Every finding on record at Life Care Center of McMinnville

Based on observation, interview and record review it was determined the facility failed to ensure residents were free of significant medication errors for 1 of 6 sampled residents (#53) reviewed for medications. This placed residents at risk for medication errors. Findings include:Resident 53 admitted to the facility in 2/2026 with diagnoses including Parkinson's and orthostatic hypotension (a sudden drop in blood pressure upon sitting or standing). The 2/26/26 admission MDS revealed a BIMS of 12 indicating a moderate cognitive impairment, but no delirium, inattention, or disorganized thinking. Resident 53 was assessed to be at risk for falls and required assistance with mobility and ADLs. The 2/26/26 Care Plan indicated Resident 53 was at risk for rehospitalization due to Parkinson's and falls. A 2/26/26 Physician Order revealed a prescription for 1.5 tablets of Carbidopa-Levodopa (a medication used to treat Parkinson's Disease) 25-200 MG every 3 hours. The facility scheduled this medication to be given at 2:00 AM, 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, 8:00 PM, and 11:00 PM.A timestamped administration history of Resident 53's Carbidopa-Levodopa from 3/1/26 at 11:00 PM through 3/10/26 at 8:00 AM showed 18 of 76 (24%) administrations exceeded the one-hour grace period. On 3/8/26 at 2:03 PM Resident 53 was observed sleeping in bed with Witness 4 (Family Member) sitting at bedside. While sleeping, Resident 53 periodically sat up, punched into the air, and demonstrated all over body tremors. Witness 4 gestured toward Resident 53 and stated she was concerned about the timing of her/his Carbidopa-Levodopa. Witness 4 stated the facility was able to give the medication an hour before or after its scheduled time, but the timing did not always work out well for the resident. On 3/9/26 at 10:21 AM Resident 53 was in her/his wheelchair awake, alert, and conversational with no involuntary movements or tremors observed. Resident 53 stated the timing for her/his Parkinson's medication was very important and bypassed her/him going into a reactionary state when given on time every three hours. Resident 53 reported she/he was in a reactionary state earlier that morning due to her/his medication being given late. Resident 53 stated her/his arms were flailing and she/he hit her/his heel on the edge of the bed, which caused pain. Resident 53 stated during a reactionary state she/he often felt jittery, anxious, fearful, and disoriented. Resident 53 acknowledged both she/he and Witness 4 communicated the importance of medication timing to the facility. On 3/11/26 at 9:10 AM Staff 3 (LPN) acknowledged a one-hour grace period for administering timed medications. Staff 3 indicated Carbidopa-Levodopa was considered a time sensitive medication but was unable to provide a reason for late administrations to Resident 53. Staff 3 identified increased tremors as a possible side effect of receiving a late dose of Carbidopa-Levodopa. On 3/11/26 at 3:10 PM Staff 25 (RN) stated the facility policy allowed for medications to be administered within one hour before or after the scheduled time. Staff 25 was unable to identify any reason Resident 53's Carbidopa-Levodopa was repeatedly given outside the one-hour grace period window. Staff 24 (Medical Director) stated in a 3/11/26 email the expectation for medication administration times was within one hour either before or after the scheduled administration time. Staff 24 acknowledged possible increased rigidity or tremors if administration of Carbidopa-Levodopa exceeded one hour outside the scheduled time.On 3/11/26 at 3:54 PM Staff 2 (DNS) acknowledged the repeatedly late administrations of Carbidopa-Levodopa to Resident 53, and stated facility staff was not used to giving medications with specific administration times.

Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained, and failed to ensure proper labeling of biologicals for 1 of 1 medication room and 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication. Findings include:1. On 3/9/26 at 9:02 AM an open Humalin N insulin pen was observed in the C hall treatment cart with no open date.On 3/9/26 at 9:02 AM Staff 3 (LPN) acknowledged the insulin pen was open and not labeled with an open date.On 3/12/26 8:15 AM Staff 2 (DNS) stated the expectation was for insulin pens to be labeled with open dates. 2. On 3/11/26 at 10:20 AM two open, undated vials of Tuberculin (used for the testing in the diagnosis of Tuberculosis) were observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening.On 3/11/26 at 10:20 AM Staff 3 (LPN) acknowledged the two vials of Tuberculin were open and not labeled with open dates.On 3/12/26 8:15 AM Staff 2 (DNS) stated the expectation was for Tuberculin to be labeled with an open date. 3. On 3/11/26 at 10:20 AM the medication refrigerator temperature logs were observed to be blank on the following dates: 3/1/26, 3/2/26, 3/3/26, 3/6/26 and 3/7/26. The medication refrigerator contained flu vaccines, insulin, and other medications. On 3/11/26 at 10:20 AM Staff 3 (LPN) acknowledged the temperature logs were blank on the identified dates and acknowledged the refrigerator contained flu vaccines, insulin, and other medications. On 3/12/26 at 8:15 AM Staff 2 (DNS) stated the expectation was for the medication refrigerator temperature to be checked and logged twice daily. Staff 2 acknowledged the identified dates with blank temperature logs.

Based on observation, interview and record review it was determined the facility to provide sufficient nursing staff to ensure residents received medications timely for 1 of 1 facility reviewed for staffing. This placed residents at risk for adverse side effects of medication. Findings include: 1. The 2/19/26 Resident Council Minutes indicated nurses were rushing during medication pass. 2. Resident 59 admitted to the facility in 2023 with diagnoses including unspecified convulsions and dementia. The 3/2/26 physician orders indicated Resident 59 was to receive the following medications:-acetaminophen three times daily-cyanocobalamin (supplement) once daily-sennosides-docusate sodium (bowel medication) once daily-carvedilol (blood pressure medication) twice daily-duloxetine (antidepressant medication) once daily-levetiracetam (anti convulsant medication) once daily -aspirin once daily-amlodipine (blood pressure medication) once daily-cholecalciferol (supplement) once dailyOn 3/9/26 at 11:55 AM Staff 4 (LPN) stated resident's morning medications were administered late almost every day because there were not enough nursing staff.On 3/10/26 at 11:26 AM Staff 4 stated she was running behind and still passing morning medications. Staff 4 stated there were three residents who did not receive their morning medications. Staff 4 was observed to administer the following morning medications to Resident 59: -acetaminophen-cyanocobalamin-sennosides-docusate sodium-carvedilol-duloxetine-levetiracetam-aspirin-amlodipine-cholecalciferolOn 3/12/26 at 8:16 AM Staff 2 (DNS) acknowledged the identified medications were administered late to Resident 59 on 3/11/26 at 11:26 AM and acknowledged there were two additional residents who did not receive medications at that time. Staff 2 stated the expectation was for morning medications to be administered by 10:00 AM.

Based on observation, interview and record review it was determined the facility failed to ensure food items stored in unit refrigerators were not expired and refrigerator temperatures were monitored for 2 of 2 unit refrigerators reviewed for food storage. This placed residents at risk for foodborne illness. Findings include: 1. On 3/9/26 at 8:19 AM the ADL kitchen refrigerator was observed and revealed the following:-The temperature log for 2026 was on the outside of the refrigerator door and had one temperature documented for 1/14/26, but no other temperatures for January, February, and March were documented.-An individual to go container dated 2/22/26.-A snack pack with moldy food inside with a use by 2/25/26 date printed on it. -A bagged salad with a use by date of 2/25/26.-A half-gallon container of milk with a best by 2/4/26 date.-Two kefir containers, one with a best by date of 1/16/26, and the second with a best by date of 12/26/25.On 3/9/26 at 11:07 AM Staff 12 (Maintenance Director) observed the refrigerator in the ADL room and confirmed the expired contents and temperature log.On 3/10/26 at 11:16 AM Staff 11 (Dietary Director) stated food stored in the unit refrigerators was to be removed after three days. Staff 11 acknowledged the items in the refrigerator and stated they should have been discarded. 2. On 3/9/26 at 10:40 AM the snack refrigerator was observed with Staff 15 (Dietary Aide). The snack refrigerator had a container of kefir dated 2/26/26 and a carton of thick and easy with a use by date of 8/14/25.On 3/10/26 at 11:16 AM Staff 11 (Dietary Director) stated food stored in the unit refrigerators was to be removed after three days. Staff 11 acknowledged the items in the snack refrigerator and stated they should have been discarded.

Based on observation, interview and record review it was determined the facility failed to ensure call lights were within reach for 2 of 7 sampled residents (#s 85 and 86) reviewed for environment. This placed residents at risk for delayed treatment and unmet care needs. Findings include:1. Resident 85 was admitted to the facility in 2/2026 with diagnoses including malnutrition, leg fracture, and history of falls. The 2/9/26 Care Plan indicated Resident 85 was at risk for falls and her/his call light needed to be within reach. The 2/13/26 admission MDS revealed Resident 85 had a history of falls, required assistance with mobility, and had a BIMS score of 14 indicating no cognitive impairment. On 3/9/26 at 8:57 AM Resident 85's call light was located behind her/him, attached to the backside of her/his pillow and out of reach.On 3/9/26 at 1:31 PM Resident 85's call light was attached to the outside of the bed on the left side, but underneath the resident's blanket and out of her/his line of sight. The resident was observed unsuccessfully attempting to locate the call light. On 3/10/26 at 9:37 AM Resident 85 stated she/he needed to use the bathroom. Resident 85 attempted to locate her/his call light, but it was looped to the bed rail behind the resident and she/he was unable to locate it. On 3/10/26 at 12:17 PM Staff 20 (CNA) stated a resident's call light was to always be within reach or attached to the resident, never on the floor or across the room. On 3/10/26 at 12:46 PM Staff 19 (CNA) stated a resident's call light was to always be within reach, never on the floor or across the room, and attached to either the bed or wheelchair depending on resident location. On 3/12/26 at 10:03 AM Staff 2 (DNS) acknowledged call lights was to always be within a resident's reach, and in a location where the resident did not have to perform an unsafe lean or reach to access it. She stated a call light not within reach placed residents at risk for falls and a lack of timely care. 2. Resident 86 admitted to the facility 3/2026 with diagnoses including stroke and history of falls. The 3/6/26 Care Plan revealed Resident 86 was at a high risk for falls and her/his call light needed to be within reach.Nursing notes for 3/7/26, 3/8/26, and 3/10/26 indicated Resident 86 was alert, oriented and able to make her/his needs known. On 3/9/26 at 8:56 AM Resident 86 was in bed and a CNA was providing care. The CNA exited the room and the resident's call light was observed under the bed on the floor, not within resident's reach. On 3/10/26 at 9:40 AM Resident 86 was up in her/his wheelchair with an oxygen nasal cannula in place. Resident 86's call light was attached to the bed rail, out of her/his reach. Resident 86 was observed attempting to reach for the call light but was restricted due to the nasal cannula and distance between the wheelchair and bed.On 3/10/26 at 12:17 PM Staff 20 (CNA) stated a resident's call light was to always be within reach or attached to the resident, never on the floor or across the room. On 3/10/26 at 12:46 PM Staff 19 (CNA) stated a resident's call light was to always be within reach, never on the floor or across the room, and attached to either the bed or wheelchair depending on resident location. On 3/12/26 at 10:03 AM Staff 2 (DNS) acknowledged call lights was to always be within a resident's reach, and in a location where the resident did not have to perform an unsafe lean or reach to access it. She stated a call light not within reach placed residents at risk for falls and a lack of timely care.

