It indicated 11 meals were served and eaten by the resident between the day the PEG tube was inserted on 5/15/14 and 5/20/14. On 7/3/14 at 12:35 pm Staff 3 (RNCM) confirmed she was on the RAR committee. She was unable to explain the apparent inaccuracies of the May 2014 Dietary Monthly Flow Report. When asked about Resident 21's greatly varying weights she stated "we thought some of the weights were spurious" and CNAs were supposed to reweigh residents if there was a three pound weight difference from the previous weight, and they were supposed to have a charge nurse observe the reweigh. When asked if staff failed to reweigh Resident 21 she replied, "apparently." The discrepancies between physician's orders [REDACTED]. She stated she had noticed that, too. Staff 2 contacted dietary and confirmed Resident 21 had not received any meal service from the kitchen from 5/15/14 through 6/30/14. Staff 2 was unable to explain the meals documented as eaten in the Dietary Monthly Flow Report.

Based on interview and record review it was determined the facility failed to have a functioning QAA program to identify areas of concerns and events contributing to harm related to feeding tube management, infection control and CNA staffing concerns. This placed residents at increased risk for medical complications [REDACTED]. On 6/30/14 at 9:00 am Staff 1 (Administrator) stated the QAA meetings were held monthly with the Administrator, DNS, RNCM, Housekeeping Supervisor, Maintenance, Activity Coordinator, Social Service Designee, Registered Dietician and the Medical Director. On 7/3/14 Staff 1 stated the facility was focusing on staffing recruitment within the local community and had plans that included newspaper ads, financial incentives, reaching out to all local CNA's, nursing school and employment agency and open house/BBQ. Staff 1 did not identify the need to meet minimum requirements or resident needs as related to staffing concerns. Staff 1 stated the facility's QAA program utilized trends and patterns for infection control concerns but had not addressed the three current residents in isolation as a QAA need. Staff 1 was questioned regarding how staff would bring concerns to the QAA committee. He stated there were comment cards at the nurse's station that anybody was encouraged to fill out. The cards would be brought to the daily standup meetings and the appropriate department would address the concerns. Refer to F322.

Based on observations, interview and record review it was determined facility staff failed to implement care planned interventions to prevent injury for 1 of 3 residents (# 1) who were at risk for injury during transfers. Resident 1 sustained a laceration to the left leg which required sutures. Findings include: Review of the Oregon State Board of Nursing, Authorized Duties and Standards for Certified Nursing Assistants [PHONE NUMBER] revealed, (6) Standards of Care for Certified Nursing Assistants. "In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse." Resident 1 was admitted to the facility in 8/2012 with [DIAGNOSES REDACTED]. According to an admission assessment the resident required extensive assistance with transfers. The resident was care planned to require two-person assistance with transfers. According to a 9/25/12 incident investigation a two-person transfer was required due to the resident's tendency to extend the legs and lean back during transfers. The resident was unpredictable and a one-person transfer was considered unsafe. On 9/21/12 the resident was transferred by Staff 1, CNA, from the bed to wheelchair. During the transfer the resident's legs extended out and the left leg caught on the leg rest attachment point. The resident sustained [REDACTED]. The resident was transported to the hospital and received sutures to close the laceration. The investigation concluded the CNA did not follow the care plan and performed a one-person transfer which caused the leg laceration. In an interview on 10/3/12 at 2:15 pm Staff 1, CNA, stated he was oriented to resident care plans and knew where they were located. Staff 1 did not know the resident required a two-person transfer because he did not look at the care plan. Staff 1 stated he transferred the resident alone one time before. In an interview on 10/4/12 at 9:00 am Staff 2, DNS, stated Staff 1 was oriented to resident care plans when he started employment. Refer to F-323 for additional information.

Based on observations, interview and record review it was determined the facility failed to implement care planned interventions to prevent injury for 1 of 3 residents (# 1) who were at risk for injury during transfers. Resident 1 sustained a laceration to the left leg which required sutures. Findings include: Resident 1 was admitted to the facility in 8/2012 with [DIAGNOSES REDACTED]. The resident was care planned to require two-person assistance with transfers. According to a 9/25/12 incident investigation a two-person transfer was required due to the resident's tendency to extend the legs and lean back during transfers. The resident was unpredictable and a one-person transfer was considered unsafe. On 9/21/12 the resident was transferred by Staff 1, CNA, from the bed to wheelchair. During the transfer the resident's legs extended out and the left leg caught on the leg rest attachment point. The resident sustained [REDACTED]. The resident was transported to the hospital and received sutures to close the laceration. The investigation concluded the CNA did not follow the care plan and performed a one-person transfer which caused the leg laceration. On 10/3/12 at 1:30 pm the resident was observed in bed. The resident stated the left leg was injured when transferred by one CNA. The resident stated the injury was not painful. The resident stated two CNAs normally assisted with transfers. The one-person transfer happened only one time. In an interview on 10/3/12 at 2:15 pm Staff 1, CNA, stated he was oriented to resident care plans and knew where they were located. Staff 1 did not know the resident required a two-person transfer because he did not look at the care plan. Staff 1 stated he transferred the resident alone one time before. In an interview on 10/4/12 at 9:00 am Staff 2, DNS, stated Staff 1 was oriented to resident care plans when he started employment. .