Based on observation, interview and record review it was determined the facility failed to provide personal hygiene services for 1 of 3 sampled residents (#48) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include:Resident 48 was admitted to the facility in 2/2026 with diagnoses including stroke and traumatic brain injury.The 2/22/26 Care Plan indicated Resident 48 required assistance with ADLs.The 3/3/26 admission MDS for Resident 48 revealed a BIMS score of 9 indicating moderate cognitive impairment. The resident had one-sided impairment for upper extremity and required substantial to maximum assistance with personal hygiene activities. The ADL Personal Hygiene task, which included hand hygiene, was documented as completed with extensive assistance on 3/8/26, and total dependence on 3/9/26, 3/10/26, and 3/11/26.The ADL Bathing task revealed Resident 48 received a shower on 3/10/26 and was totally dependent. Resident 48 was observed to have soiled fingernails with a brown substance underneath all the fingernails on her/his right hand on 3/8/26 at 10:49 AM, 3/9/26 at 8:51 AM, 3/9/26 at 10:37 AM, 3/9/26 at 1:35 PM, 3/10/26 at 9:50 AM, 3/10/26 at 12:08 PM, and 3/11/26 at 9:11 AM. On 3/10/26 at 2:42 PM Staff 21 (CNA) stated the ADL Personal Hygiene tasks included hand hygiene, and a shower included cleaning under a resident's fingernails. Staff 21 acknowledged a resident's fingernails could be cleaned at any time and was not limited to morning hygiene tasks or a shower. Staff 21 stated Resident 48 was dependent for hand hygiene and bathing. On 3/10/26 at 3:04 PM Staff 22 (CNA) stated cleaning fingernails could be done during or after a shower, and as needed when noticed by staff. Staff 22 acknowledged providing Resident 48 with a shower at approximately 7:00 AM that morning. Staff 22 stated she cleaned Resident 48's hands with a washcloth, but did not clean under her/his fingernails. On 3/11/26 at 12:52 PM Staff 8 (LPN Unit Care Coordinator) stated the expectation was for resident fingernails to be cleaned daily, and it was unacceptable for a resident to have dirty fingernails multiple days in a row.

Based on observation, interview and record review it was determined the facility failed to provide pain management for 1 of 1 sampled resident (#86) reviewed for pain management. This placed residents at risk for unmanaged pain. Findings include:Resident 86 admitted to the facility in 3/2026 with diagnoses including stroke and a history of falls. The 3/6/26 Care Plan revealed a goal for Resident 86 to express pain relief, and she/he was to receive pain medication as ordered. Nursing notes from 3/7/26, 3/8/26, and 3/10/26 indicated Resident 86 was alert, oriented, and able to make her/his needs known. Physician orders revealed an order on 3/6/26 for acetaminophen 500 mg to be given every six hours as needed for pain, and an order on 3/9/26 for use of a warm compress (washcloth) to be used PRN for pain. The 3/2026 Treatment Administration Record showed documented pain ratings of zero for 3/8/26, 3/9/26, 3/10/26, and 3/11/26, and there were no documented uses of the warm compress for pain relief from 3/9/26 through 3/11/26. The 3/2026 Medication Administration Record showed no administrations of PRN acetaminophen for pain on 3/8/26 through 3/11/26. On 3/9/26 at 8:56 AM Resident 86 stated she/he had pain on the left side of her/his neck and shoulder. Resident 86 felt a heat source would help relieve the pain and stated she/he requested use of a warm towel from staff. On 3/9/26 at 1:27 PM Resident 86 stated her/his pain was at an 8 or 9 on a scale of 0-10 and she/he felt very uncomfortable. Resident 86 stated no one brought her/him the requested warm towel for pain. Resident 86 also stated she/he was in tears the previous night due to pain and staff was notified of the pain at the time. On 3/10/26 at 9:40 AM Resident 86 demonstrated facial grimacing and appearance of fatigue. Resident 86 rated her/his pain at an 8 or 9 on a scale of 0-10 and stated ongoing neck pain was causing her/him to feel tired. Resident 86 indicated she/he was not been given a warm towel the day before as requested. On 3/11/26 at 9:17 AM Resident 86 was in bed, demonstrated facial grimacing, and appeared painful. Resident 86 rated pain at a five or six on a scale of zero -10 and stated she/he was not at a zero level of pain during her/his stay in the facility. Resident 86 acknowledged the pain had an impact on her/his ability to participate in therapy due to feeling drained and low on energy. On 3/10/26 at 12:17 PM Staff 20 (CNA) acknowledged Resident 86 reported neck pain to her the previous day. Staff 20 stated she reported the pain to Staff 3 (LPN).On 3/10/26 at 2:27 PM Staff 23 (Physical Therapy Assistant) stated Resident 86 informed her of neck pain. Staff 23 indicated she reported the pain and the resident's need for pain medication to Staff 3. On 3/11/26 at 10:10 AM Staff 3 (LPN) acknowledged Resident 86 and a CNA reported the resident had pain. Staff 3 was unable to recall Resident 86's pain medication regimen or if pain medications were administered. On 3/11/26 at 3:45 PM Staff 2 (DNS) acknowledged there were no documented pain interventions for Resident 86 from 3/8/26 through 3/11/26.

Based on observation, interview and record review it was determined the facility failed to accurately assess functional mobility for 1 of 1 sampled resident (#68) reviewed for positioning and mobility. This placed residents at risk for unmet needs. Findings include: Resident 68 admitted to the facility in 5/2025 with left side hemiparesis (paralysis of half of the body).A 5/19/25 hospital History and Physical revealed Resident 68 had left side hemiparesis.A 5/18/25 progress note revealed Resident 68's left side was very flaccid and she/he had no strength or independent movement to the leg or arm.A 5/23/25 admission MDS indicated Resident 68 did not have functional limitation in range of motion in her/his upper extremities. On 3/8/26 at 11:05 AM Resident 68 was observed with her/his left arm bent at 90 degrees and stated as a result of a stroke she/he could not move it. On 3/11/26 at 1:12 PM Staff 7 (RN MDS Coordinator) stated on admission to the facility Resident 68 had limited ROM on her/his left upper extremity and the admission MDS was coded inaccurately.

Based on interview and record review it was determined the facility failed to complete a thorough discharge summary for 3 of 3 sampled residents (#s 3, 6, and 7) reviewed for discharge. This placed residents at risk for lack of information related to discharge. Findings include: 1. Resident 3 admitted to the facility in 6/2025 with a diagnosis of femur fracture. A 7/14/25 Discharge Summary Information assessment revealed Resident 3 was to discharge to her/his home with home health services. The Discharge Summary Information did not include information related to what company was to provide home health services to Resident 3, post discharge instructions, or include a recapitulation of Resident 3's stay. On 12/10/25 at 12:33 PM Staff 2 (DNS) confirmed Resident 3's Discharge Summary Information assessment was not completed thoroughly. 2. Resident 6 admitted to the facility in 11/2025 with a diagnosis of respiratory failure.A 12/2/25 Discharge Summary Information assessment revealed Resident 6 was to discharge to her/his home. The Discharge Summary Information assessment did not include home instructions or a recapitulation of Resident 6's stay. On 12/10/25 at 1:07 PM Staff 2 (DNS) confirmed the Discharge Summary Information assessment was not completed thoroughly. 3. Resident 7 admitted to the facility in 11/2025 with a diagnosis of anemia.A Discharge Summary Information assessment reveled Resident 7 was to discharge to her/his home. The Discharge Summary Information assessment did not include home instructions or a recapitulation of Resident 7's stay. On 12/10/25 at 1:07 PM Staff 2 (DNS) confirmed the Discharge Summary Information assessment was not completed thoroughly.