Based on interview and record review it was determined the facility failed to provide the necessary care and services which resulted in a fall for 1 of 4 sampled resident's (# 1) who had experienced falls. Resident 1 had three falls in one day. The third fall resulted with the resident sustaining an avoidable fractured wrist. Findings include: Resident 1 was admitted to the facility in the fall of 2010. [DIAGNOSES REDACTED]. The Interim Care Plan dated 9/18/10 indicated the resident required assistance from staff for most ADLs. The care plan indicated the resident was at risk for injury from falls. Contributing factors included history of falls, use of pain medication and visual problems. The interventions listed were to have two staff members for transfers, use hip protectors and the resident was to have a low bed. The Nursing Care Directives, used by the CNAs to provide care were not available. Resident 1 had discharged from the facility, that document was not saved as part of the medical record. Information was confirmed with Staff 2 (DNS) on 11/2/10 at 1:20 pm. The admission MDS dated [DATE] indicated the resident had short term memory deficits and was dependant on staff for most ADLs. The MDS indicated the resident was at times resistive to care. According to the "Incident Follow-up & Recommendation Form" dated 10/31/10 at 5:55 am, Resident 1 was found on the floor of the resident's room. The facility's investigative report indicated that "no new interventions were initiated." On 10/31/10 at 1:55 pm, the Incident Follow-up Form indicated that Resident 1 was again found on the floor next to the bed. According to the report the resident's bed was in the lowest position and hips guards were on. The recommendations/actions taken (portion of the form) indicated "the CNAs were instructed to place an alarm but they got busy and forgot." On 10/31/10 at 5:00 pm, Resident 1 fell for the third time and complained of left wrist pain. The "Summary of Investigative Facts" indicated the resident had "two non-injury falls earlier in the day. The CNAs were asked to put a tab alarm on the resident but they forgot." Recommendations were to place an alarm in the resident's chair and bed as well as put fall mats down on both sides of the bed. The nurses notes dated 10/31/10 at 5:55 am, indicated the resident was found on the floor on the window side of the bed. The resident did not know what had happened. The nurse documented that a gait belt and two staff members assisted the resident back to bed. No injuries were noted. On 10/31/10 at 1:55 pm, the nurses notes indicated the resident was found on the floor next to the bed. No apparent injuries were noted and neuro checks were instituted. The resident was assisted back to bed. The nurse documented there were no new orders from this fall or the previous fall. At 5:00 pm on 10/31/10 the nurses notes indicated the resident fell and was found between the two beds in the room. The resident complained of left wrist pain, the nurse documented there was increased swelling and bruising. An alarm was put on the resident's bed. The physician ordered lab work and a urinalysis to be done right away. At 6:35 pm, the resident was sent to the Hospital's emergency room due to swelling of the left wrist. A fractured wrist was confirmed, the resident returned to the facility at 9:40 pm, with new orders from the Physician. Staff 13's (RN) investigative recapitulation report dated 11/1/10 indicated she knew from the shift report that Resident 1 had fallen earlier that morning. Staff 13 indicated she had asked the CNAs if the resident had a tab alarm on. "I did not get a clear answer from them." At the end of her shift, Staff 13 documented she gave report to the evening nurse, that included information about the resident's falls. Staff 13 informed Staff 12 (evening nurse) the CNAs did not answer her whether the resident had the alarm. On 12/2/10 at 11:40 am, Staff 2 (DNS) stated the resident fell on [DATE] which was a Sunday, she was notified of the fall on Monday 11/1/10. Staff 2 stated the resident had sustained a fractured wrist after several falls that day. Staff 2 stated "the day shift nurse on duty 10/31/10 (during report) asked the CNAs to institute a tab alarm for the resident however, they all thought someone else obtained the alarm and put it on the resident." Staff 2 stated none of the CNAs got the tab alarm after the second fall as they were instructed to. The nurse did not follow up and assess the resident to see if the tab alarm had been instituted. On 11/2/10 at 3:05 pm, Staff 4 (RNCM) stated the resident had a history of [REDACTED]. Staff 4 stated that Resident 1 had a low bed and wore hip pads. Resident 1 was scheduled to discharge to a foster home on 11/1/10 but stayed a few extra days due to the fractured wrist. Staff 4 stated on Monday 11/1/10 during their morning stand up meeting, she informed Staff 2 (DNS) about the resident's falls and the fractured wrist. Staff 4 stated the resident had a history of [REDACTED]." Staff 4 stated it appeared on 10/31/10 the resident was experiencing more confusion than usual. On 12/7/10 at 1:30 pm, Staff 11 (CNA) stated she was one of the CNAs that worked on 10/31/10. She felt terrible that Resident 1 fell and sustained a fractured wrist that evening. She was orienting that evening and "thought someone else gotten the tab alarm."