Based on interview and record review, it was determined the facility failed to protect residents' right to be free from misappropriation of property for 2 of 3 sampled residents (#s 101 and 102) reviewed for misappropriation of resident property. This placed residents at risk for loss of property. Findings include: 1. Resident 101 was admitted to the facility in 6/2025, with diagnoses including difficulty walking and fracture of the right arm. On 7/29/25 at 9:23 AM, Staff 1 (Administrator) stated on 7/14/25, two Police Officers came to the facility and showed Staff 1 a picture, which she identified as Staff 4 (CMA/CNA), an employee of the facility. The Officers informed Staff 1 that Resident 101 and Resident 102 had their debit/credit cards stolen, and Staff 4 was under investigation. Staff 1 stated the police called her on 7/15/25 and informed her they had taken Staff 4 into custody and lodged her at the County jail. The officers also told Staff 1 that Staff 4 had admitted to taking and using the residents' cards. Staff 1 stated she had testified at the Grand Jury, and there were 10 counts pending against Staff 4 including felony charges.A 7/16/25 Police Case Report indicated that on 6/28/25, Witness 2 (Police Officer) received a report from Resident 101 regarding a stolen credit card. Resident 101 had been staying at the nursing facility during the time the unauthorized charges occurred. Two of the charges were made at a large discount department store, which provided video footage of the person using the card. The person using the card was identified as Staff 4, an employee at the nursing facility. Witness 2 indicated he went to Staff 4's residence, where she admitted to taking both Resident 101's and Resident 102's debit/credit cards. She also confessed to committing thefts at the hospital where she previously worked. Witness 2 then arrested and transported Staff 4 to the County Correctional Facility. The report also included Staff 4 had a warrant out of [NAME] County for Elder Abuse.On 7/29/25 at 10:16 AM, Witness 1 (District Attorney) stated there were two victims identified who had been residents at the nursing facility, Residents 101 and 102. The Grand [NAME] did indict Staff 4 on ten charges, five charges for each victim. Staff 4 was still in custody. On 7/29/25 at 10:29 AM, Resident 101 stated that on the last Friday in June she/he had checked her/his bank account and found it empty. Resident 101 then checked her/his wallet and found her/his debit card was gone. Resident 101 said she/he reported it to the police, the bank, and the nursing facility. The Officer who responded to her/his report showed her/him a picture of the person who used the card, and she/he recognized the picture as an employee of the nursing facility.On 7/29/25 at 2:45 PM, Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Director) were interviewed and acknowledged that misappropriation of property had occurred.2. Resident 102 was admitted to the facility in 5/2025, with diagnoses including hip fracture, muscle weakness, and chronic pain. On 7/29/25 at 9:23 AM, Staff 1 (Administrator) stated that on 7/14/25, two Police Officers came to the facility and showed Staff 1 a picture, which she identified as Staff 4 (CMA/CNA), an employee of the facility. The Officers informed Staff 1 that Resident 101 and Resident 102 had their debit/credit cards stolen, and Staff 4 was under investigation. Staff 1 stated the police called her on 7/15/25 and informed her they had taken Staff 4 into custody and lodged her at the County jail. The officers also told Staff 1 that Staff 4 had admitted to taking and using the residents' cards. Staff 1 stated she had testified at the Grand Jury, and there were 10 counts pending against Staff 4, including felony charges.A 7/15/25 Police Case Report indicated Witness 5 (Police Officer) spoke with Resident 102's daughter, who stated she was notified on 7/1/25 that the resident's debit card had been used in the city of Molalla, while the resident was recovering in the nursing facility. The report indicated some charges were made at a local discount department store where a still photograph of the suspect was identified as the same suspect from another case involving Resident 101 at the same nursing facility. Witness 5 went to the nursing facility and verified the identification of Staff 4 (CMA/CNA) as the alleged suspect. The report indicated Witness 2 (Police Officer) went to Staff 4's residence and arrested her. Witness 5 spoke briefly with Staff 4. Staff 4 confessed she/he did not remember using the resident's card, but she/he probably did.On 7/29/25 at 10:16 AM, Witness 1 (District Attorney) stated there were two victims identified who had been residents at the nursing facility, Residents 101 and 102. The Grand [NAME] did indict Staff 4 on ten charges, five charges for each victim. Staff 4 was still in custody. On 7/29/25 at 12:58 PM, Witness 4 (family member/POA) stated the resident had a fall and broke her/his hip and could not get out of bed. The resident could not have made the charges found on her/his debit and credit cards. Witness 4 stated she/he had bank alerts on her/his phone for the resident, which enabled her/him to recognize the fraudulent charges. Witness 4 stated she/he filed a police report and were aware Staff 4 was arrested.On 7/29/25 at 2:45 PM, Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Director) were interviewed and acknowledged that misappropriation of property had occurred.On 7/25/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined that there was misappropriation of property. The Plan of Correction included: 1. Staff conducted interviews with all current residents. 2. Abuse in-services were completed with all staff with particular attention to identification of types of abuse, abuse reporting and response regarding suspicion of a crime, and the Elder Justice Act. 3. Monitoring: abuse and neglect-staff interviews and observations of three staff members 5 times per week for 1 week, 3 times per week for 3 weeks, then once a week for 2 months, to be done in various areas such as resident rooms, shower room, activities, dining rooms, and hallways. 4. DON or designee will audit nurses' notes and review risk management reports in the morning clinical meeting 5 times a week for 1 month, then weekly for 2 months for any signs of abuse or neglect. If any evidence is found that has not already been reported, the Executive Director will be notified immediately, and the Abuse Policy will be followed.

Based on interview and record review it was determined the facility failed to ensure a physician supervised the resident's medical care and evaluated the effectiveness of wound care treatments for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for increased pain, worsening wounds and hospitalization . Findings include: Resident 2 admitted to the facility in 11/2024, with diagnoses including atrial fibrillation (irregular heartbeat), malnutrition and colostomy. The 11/19/24 Hospital History and Physical indicated Resident 2's abdominal ostomy site had surrounding erythema (redness) and one spot of skin breakdown. Resident 2's 11/20/24 and 11/27/24 Ostomy and Skin Care Plans revealed she/he had a colostomy and was at risk for a decline in skin integrity. Staff were to keep the skin clean, dry and protected from the ostomy drainage, and to clean and apply moisture barrier to the skin after each leaking episode. The 11/21/24 Physician Note revealed Resident 2 had a colostomy and indicated all chronic conditions were relatively stable. The note did not include information related to Resident 2's leaking ostomy or the condition of her/his surrounding skin. Resident 2's Progress Notes dated 11/22/24 through 11/24/24 and 11/26/24 through 12/2/24 described an abdominal ostomy with constant drainage, and the surrounding skin as red and inflamed. A 12/6/24 Progress Note indicated Resident 2's colostomy bag did not stay in place, her/his abdominal skin was excoriated, blistered, tender to touch and caused irretractable pain due to the constant colostomy drainage. Resident 2's skin was inflamed mid abdomen to the perineum and in-between her/his thighs. Resident 2 was transferred to the hospital for evaluation and treatment on 12/5/24. A 12/5/24 Emergency Department Note indicated Resident 2 had extensive skin breakdown and maceration which extended from the right-sided ostomy and the entire abdomen was tender due to the skin maceration. Differential diagnoses included ostomy bag malfunction skin maceration and atrial fibrillation. The physician noted Resident 2 had extensive skin maceration and erythema to her/his entire abdominal wall skin related to the leakage from the ostomy bag which resulted in significant pain. The physician indicated IV (intravenous) medications were needed for pain control and the resident would require extensive wound care for the abdominal wall maceration. A 12/6/24 Hospital Note revealed Resident 2 had right sided abdominal red and raw skin which extended to the perineal and inner thighs. Resident 2's 12/10/24 Progress Notes revealed she/he readmitted to the facility. Resident 2's 12/12/24 Physician Note indicated the resident continued with a colostomy which functioned normally. The note did not include any assessment of the resident's skin surrounding the leaking colostomy site. On 4/16/25 at 9:47 AM, Staff 5 (CNA) stated Resident 2's ostomy constantly leaked, the colostomy bag would fall off, and the resident's skin was raw, red and sore. Staff 5 stated she would constantly report the issue to the nurse who would clean the site and replace the colostomy bag. On 4/16/25 at 9:55 AM, Staff 4 (LPN) stated Resident 2's ostomy leaked a lot, wound care was completed frequently, and the resident's skin got very irritated. Staff 4 stated one time as soon as she completed all the wound care and the new colostomy bag was on, it immediately fell back off and the care had to be done again, which was a common occurrence. Staff 4 stated all staff were aware of Resident 2's skin issues and the leaking colostomy. Additionally, Staff 4 stated the resident went to an appointment related to her/his colostomy on 12/12/25 and returned with no new orders which frustrated staff since it did not address the colostomy leakage concern. On 4/16/25 at 12:36 PM, Staff 2 (DNS) and Staff 3 (LPN/RCM) acknowledged Resident 2's colostomy constantly leaked and her/his abdominal skin condition declined although skin treatments were in place. On 4/18/25 at 10:28 AM, Witness 8 (Physician) stated he focused on Resident 2's cardiac concerns and osteomyelitis which were the main reasons she/he admitted to the facility. Witness 8 further stated he was unable to recall if the facility staff ever reached out to him related to colostomy concerns or skin problems and when Resident 2 returned from the hospital he believed her/his colostomy functioned normally. Witness 8 verified he did not observe Resident 2's abdominal wound when he examined her/him on 12/12/24.

Based on interview and record review it was determined the facility failed to assess a skin wound for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include: Resident 2 admitted to the facility in 11/2024, with diagnoses including malnutrition and colostomy. The 11/19/24 Hospital History and Physical indicated Resident 2's abdominal ostomy site had surrounding erythema (redness) and one spot of skin breakdown. The 11/20/24 Admission Skin Assessment indicated no abdominal wounds. Resident 2's Progress Notes dated 11/22/24 through 11/24/24 and 11/26/24 through 12/2/24 described an abdominal ostomy with constant drainage, and the surrounding skin as red and inflamed. A 12/6/24 Progress Note indicated Resident 2's colostomy bag would not stay in place, her/his abdominal skin was excoriated, blistered, tender to touch and caused irretractable pain due to the constant colostomy drainage. Resident 2's skin was inflamed mid abdomen to the perineum and thighs. Resident 2 was transferred to the hospital for evaluation and treatment. Resident 2's Progress Notes revealed she/he readmitted to the facility on [DATE] and passed away on 12/15/24. Review of Resident 2's clinical record revealed no weekly wound assessments for the worsening abdominal wound from 11/20/24 through 12/15/24. On 4/16/25 at 12:36 PM, Staff 2 (DNS) and Staff 3 (LPN/RCM) verified no wound assessments were completed on Resident 2's worsening abdominal wound.

Based on observation, interview and record review it was determined the facility failed to ensure the facility maintained a medication error rate of less than 5%. There were six errors in 26 opportunities resulting in a 23% medication error rate. This placed residents at risk for adverse side effects from medications. Findings include: 1. Resident 152 admitted to the facility in 2024 with diagnoses including heart failure, gastroesophageal reflux disease (GERD) and fibromyalgia. a. The 11/1/24 physician order indicated Resident 152 was to receive duloxetine (antidepressant medication) delayed release 60 mg once daily for chronic pain. On 11/6/24 at 9:01 AM Staff 5 (Agency RN) was observed to prepare morning medications for Resident 152. Staff 5 prepared duloxetine 30 mg in the medication cup and continued to the next medication. The State Surveyor stopped Staff 5 and asked her to review the order since the prepared medication did not match the order. Staff 5 acknowledged she prepared duloxetine 30 mg instead of the ordered duloxetine 60 mg. Staff 5 then prepared the correct dose of the medication. On 11/6/24 at 10:49 AM Staff 2 (DNS) acknowledged the identified findings and provided no additional information. b. The 11/1/24 physician order indicated Resident 152 was to receive Eliquis (anticoagulant medication) 2.5 mg twice daily for heart failure. On 11/6/24 at 9:01 AM Staff 5 (Agency RN) was observed to prepare morning medications for Resident 152. Staff 5 prepared Eliquis 5 mg in the medication cup and continued to the next medication. The State Surveyor stopped Staff 5 and asked her to review the order since the prepared medication did not match the order. Staff 5 acknowledged she prepared Eliquis 5 mg instead of the ordered 2.5 mg. Staff 5 then prepared the correct dose of the medication. On 11/6/24 at 10:49 AM Staff 2 (DNS) acknowledged the identified findings and provided no additional information. c. The 11/1/24 physician order indicated Resident 152 was to receive omeprazole 40 mg twice daily for GERD. The manufacturer recommendations indicated omeprazole was to be administered before meals. On 11/6/24 at 9:01 AM Staff 5 (Agency RN) was observed to prepare morning medications for Resident 152 including omeprazole 40 mg. On 11/6/24 at 9:01 AM Staff 5 acknowledged omeprazole was to be administered prior to breakfast but was administered after Resident 152 ate breakfast. On 11/6/24 at 10:49 AM Staff 2 (DNS) acknowledged the identified findings and provided no additional information. d. The 11/1/24 physician order indicated Resident 152 was to receive Tylenol 1000 mg three times daily for pain. On 11/6/24 at 9:01 AM Staff 5 was observed to prepare morning medications for Resident 152. The medications did not include Tylenol. On 11/6/24 at 9:28 AM Resident 152 was observed to ask Staff 5 for the Tylenol and stated it was scheduled. Staff 5 then prepared the Tylenol 1000 mg. On 11/6/24 at 9:31 AM Staff 5 stated the Tylenol was due at 8:00 AM but she did not see it because she pulled up medications that were due at 9:00 AM. Staff 5 administered the Tylenol to Resident 152 and acknowledged it was administered late. On 11/6/24 at 10:49 AM Staff 2 (DNS) acknowledged the identified findings and provided no additional information. e. The 11/1/24 physician order indicated Resident 152 was to receive loratadine 10 mg once daily for allergies. The physician order did not include cetirizine 10 mg. On 11/6/24 at 9:46 AM Staff 5 was observed to prepare cetirizine 10 mg for Resident 152. The State Surveyor stopped Staff 5 and asked her to review the order. Staff 5 reviewed the order and looked up cetirizine in the computer and acknowledged loratadine and cetirizine were two different drugs. Staff 5 stated she needed to check with the nurse as she could not find the loratadine in the medication cart or the medication room. On 11/6/24 at 10:49 AM Staff 2 (DNS) acknowledged the identified findings and provided no additional information. 2. Resident 10 admitted to the facility in 2024 with diagnoses including major depressive disorder. The 11/1/24 physician order indicated Resident 10 was to receive sertraline 50 mg two tabs once daily. On 11/7/24 at 8:07 AM Staff 3 (LPN) was observed to prepare morning medications for Resident 10. Staff 3 prepared sertraline 50 mg in a medication cup and continued to the next medication. The State Surveyor stopped Staff 3 and asked her to review the order since the prepared medication did not match the order. Staff 3 clarified the order with Staff 2 (DNS) and acknowledged she prepared sertraline 50 mg instead of the ordered 100 mg. Staff 3 then prepared the correct dose of the medication. On 11/7/24 at 1:26 PM Staff 2 (DNS) acknowledged the identified findings and provided no additional information.

Based on interview and record review it was determined the facility failed to provide a restorative program to prevent decline in range of motion for 1 of 1 sampled resident (#46) reviewed for RA. This placed residents at risk for physical decline. Findings include: Resident 46 admitted to the facility in 2024 with diagnoses including stroke and left sided hemiparesis (paralysis to one side of the body). The 8/7/24 care plan indicated Resident 46 had left sided weakness, impaired mobility and required assistance with ADL care. The 9/23/24 Physical and Occupational Therapy Discharge Summaries indicated Resident 46 made consistent progress throughout the plan of treatment and responded positively to techniques to stimulate functional performance and enhance safety to prevent further decline. Notes further indicated she/he had upper extremity hemiparesis which did not improve. The restorative program was, not indicated at this time. On 11/4/24 at 12:43 PM Resident 46 was observed to have her/his hand to be closed into a fist and stated she/he did not receive range of motion exercises for her/his hand and wanted to participate in an RA program. On 11/5/24 at 10:58 AM Staff 6 (PT) stated Resident 46 was discharged from therapy on 9/19/24. Staff 6 stated the resident was a good candidate for RA services after she/he discharged from therapy due her/his left sided stroke and difficulty using her/his left hand due to it tensing up. Staff 6 stated she was unable to make a referral to RA as the facility did not offer an RA program. On 11/5/24 at 10:51 AM and 11/7/24 at 1:33 PM Staff 2 (DNS) stated the facility did not have an RA program and was unsure of the last time RA was offered to residents. Staff 2 acknowledged Resident 46 had left sided weakness and would have benefited from an RA program.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 2 of 5 sampled residents (#s 14 and 28) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication. Findings include: 1. Resident 14 admitted to the facility in 2021 with diagnoses including delusional disorder. Resident 14's 9/26/24 pharmacy recommendation indicated the following: -The resident received haloperidol (antipsychotic medication) 2.5 mg in the morning and 5 mg at bedtime for psychosis related to metabolic encephalopathy (brain dysfunction) and hallucinations. -Nursing assessments indicated no episodes of delusions or hallucinations in the last three months. -Please attempt a gradual dose reduction of haloperidol to 5 mg at bedtime. - The pharmacy recommendation was signed by the physician on 9/26/24 and indicated the recommendations were accepted and to be implemented as written. The pharmacy recommendation was not noted by Staff 2 (DNS) until 10/8/24 (13 days later). On 11/7/24 at 1:23 PM Staff 2 stated the facility received the recommendation but did not have a system in place to ensure pharmacy recommendations were addressed. Staff 2 acknowledged Resident 14's pharmacy recommendations were not addressed timely. 2. Resident 28 admitted to the facility in 2022 with diagnoses including atrial fibrillation. On 11/8/24 a request was made from Staff 2 (DNS) for the 10/2024 pharmacy recommendations for Resident 28 as they were not located in the clinical record. Resident 28's 10/16/24 pharmacy recommendation indicated the following: -During the review of the resident's Eliquis (anticoagulant medication) tablet 5 mg twice daily directions include to resume on 4/27/24 after Paxlovid (antiviral medication) was complete. -Please remove the following from the order: resume on 4/27/24 after Paxlovid was complete. On 11/8/24 at 11:27 AM Staff 2 acknowledged the 10/16/24 pharmacy recommendation was not addressed as of 11/8/24. Staff 2 stated she did not recall receiving the pharmacy recommendation and had to go online on 11/8/24 to find the recommendation.

Based on observation, interview and record review it was determined the facility failed to ensure a resident received assistance with fingernail care for 1 of 4 sampled residents (#46) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: Resident 46 admitted to the facility in 2024 with diagnoses including stroke and left sided hemiparesis (paralysis to one side of the body). The 8/7/24 care plan indicated Resident 46 had left sided weakness and required assistance with ADL care. The 10/2024 TAR indicated Resident 46 received nail care on 10/31/24. On 11/4/24 at 12:43 PM Resident 46 was observed to have long fingernails. Resident 46 stated she/he requested to have her/his nails trimmed but staff did not provide nail care. On 11/6/24 at 2:10 PM Staff 7 (CNA) stated nail care was completed or offered for all residents on shower days. Staff 7 acknowledged Resident 46 was dependent on staff for nail care and her/his fingernails were long. On 11/6/24 at 2:15 PM Staff 2 (DNS) observed Resident 46's fingernails and acknowledged her/his fingernails were long and nail care was not completed.

Based on interview and record review it was determined the facility failed to provide appropriate treatment for a resident receiving dialysis including monitoring of the dialysis site and communication with the dialysis provider for 1 of 1 sampled resident (#30) reviewed for dialysis. Findings include: Resident 30 admitted to the facility in 2022 with diagnoses including renal dialysis. a. The facility's Hemodialysis Offsite Policy, revised in 2023, indicated staff were to initiate the Pre/Post Dialysis Communication Form that was to be sent to the dialysis clinic with the resident. The policy further indicated upon return from dialysis the Pre/Post Dialysis Communication Form was to be completed. The 11/20/23 care plan indicated Resident 30 received dialysis three days a week on Tuesdays, Thursdays, and Saturdays. Review of the Pre/Post Dialysis Communication Form from 7/2024 through 10/2024 revealed the following: - 7/2024 five instances when the dialysis forms were not completed. - 8/2024 10 instances when the dialysis forms were not completed. - 9/2024 10 instances when the dialysis forms were not completed. - 10/2024 10 instances when the dialysis forms were not completed. On 11/7/24 at 12:11 PM Staff 4 (LPN) stated Resident 30 took the dialysis book (which contained the communication form) with her/him to each appointment. Staff 4 stated the communication form was used to communicate with dialysis with any updates or changes to Resident 30's care. Staff 4 stated nursing staff were supposed to complete the Pre/Post Dialysis Communication Form before and after the resident's dialysis appointments. Staff 4 acknowledged nursing staff did not always complete the dialysis communication forms. On 11/8/24 at 10:34 AM Staff 2 (DNS) stated the Pre/Post Dialysis Communication Forms were to be completed by nursing staff at each dialysis appointment and acknowledged the forms were not completed for the identified dates. b. The 9/24/24 care plan indicated Resident 30 had a right chest wall dialysis access site. An intervention included for the site to be checked daily. Review of Resident 30's medical record revealed no evidence Resident 30's access site was checked daily. On 11/7/24 at 10:00 AM Resident 30 stated staff did not assess her/his dialysis site after she/he returned from dialysis. On 11/8/24 at 10:34 AM Staff 2 (DNS) stated nursing staff were to check Resident 30's chest and it was to be documented on the TAR. Staff 2 acknowledged there was no evidence Residents 30's chest wall dialysis site was being checked on the TAR or in the resident's medical record.

Based on interview and record review it was determined the facility failed to promptly respond for 2 of 3 months of Resident Council minutes reviewed. This placed residents at risk for unresolved quality of life and care issues. Findings include: The facility's revised 9/27/23 Resident Council policy stated, the facility must act promptly upon the recommendations of such groups concerning issues of resident care and life in the facility. The Activities Director will facilitate follow-up on all suggestions and ideas presented at the council meeting and will report results at the next meeting. Each Department Director will be responsible for filling out a comment form prior to the next meeting. Resident Council Minutes were reviewed from 7/2024 through 9/2024 and indicated the following residents' concerns: *7/10/24: Do not close doors without permission, make sure call lights are within reach, beds have been squeaking, can people be informed? There was no follow up after the 7/10/24 Resident Council meeting regarding the residents' concerns and recommendations. *8/7/24: Cooler for food items, diet reports not being followed, room not getting cleaned daily, call lights and medications take forever, make a form for residents to address concerns between Resident Council meetings. There was no follow up after the 8/7/24 Resident Council meeting regarding the residents' concerns and recommendations. *9/11/24: Make sure allergy/dislikes being followed, more diabetic options, clothes not being put in correct closets, med times and call lights taking awhile at times, trash cans not being taken out daily. There was no follow up from dietary and maintenance after the 9/11/24 Resident Council meeting regarding the residents' concerns and recommendations. On 10/2/24 at 3:52 PM, Staff 3 (Activities Director) stated Resident Council meetings are held monthly. Following the meetings Staff 3 stated she copied the meeting notes and gave copies to each Department Head Manager. Staff 3 stated she did not get responses back from the department head managers. On 10/14/24 at 12:16 PM, Staff 1 (Administrator) stated she would expect department managers to respond to Resident Council concerns within seven to 10 days.

Based on interview and record review it was determined the facility failed to investigate an allegation of sexual abuse for 1 of 1 sampled resident (#1) reviewed for allegations of sexual abuse. This placed residents at risk for further sexual abuse. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including anxiety and adult failure to thrive. A 8/18/23 a Progress Note revealed Resident 1 was sent to the hospital due to a change of condition. On 1/3/24 at 3:27 PM Witness 1 (Complainant) stated on 9/1/23 she was informed by a social worker that Resident 1 reported she/he did not want to return to the facility from the hospital because they, indicating staff, were having sex with [her/him]. On 1/4/24 at 1:46 PM Staff 4 (Social Service Director) stated she contacted Witness 2 (Family Member) around Christmas time because Resident 1 had a box of items left at the facility. Witness 2 refused to step foot into the facility, claiming Resident 1 was raped every day at the facility. Staff 4 stated Witness 2 was very mad and angry about the situation. Staff 4 stated she notified Staff 1 (Administrator) about the concern. Staff 4 stated she did not document the conversation with Witness 2. There was no evidence a FRI (Facility Reported Incident) was initiated. On 1/4/24 at 4:37 PM and 5:13 PM Staff 1 (Administrator) and Staff 4 were present for an interview. Staff 1 stated Staff 4 spoke with her regarding the phone conversation Staff 4 had with Witness 2. Staff 1 acknowledged no investigation was completed regarding the allegation of sexual abuse. -Refer to F609

Based on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of sexual abuse for 1 of 1 sampled resident (#1) reviewed for sexual abuse. This placed residents at risk for sexual abuse. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including anxiety and adult failure to thrive. A 8/18/23 a Progress Note revealed Resident 1 was sent to the hospital due to a change of condition. On 1/3/24 at 3:27 PM Witness 1 (Complainant) stated on 9/1/23 she was informed by a hospital social worker, Resident 1 reported she did not want to return to the facility from the hospital because they, indicating staff, were having sex with [her/him]. On 1/4/24 at 1:46 PM Staff 4 (Social Service Director) stated she contacted Witness 2 (Family Member) around Christmas time because Resident 1 had a box of items left at the facility. Witness 2 refused to step foot into the facility, claiming Resident 1 was raped every day at the facility. Staff 4 stated Witness 2 was very mad and angry about the situation. Staff 4 stated she notified Staff 1 (Administrator) about the concern. Staff 4 stated she did not document the conversation with Witness 2. On 1/4/24 at 3:46 PM Witness 3 (Family Member) indicated Resident 1 was sent out to the hospital in 8/2023 from the facility and when Witness 3 spoke with Resident 1 she/he did not want to return to the facility because she/he was molested there. On 1/4/24 at 4:15 PM Witness 2 (Family Member) indicated Resident 1 was hospitalized on [DATE] due to a change of condition. When Witness 2 spoke to Resident 1, the resident stated she/he did not want to return to the facility because she/he was raped every day. Witness 2 asked if the resident heard any noises or knew the gender of the perpetrator. Resident 1 stated she/he could not see them, but they played loud music. Witness 2 asked the resident if they had intercourse with her/him and the resident stated no but they dragged her/him out of bed and kissed her/him. Witness 2 expressed this was very emotional to hear. Witness 2 stated a social worker interviewed Resident 1 at the hospital but Resident 1 was less cooperative. Witness 2 stated she informed Staff 4 about her concerns in 12/2023 regarding Resident 1 being raped at the facility and Staff 4 was shocked. There was no evidence a FRI (Facility Reported Incident) was sent to the State Survey Agency. On 1/4/24 at 4:37 PM and 5:13 PM Staff 1 (Administrator) and Staff 4 were present for an interview. Staff 1 stated Staff 4 spoke with her regarding the phone conversation Staff 4 had with Witness 2. Staff 1 acknowledged the State Agency was not notified and a FRI was not initiated for the allegation of sexual abuse.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 when it failed to conduct COVID testing in a manner that was consistent with current standards of practice. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms of cough, fever, and in severe cases difficulty breathing that could result in severe impairment or death. Specifically, 3 of 3 staff (Registered Nurse 1, interim Director of Nursing, and Infection Preventionist), who conducted resident and staff COVID-19 testing, failed to collect nasal specimens from both nostrils and did not rotate swab 5 times for 15 seconds per nostril and did not wear isolation gowns when collecting nasal specimens. On [DATE] at 4:43 PM the facility's Administrator and interim Director of Nursing (IDON) was notified of an Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (h) (F886) related to the improper collection of specimens for resident and staff COVID-19 testing as part of facility's COVID outbreak that started on [DATE]. The facility did not conduct COVID testing per manufacturer's instructions or current standards of practice, as outlined in the Centers for Disease Control and Prevention (CDC) guidance, manufacturer's instructions, and facility policy and procedure, which increased the likelihood for inaccurate test results leading to delayed identification/[DIAGNOSES REDACTED]. These failures increased the likelihood for serious injury, serious harm, or death and required immediate action to ensure COVID-19 test results were reliable and accurate in facility with COVID outbreak and had the potential to affect all 32 residents in the facility. On [DATE] at 11:32 AM the Administrator was notified the immediacy was removed based on onsite verification that IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at a scope of F (widespread, no actual harm with potential for more than minimal harm). Findings include: During an interview on [DATE] at 10:58 AM Interim Director of Nursing (IDON) stated that the facility was currently experiencing a COVID-19 outbreak with five COVID-19 positive residents in red hall. The outbreak started on [DATE] when staff tested positive and the next day two residents tested positive. The facility was currently testing all residents and staff twice weekly and there has been no resident or staff who has refused testing. Review of CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19), https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html, dated [DATE], showed both nostrils were to be sampled with the same swab, when collecting an anterior nasal specimen. Review of CDC Performing Facility-wide [DIAGNOSES REDACTED]-CoV-2 (Severe acute respiratory syndrome coronavirus 2, [DIAGNOSES REDACTED]-CoV-2, is [MEDICAL CONDITION] that causes COVID-19) Testing in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-facility-wide-testing.html, dated [DATE], showed PPE (personal protective equipment) for swabbing HCP (health care personnel) in the room or specimen collection area should wear an N95 or higher-level respirator (or facemask if a respirator is not available) and eye protection. A single pair of gloves and a gown should also be worn for specimen collection Review of facility provided instructions for BinaxNOW COVID-19 Ag Card (Abbott) (a rapid test that detects protein [MEDICATION NAME] to [DIAGNOSES REDACTED]-CoV-2 directly from anterior nasal (nares) swab specimens), dated ,[DATE], showed Specimen Collection and handling .Inadequate specimen collection or improper sample handling/storage/transport may yield erroneous results. Refer to CDC interim guidelines for collecting .Nasal Swab .To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible .Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril . Review of BinaxNOW COVID-19 Ag Card (Abbott) instructions for use, revision date ,[DATE], showed Specimen Collection and handling .to collect a nasal swab sample, carefully insert the entire absorbent tip of the swab into the nostril. Firmly sample the nasal wall by rotating the swab in a circular path against the nasal wall 5 times or more for a total of 15 seconds, then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. Review of facility policy [DIAGNOSES REDACTED]-CoV-2 POC (Point of Care) Testing, revision date [DATE], showed Specimen Collection: the CDC states that the reliability of tests results is impacted by proper specimen collection and handling. This could include inadequate specimen collection .Providers should refer to the CDC's guidance on Collecting, Handling, and Testing Clinical Specimens for COVID-19 and also follow the manufacturer's instructions. The policy also showed Follow Standard Precautions when handling clinical specimens, including hand hygiene and the use of PPE which includes gown, when collecting specimens. Observation on [DATE] at 1:16 PM showed Registered Nurse (RN)1 collecting a specimen for COVID-19 testing from Certified Nurse Aide (CNA) 1. RN1 wore a face shield, N95 mask, and gloves but did not wear an isolation gown. RN1 placed a swab halfway up one of the CNA's nostril, rotated the swab three times for approximately five seconds and placed the swab on the collection card. RN1 did not rotate swab in CNA1's nostril five times for 15 seconds and failed to obtain a specimen from the CNA's other nostril. Observation on [DATE] at 1:18 PM showed RN1 collecting a specimen for COVID-19 testing from Cook1. RN1 said, which one? with Cook1 indicating left nostril. RN1 placed a swab halfway up Cook1's left nostril, rotated the swab three times for approximately five seconds and placed the swab on the collection card. RN1 did not rotate swab in Cook1's left nostril five times for 15 seconds and failed to obtain a specimen from the Cook1's right nostril. RN1 did not wear an isolation gown during specimen collection. During an interview on [DATE] at 1:20 PM RN1 stated that she conducts the staff COVID-19 testing twice last week and is doing testing today. Testing is conducted on Mondays and Thursdays. Observation on [DATE] at 1:27 PM showed RN1 collecting a specimen for COVID-19 testing from CNA2. RN1 said, which one? and CNA2 said either/or. RN1 then placed a swab halfway up CNA2's left nostril, rotated the swab three times for approximately five seconds and placed the swab on the collection card. RN1 did not rotate swab in CNA2's left nostril five times for 15 seconds and failed to obtain a specimen from the CNA2's right nostril. RN1 did not wear an isolation gown during specimen collection. Observation on [DATE] at about 1:30 PM showed RN1 collecting a specimen for COVID-19 testing from Rehabilitation Director (RD). RN1 placed a swab halfway up RD's nostril, rotated the swab three times for approximately five seconds and placed the swab on the collection card. RN1 did not rotate swab in RD's nostril five times for 15 seconds and failed to obtain a specimen from the RD's other nostril. RN1 did not wear an isolation gown during specimen collection. During an interview on [DATE] at 1:35 PM RD stated that she has been tested for COVID-19 twice a week during the last several weeks and swab is placed in one nostril only. During an interview on [DATE] at 1:43 PM when asked to outline steps for COVID-19 nasal specimen collection, Infection Preventionist (IP) stated that she places 6 drops on Binax Abbott card, places swab in one nostril and then places swab on card and reads results. IP stated that she taught RN1 how to collection specimen. RN1 nodded head in agreement with IP's statement. IP stated that she was taught how to collect specimen from Interim Director of Nursing (IDON). During an interview on [DATE] at about 1:44 PM when asked to outline steps for COVID-19 nasal specimen collection, IDON stated that she swabs one nostril. IDON stated that staff tells us which nostril they prefer, right or left or some staff alternate nostril and have right side one day and left side the next time. IDON stated that she, IP and RN1 have been collecting specimens using Binax Abbot tests for staff and resident testing since start of [DATE] outbreak. When asked to review facility provided BinaxNOW COVID-19 Ag Card instructions, dated ,[DATE], which showed that both nostrils should be swabbed, IDON stated our policy doesn't say both nostrils. IDON and surveyor then reviewed facility's [DIAGNOSES REDACTED]-CoV-2 POC policy which did not provide instructions on specimen collection on one or both nostrils but directed staff to follow CDC's guidance on Collecting, Handling, and Testing Clinical Specimens for COVID-19 and manufacturer's instructions. The policy included reference links to Abbot BinaxNOW resources such as video for performing testing, website and test instructions and Lippincott procedures and skills checklist for specimen collection. During an interview on [DATE] at 3:45 PM IDON stated that prior to [DATE] outbreak testing was done via PCR (Polymerase chain reaction; type of laboratory test, which uses nasopharyngeal swabs, sample of secretions from the back of the nose and throat, which only required sample collection from one nostril) and it was sent out to a laboratory for processing but the turn-around-time was too long. Therefore, the facility switched to using BinaxNOW tests (which required collection from both nostrils). When asked about training received related to specimen collection and testing for BinaxNOW testing, IDON stated that BinaxNOW procedure cards were reviewed. Review of BinaxNOW procedure cards showed instructions for sample test procedures and result interpretation but not specimen collection. During an interview on [DATE] between 4:30 to 4:45 PM with Administrator, IDON and IP, Administrator confirmed expectation that the facility's COVID-19 testing would be conducted in accordance with CDC's guidelines and manufacturer's instructions for use. The Administrator confirmed that it was important that staff were trained and collected specimens accurately to ensure the facility received accurate test results. IDON and surveyor reviewed CDC's reference source for use of PPE gown when collecting nasal specimens and IDON nodded her head in agreement. Administrator was informed of Immediate Jeopardy related to the improper collection of specimens for resident and staff COVID-19 testing as part of facility's COVID outbreak that started on [DATE]. During concurrent interview and observation on [DATE] at 5:46 PM, after IJ was called, bus driver, stated that he was tested today but came to the facility after receiving a text to come in for re-testing. During testing, bus driver stated, what, both nostrils? and also said, you have to wear one of those for everyone, too? in response isolation gown being worn during testing. During an interview on [DATE] at 10:03 AM IDON stated that prior to IJ, isolation gowns were not worn when staff were tested for COVID. During interview on [DATE] at 12:10 PM Licensed Nurse (LN)1 stated that twice weekly testing has always been done without tester wearing isolation gowns and only one nostril was swabbed but today it was done differently. Review of list of covid residents, undated, showed 38 residents tested positive for COVID-19 from [DATE] to [DATE]. Review of Associate COVID testing log, undated, showed 13 staff tested positive for COVID-19 from [DATE] to [DATE]. Review of Respiratory Line Listing, undated, showed between [DATE] and [DATE], 6 residents who tested positive for COVID-19 were hospitalized , 5 died and 3 of these residents were asymptomatic for COVID-19. On [DATE] at 11:32 AM the Administrator was notified the immediacy was removed based on onsite verification that IJ removal plan was implemented. The IJ removal plan included staff members responsible for COVID-19 testing were trained in the proper method of collecting specimens, applicable residents who continue to receive negative test results (4 residents) were re-tested , and staff were re-tested , prior to returning to work.

Based on interview and record review it was determined the facility failed to protect a resident from sexual abuse for 1 of 2 sampled residents (#s 1 and 2) reviewed for abuse. As a result, Resident 1 experienced sexual abuse and displayed symptoms of negative psychosocial impact as evidenced by fearful statements and refusals of care. Findings include: Resident 1 was admitted to the facility in 2018 with [DIAGNOSES REDACTED]. The facility Protection of Residents policy dated 11/2016 stated: it is the policy of the facility that all residents will be protected from abuse and/or neglect. The document defined sexual abuse as: Non-consensual sexual contact of any type with a resident. The facility's Abuse/Adverse Event Investigation Packet dated 8/5/20 indicated Staff 10 (CNA) reported to Staff 4 (Staffing Coordinator/LPN) and Staff 5 (Activities Director) following his shift on 8/5/20 he had touched someone like you weren't supposed to. Staff 10 stated he was changing Resident 1's brief and started wiping the resident repetitively and then digitally penetrated the resident's genital area. Per the report, Staff 10 was immediately terminated and the police and other appropriate entities were notified. On 8/6/20 at 3:59 PM a Health Status Progress Note indicated Resident 1 was making a lot of inappropriate comments during a shower such as; asking the CNA if she was going to drown her/him or if the CNA was going to hurt her/him while giving the shower. On 8/10/20 at 2:23 PM Staff 5 stated she had stopped to give Staff 10 a ride home from the facility on 8/5/20. Staff 5 indicated Staff 10 was upset and started to cry and stated he wanted to confess something. Staff 5 stated Staff 10 revealed he had sexually abused a resident at the facility. On 8/10/20 at 2:41 PM Staff 4 indicated she had received a phone call from Staff 5 who was in her car with Staff 10 regarding an incident which occurred with Staff 10 and a resident in the facility. Staff 4 met with Staff 10 in Staff 5's car and Staff 10 revealed to her that he had sexually abused Resident 1. Staff 10 indicated he had thought about doing the abuse previously and he was aware it was wrong. Staff 4 indicated they immediately reported the incident to the facility. On 8/11/2020 at 10:30 AM Witness 2 (Detective Sergeant McMinnville PD) indicated they received a call from the facility on 8/5/20. The alleged perpetrator (Staff 10/CNA) confessed what he had done to Resident 1. Witness 2 stated he did not feel there were other residents involved. Witness 2 indicated there was a high level of excitement indicated by Staff 10 and his mindset was he knew he was doing wrong. Staff 10 revealed he preset the room up so he could have the contact with the resident. Staff 10 knew the resident sometimes made sexual remarks, but did not give consent and Staff 10 appeared remorseful. The Police Department would not be able to provide a police report at this time because it was still an open and on-going case and they would need to get approval from the District Attorney. On 8/11/20 at 4:10 PM Resident 1 stated she/he had a girlfriend/boyfriend who worked at the facility. Resident 1 stated she/he was not supposed to talk about it because the girlfriend/boyfriend was too young for her/him. Resident 1 indicated she/he was lonely and so was the staff member and it was nice to have a girlfriend/boyfriend at the facility. The resident did not want to discuss any physical interactions that may have occurred. Numerous attempts were made to contact Staff 10 by telephone for an interview, but they were unsuccessful, and the voice mailbox was full. On 8/12/20 at 9:02 AM Witness 3 (Oregon State Board of Nursing Investigator) indicated Staff 10 revealed he had sexual contact with Resident 1 and it was not just a chance happening. Staff 10 revealed he had thought about doing it before he did it and he had set up the room in advance by lowering the blinds and turning the slats so no one could see into the room. Staff 10 was aware Resident 1 had cognitive issues and even if Resident 1 made sexual comments to him it was not appropriate for him to act on them, but he did anyway. Staff 10 reported to Witness 3 he had spent 20 minutes changing the resident and while doing so had digitally penetrated the resident's genitals for approximately 3 to 5 minutes. Staff 10 then indicated he lowered his pants and underpants and crawled into bed with the resident. Staff 10 stated he became overwhelmed by guilt and hopped down off the resident. Staff 10 indicated a staff member may have seen him in the room with the resident, but he did not indicate who that was by name. Witness 3 felt Staff 10 was not as forthcoming with details when he spoke to the police. The following are two progress notes and an interview which evidence psychosocial harm to Resident 1: -On 8/14/20 at 2:53 PM a Progress Note indicated Resident 1 refused to allow staff to put a shirt on her/him. Refusal of care is associated with psychosocial harm. -An interview on 8/17/20 at 12:45 PM Staff 7 (CNA) indicated Resident 1 wasn't allowing her or her female CNA partner to do brief changes. The resident didn't want anyone to see her/his body. Staff 7 indicated that a few weeks prior to the event the resident had been making sexual remarks about Staff 10. Refusals of care are associated with psychosocial harm. Inappropriate or increased sexual comments are indicators of sexual abuse. -On 8/19/20 at 10:44 AM a Progress Note indicated Resident 1 was on alert charting for the incident of sexual abuse with possible psychosocial harm. On 8/19/20 while two CNAs and a nurse were assisting the resident with a brief change, the resident asked what male was in the room. The staff informed the resident no males were in the room. The resident asked what male was in her/his room last night and the resident said she/he did not like what he did and that it hurt. The current care plan has only female caregivers for the resident so the statement most likely refers to the previous episode of abuse. On 8/19/20 at 3:30 PM Staff 1 (Interim Administrator), Staff 2 (New Administrator) and Staff 3 (DON) acknowledged Resident 1 had been sexually abused by Staff 10. The resident was placed on alert charting for sexual abuse and possible psychosocial harm associated with that event. In an email received on 9/25/20 at 10:03 PM Witness 4 (Police Officer) indicated he believed the abuse was limited to the one resident. The exact date of the incident was 8/3/20. Witness 4 was told another employee may have entered or was waiting to enter the room as Staff 10 left the room, however Staff 10 did not identify the staff member. It was unclear as to the full extent of the sexual contact by Staff 10 but Witness 4 felt in part Staff 10 was lying related to the question of penile penetration. Witness 4 indicated the resident being unable to fully cooperate with the investigation did not help to clarify what occurred. Witness 4 was hoping to receive further findings from the Oregon State Police crime lab in the near future.

1. Based on interview and record review it was determined the facility failed to ensure residents received treatment when symptoms of dehydration were displayed for 1 of 4 residents (#246) reviewed for hydration. This failure resulted in Resident 246's hospitalization for severe dehydration and kidney failure. Findings include: Resident 246 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's care plan, updated 1/16/19, indicated Resident 246 used a urinary catheter to void and was at risk for dehydration. Staff were to provide fluids and monitor fluid intake PRN, encourage intake of fluids PRN, monitor for signs of dehydration and notify the physician as indicated. a. The 3/27/19 MAR indicated [REDACTED]. Output monitoring records from 3/27/19 indicated Resident 246 voided only 50 mL (less than two ounces) from her/his bladder during day shift and did not void from her/his bladder during evening shift. No vital statistics or other evidence was found in the resident's clinical record to indicate the resident was assessed for symptoms of dehydration on 3/27/19. b. The 3/28/19 MAR indicated [REDACTED]. Output monitoring records from 3/28/19 indicated Resident 246 voided 10ml (less than one ounce) from her/his bladder during day shift and voided 150 ml (about five ounces) during evening shift. No vital statistics or other evidence was found in the resident's record to indicate the resident was assessed for symptoms of dehydration on 3/28/19. c. A 3/29/19 progress note written by Witness 2 (Former RN) indicated Resident 246 was lethargic and flushed, would not open her/his eyes, did not urinate and refused fluids. A bladder scan revealed no fluid in the resident's bladder. The note stated, CNAs report (patient) has not been eating or drinking for past couple days. The physician was notified, 911 was called and the resident was sent to the emergency room for evaluation. The resident's vital statistics included a temperature of 99.4 and respirations of 28 per minute (indicating rapid breathing). Hospital records dated 3/29/19 indicated Resident 246 was diagnosed with [REDACTED]. From 6/11/19 through 6/13/19 interviews were completed with Staff 5 (CNA), Staff 6 (CMA), Staff 7 (CNA), Staff 13 (CNA), Staff 14 (CMA), Witness 3 (Former CNA), Staff 15 (CNA), Staff 21 (CNA) and Staff 19 (Restorative Aide/CNA). None of the staff remembered when the resident began to show symptoms of dehydration but indicated they always informed the charge nurse when residents did not void from the bladder sufficiently (less than 240 mL) during a shift. During interviews with Staff 4 (Staff Development) and Staff 2 (DNS) on 6/12/19 at 11:34 AM and 6/12/19 at 12:08 PM Staff 2 and Staff 4 acknowledged there was no evidence to indicate Resident 246 was assessed for symptoms of dehydration until 3/29/19, despite showing symptoms on 3/27/19. Staff 4 and Staff 2 indicated residents with less than 240 mL of urine output in an eight-hour shift were to be assessed by the nurse. 2. Based on observation, interview and record review it was determined the facility failed to ensure residents nutrition and hydration needs were met for 1 of 1 sampled resident (#4) reviewed for hospice. This placed residents at risk for dehydration and unmet nutritional needs. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 9/6/18 Significant Change MDS Nutritional Status CAA indicated Resident 4 received hospice services, had difficulty in making her/his needs knows and required one person assistance with meals. The care plan, last updated 9/17/18, indicated Resident 4 required one person assistance for eating and the resident was to be in the dining room for all meals as the resident allowed and encourage intake as the resident allowed. The care plan further indicated to encourage fluid intake PRN as tolerated. A 5/2/19 physician order [REDACTED]. On 6/11/19 at 9:11 AM Resident 4 was observed to be in bed with no fluids in the room. On 6/11/19 at 11:36 AM Resident 4 was observed to be in bed and did not respond when spoken to. There were no fluids observed in the resident's room. On 6/11/19 at 12:10 PM Staff 29 (CNA) stated he was not going to get Resident 4 up for lunch in the dining room and was not going to assist the resident to eat in her/his room. When asked what the resident's routine was for meals, Staff 29 stated Resident 4 got up for breakfast and dinner but did not get up for lunch. He stated residents that needed assistance with meals ate in the dining room. On 6/11/19 at 1:34 PM Resident 4 was observed to be awake in bed with no fluids in the room. On 6/11/19 at 1:57 PM a full cup of nectar thick liquid was observed next to the resident's sink. On 6/11/19 at 2:30 PM Staff 29 (CNA) acknowledged he was Resident 4's primary CNA that day and was asked if the resident was offered anything to drink on 6/11/19, he stated No I didn't have time to make it a priority. Staff 29 ended the interview. On 6/11/19 at 2:38 PM Resident 4 was observed to be awake in bed, the thickened liquids were still observed to be sitting by the sink with the lid on it and it was full. On 6/11/19 at 2:55 PM Resident 4 was observed in bed awake moving her/his jaw back and forth, the thickened liquid drink was still full by the sink. On 6/11/19 at 3:19 PM two evening CNA staff were observed to enter the room and close the door behind them. Resident 4 was then assisted out of the room to the dining room to an activity. On 6/11/19 at 3:27 PM Staff 36 (CNA) and Staff 13 (CNA) stated the resident was given 240 cc of the thickened water before they brought the resident out of the room. Staff 36 and 13 further stated drinks are only offered to the resident during meals and hydration passes and do not offer the resident drinks in between those times. Staff 36 and Staff 13 were asked if the resident could indicate if she/he was hungry or thirsty, they stated no. They further stated there were non-verbal cues to communicate whether the resident was thirsty or hungry. On 6/12/19 at 11:47 AM Witness 12 (Hospice RN) stated he cared for Resident 4 since 12/2018. He stated the resident was non-verbal and expected staff to assist the resident to the dining room for all meals since the resident did not eat in her/his room. Witness 12 stated he did not recall observing fluids in the resident's room when he visited weekly since 12/2018. On 6/12/19 at 3:21 PM Staff 2 (DNS) stated Resident 4 was totally dependent on staff for food and fluids. She further stated the expectation was for fluids to be offered at meals and in between meals as needed and the resident was to be up in the dining room for all meals. She stated as of 6/12/19 Staff 29 was not working for the next two weeks and she would follow up once Staff 29 returned.

1. Based on interview and record review it was determined the facility failed to ensure Staff 10 (LPN) adhered to professional standards of practice related to assessing residents with a change of condition and documentation of treatment. This failure resulted in Resident 246's hospitalization and [DIAGNOSES REDACTED]. Findings include: Per Oregon Administrative Rule Chapter 851, Division 45: Standards and Scope of Practice for the Licensed Practical Nurse and Registered Nurse: 851-045-0050 Scope of Practice Standards for Licensed Practical Nurses includes: (3) Standards related to the LPN's responsibility for nursing practice. Applying practical nursing knowledge, at the clinical direction and under the clinical supervision of the RN or LIP, the LPN shall: (a) Conduct focused assessments by: (A) Collecting data through observations, examinations, interviews, and records in an accurate and timely manner as appropriate to the client's health care needs and context of care; (B) Validating data by utilizing available resources, including interactions with the client and health care team members; 851-045-0070 Conduct Derogatory to the Standards of Nursing Defined includes: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing practice. Actual injury need not be established; (3) Conduct related to the client's safety and integrity: (b) Failing to take action to preserve or promote the client ' s safety based on nursing assessment and judgment; (4) Conduct related to communication: (a) Failure to accurately document nursing interventions and nursing practice implementation; (b) Failure to document nursing interventions and nursing practice implementation in a timely, accurate, thorough, and clear manner. This includes failing to document a late entry within a reasonable time period; (c) Entering inaccurate, incomplete, falsified or altered documentation into a health record or agency records. This includes but is not limited to: (A) Documenting nursing practice implementation that did not occur; (B) Documenting the provision of services that were not provided; (C) Failing to document information pertinent to a client ' s care; (E) Falsifying data; (G) Entering late entry documentation into the record that does not demonstrate the date and time of the initial event documented, the date and time the late entry is being placed into the record, and the signature of the licensee entering the late entry to the record. Resident 246 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's care plan, updated 1/16/19, indicated Resident 246 used a urinary catheter to void and was at risk for dehydration. Staff were to provide fluids and monitor for fluid intake PRN, encourage intake of fluids PRN, monitor for signs of dehydration and notify the physician as indicated. The 3/28/19 MAR indicated [REDACTED]. Output monitoring records from 3/28/19 indicated Resident 246 voided 10 ml (less than one ounce) from her/his bladder during day shift and voided 150 ml (about five ounces) during evening shift. No vital statistics or other evidence was found in the resident's record to indicate the resident was assessed for symptoms of dehydration on 3/28/19. A 3/29/19 progress note written by Witness 2 (Former RN) indicated Resident 246 was lethargic and flushed, would not open her/his eyes, did not urinate and refused fluids. A bladder scan revealed no fluid in the resident's bladder. The note stated, CNAs report (patient) has not been eating or drinking for past couple days. The physician was notified, 911 was called and the resident was sent to the emergency room for evaluation. The resident's vital statistics included a temperature of 99.4 and respirations of 28 per minute (indicating rapid breathing). Hospital records dated 3/29/19 indicated Resident 246 was diagnosed with [REDACTED]. A late entry progress note written on 3/29/19 at 5:38 PM by Staff 10 (LPN) indicated she assessed the resident on 3/28/19 after the resident refused a health shake and meal. Vital signs were stable, the patient was urinating with normal color, the patient had no complaints of pain and was resting comfortably in bed. The progress note did not indicate what time the resident was assessed, did not indicate the amount of fluid in the catheter bag, did not include information on the resident's lack of voiding and did not include values for the resident's vital statistics. From 6/11/19 through 6/13/19 interviews were completed with Staff 5 (CNA), Staff 6 (CMA), Staff 7 (CNA), Staff 13 (CNA), Staff 14 (CMA), Witness 3 (Former CNA), Staff 15 (CNA), Staff 21 (CNA) and Staff 19 (RA/CNA). None of the staff remembered when the resident began to show symptoms of dehydration but indicated they always informed the charge nurse when residents did not void from the bladder sufficiently (less than 240 mL) during a shift. On 6/11/19 at 2:06 PM Witness 2 (Former RN) stated she was the charge nurse on the morning of 3/29/19 when the resident went to the hospital. Witness 2 stated she was informed by a CMA that something was wrong with Resident 246. Witness 2 had not seen the resident yet that morning and nothing was reported to her about the resident's condition by the previous shift nurse, Staff 10 (LPN). The resident was not on alert status. Witness 2 stated Resident 246 was flushed, would not open her/his eyes and lashed out at staff when touched. Witness 2 stated CNAs informed her the resident was in that condition the past two days and the concern was reported to Staff 10 the day before. Witness 2 checked the resident's vitals and they were out of normal range. Witness 2 stated the resident appeared dehydrated and the resident was sent to the hospital. On 6/12/19 at 1:28 AM Staff 11 (LPN) stated she was the charge nurse on duty from the evening of 3/28/19 until the morning of 3/29/19. Staff 11 stated nothing was communicated to her about Resident 246 by Staff 10 when Staff 11 arrived for her shift. Staff 11 stated Resident 246 was not on alert status on 3/28/19. Staff 11 stated she did not remember any concerns with Resident 246 during her shift. A review of the facility's alert charting revealed no indication Resident 246 was on alert status at any time from 3/27/19 through 3/29/19. During interviews with Staff 4 (Staff Development) and Staff 2 (DNS) on 6/12/19 at 11:34 AM and 6/12/19 at 12:08 PM Staff 2 and Staff 4 indicated an unidentified staff member reported a concern to Staff 10 on 3/28/19 via the facility's stop and watch (the facility system for alert charting). It was reported that Resident 246 ate less, was flushed and did not act normally. Staff 4 and Staff 2 acknowledged there was no evidence to indicate Resident 246 was assessed for symptoms of dehydration until 3/29/19, despite evidence indicating nursing staff were alerted to the resident's change of condition on 3/28/19. Staff 4 and Staff 2 acknowledged the late entry progress note written on 3/29/19 at 5:38 PM by Staff 10, which indicated the resident's vitals were normal and the resident was urinating, was inconsistent with the resident's clinical record which indicated no vitals were taken on 3/28/19 and the resident only voided 10 mL from her/his bladder. Staff 4 and Staff 2 acknowledged any assessment of the resident should have included a review of the resident's output record but there was no evidence to indicate the resident's output was reviewed. Staff 4 indicated the facility in-serviced Staff 10 on the requirements for timely assessments and documentation as a result of this incident. During interviews with Staff 10 (LPN) on 6/11/19 at 1:45 PM and 6/14/19 at 9:32 AM Staff 10 stated she was the charge nurse on duty for the day shift on 3/28/19. Staff 10 stated she was informed that Resident 246 was having complaints and refusing medication and health shakes, which was not abnormal for the resident. Staff 10 stated she saw the resident around lunch time (the facility's lunch time is 12:00 PM) and the resident had about 100 mL of normal colored urine in the catheter bag. Staff 10 stated she was not told that Resident 246 was not urinating. Staff 10 stated she checked the resident's vital statistics and they were normal. Staff 10 stated she put the resident on alert status in the alert book and passed the information on to the next shift. When asked about the discrepancy between her previous statement indicating there was 100 mL in the catheter bag at lunch time and documentation which showed only 10 mL of urine voided during that shift, Staff 10 stated she assessed the resident at 3:00 PM and there was 50-75 mL of urine in the bag, which was after day shift ended. When asked about the discrepancy between her statement that vital statistics were checked and the resident's vital statistics record which indicated vitals were not checked on 3/28/19, Staff 10 stated she did not document the vitals statistics because they were normal. When asked about the discrepancy between her statement that she placed Resident 246 on alert monitoring and the facility's alert book, the resident's clinical record, and statements from other nursing staff which all indicated the resident was not on alert status on 3/28/19, Staff 10 stated, I put (Resident 246) on alert. Refer to F692 2. Based on observation, interview and record review it was determined the facility failed to ensure Staff 29 (CNA) adhered to professional standards of practice related to the provision of food and fluids to dependent residents. This placed residents at risk for neglect. Findings include: Per Oregon Administrative Rule Chapter 851, Division 63: Standards and authorized duties for the certified nursing assistant: 851-063-0090 Conduct Unbecoming a Nursing Assistant: A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established; (3) Conduct related to client safety and integrity: (b) Failing to implement the plan of care developed by the registered nurse; (7) Conduct related to safe performance of authorized duties: (e) Neglecting a person; Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 9/6/18 Significant Change MDS Nutritional Status CAA indicated Resident 4 received hospice services, had difficulty in making her/his needs knows and required one person assistance with meals. The care plan, last updated 9/17/18, indicated Resident 4 required one person assistance for eating and the resident was to be in the dining room for all meals as the resident allowed and encourage intake as the resident allowed. The care plan further indicated to encourage fluid intake PRN as tolerated. A 5/2/19 physician order [REDACTED]. On 6/11/19 at 9:11 AM Resident 4 was observed to be in bed with no fluids in the room. On 6/11/19 at 11:36 AM Resident 4 was observed to be in bed and did not respond when spoken to. There were no fluids observed in the resident's room. On 6/11/19 at 12:10 PM Staff 29 (CNA) stated he was not going to get Resident 4 up for lunch in the dining room and was not going to assist the resident to eat in her/his room. When asked what the resident's routine was for meals, Staff 29 stated Resident 4 got up for breakfast and dinner but did not get up for lunch. He stated residents that needed assistance with meals ate in the dining room. On 6/11/19 at 1:34 PM Resident 4 was observed to be awake in bed with no fluids in the room. On 6/11/19 at 1:57 PM a full cup of nectar thick liquid was observed next to the resident's sink. On 6/11/19 at 2:30 PM Staff 29 (CNA) acknowledged he was Resident 4's primary CNA on 6/11/19 and was asked if the resident was offered anything to drink that day, he stated No I didn't have time to make it a priority. Staff 29 ended the interview. On 6/12/19 at 11:47 AM Witness 12 (Hospice RN) stated he cared for Resident 4 since 12/2018. He stated the resident was non-verbal and expected staff to assist the resident to the dining room for all meals since the resident did not eat in her/his room. Witness 12 stated he did not recall observing fluids in the resident's room when he visited weekly since 12/2018. On 6/12/19 at 3:21 PM Staff 2 (DNS) stated Resident 4 was totally dependent on staff for food and fluids. She further stated the expectation was for fluids to be offered at meals and in between meals as needed and the resident was to be up in the dining room for all meals. She stated as of 6/12/19 Staff 29 was not working for the next two weeks and she would follow up once Staff 29 returned. Refer to F692

Based on interview and record review it was determined the facility failed to provide clinical justification for the deterioration of a pressure ulcer for 1 of 3 sampled residents (#2) reviewed for wounds. Resident 2's wound became infected with tendons visible and required evaluation and treatment at the hospital. Findings include: The National Pressure Ulcer Advisory Panel defined the following pressure ulcer stages: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident 2 was admitted to the facility in July 2015 with [DIAGNOSES REDACTED]. A hospital CWON (Certified Wound Ostomy Nurse) Progress Note dated 7/17/15 indicated Resident 2 had a large blister on the top of the right foot which was de-roofed (the layer of tissue above the blister was removed) on 7/17/15. It was a partial thickness wound and the plan was to apply wound gel and cover with adhesive foam dressings. An Initial Data Collection Tool/Nursing Service form dated 7/18/15 indicated Resident 2 admitted to the facility with a 9x6 skin condition to the top of the right foot. The form failed to identify the scale used (centimeters or inches), the type of skin condition or any other wound characteristics such as appearance, color, odor or drainage. Resident 2's Care Plan with an onset date of 7/18/15 indicated to notify the physician of a changes in skin status including signs or symptoms of infection, non-healing or new areas. A Physician's Progress Notes dated 7/21/15 indicated Resident 2 had an 8.0 cm by 4.0 cm ulcer to the top of the right foot. The note failed to indicate if the ulcer was pressure related or describe any other wound characteristics. The note indicated the facility was to continue the present wound orders. Resident 2's Non-Pressure Skin Condition Records revealed the following: - On 7/18/15 the resident had a skin condition to the top of the right foot. The type of wound, measurements and other wound characteristics were not noted. - On 7/29/15 (11 days since the previous assessment) the wound was black necrotic and measured 8.0 cm by 4.0 cm. The wound had no depth, drainage or odor. - On 8/5/15 the wound measured 9.3 cm by 5.0 cm and it was indicated the wound was otherwise unchanged from the previous assessment. - On 8/12/15 the wound measured 8.0 cm by 5.0 cm, had scant drainage and was indicated as improved in condition. - On 8/20/15 the wound measured 8.3 cm by 5.3 cm, had a small amount of drainage, was brown and yellow in color, appeared granular (new tissue formed on a wound during the healing process) with slough (soft moist dead tissue) and was indicated as improved in condition. - On 8/26/15 the wound measured 8.0 cm by 5.5 cm and was yellow and pink on color. The assessment indicated the wound was improved in condition. - On 9/1/15 the wound measured 8.0 cm by 5.0 cm. The assessment indicated the wound was improved in condition. - On 9/9/15 the wound measured 7.0 cm by 4.2 cm, had a moderate amount of drainage, was creamy yellow with pink beefy granulation edges. The assessment indicated the wound was improved in condition. - On 9/16/15 the wound measured 6.3 cm by 5.0 cm with a depth of 0.6 cm (this was the first indication the wound had any depth). The odor was described as sweat/breakdown. The assessment indicated the wound was improved in condition. Resident 2's Progress Notes revealed the following: - A late entry for 7/18/15 indicated the resident had a slough area to anterior right foot. - On 7/19/15 the wound bed to the top of the right foot was pink with scant white slough and slight blackness around the edge. - On 7/21/15 the redness to the top of the right foot appeared to be 50% less in diameter. No previous description of redness to the top of the right foot was found in the resident's clinical record. - On 7/23/15 it was noted the resident had unstageable pressure ulcers on the feet. No clarifying description of the wounds size or location was noted. - On 7/25/15 the wound to the top of the right foot appeared black. Based on this description, the wound should have been classified as unstageable. This was a significant change in the condition of the wound and the physician should have been notified. A review of the resident's clinical record revealed no indication the physician was notified of the wound change in condition, the wound treatment was changed in response, or a clinical justification for the decline in the wound condition. - On 7/29/15 the dressing was stuck to the wound on the top of the right foot. The wound bed was covered with necrotic tissue. - On 8/12/15 the wound to the top of the right foot remained black with slight redness (redness can be a sign of infection) noted at the wound edges. - On 9/1/15 the wound to the top of the right foot measured 8.0 cm by 5.0 cm, was covered by softened eschar with edges lifting and exposed granulation and slough. The size of the wound was not changed but showed overall improvement. - On 9/7/15 the wound to the top of the right foot had a moderate amount of drainage and tendon was visible where the slough came off. The area was painful. Based on this description, the wound should have been classified as a Stage 4. This was a significant change in the condition of the wound and the physician should have been notified. A review of the resident's clinical record revealed no indication the physician was notified of the wound change in condition, the wound treatment was changed in response, or clinical justification for the decline in the wound condition. - On 9/9/15 the wound to the top of the right foot measured 7.0 cm by 4.2 cm with slough and soft eschar present, visible tendon and foul odor. A foul odor from a wound can be a sign of infection and the physician should have been notified. A review of the resident's clinical record revealed no indication the physician was notified of the wound change in condition, the wound treatment was changed in response, or clinical justification for the decline in the wound condition. - On 9/13/15 the wound to the top of the right foot had a foul odor with slough and tendon was visible. - On 9/16/15 the wound to the top of the right foot measured 6.3 cm by 5.0 cm and 0.6 cm deep. The wound had softened eschar with granulating edges, exposed tendon and foul odor. There were no further assessments of the wound to the top of Resident 2's right foot from 9/16/15 through 9/20/15 when the resident was discharged to another facility. A review of physician's orders [REDACTED]. - Physician order [REDACTED]. The order indicated to apply wound gel and cover with an adhesive foam dressing until it was resolved, every three days and as needed. - A TO (Telephone Orders) dated 7/31/15 indicated new treatment orders for the right foot wound to cleanse with normal saline, apply iodasorb gel (antibacterial gel which absorbs drainage and slough), silver [MEDICATION NAME] (antibacterial) dressing and cover with gauze every Tuesday, Thursday and Saturday. A review of Resident 2's clinical record revealed no assessment to indicate the rationale for the treatment change. - A TO dated 8/14/15 indicated new treatment orders for the wound on the top of Resident 2's right foot. The order indicated to cleanse the wound with normal saline, apply skin-prep to the surrounding skin, apply [MEDICATION NAME] (a normal saline wound gel), cover with a foam dressing and wrap with gauze daily and as needed until resolved. A review of Resident 2's clinical record revealed no assessment to indicate the rationale for the treatment change. - A TO dated 9/16/15 indicated a new treatment order for physical therapy five times a week for 12 weeks including therapeutic exercise, therapeutic activities, wound care, diathermy (application of heat through high-frequency electrical currents to stimulate circulation and destroy unhealthy tissue), electrical stimulation (application of an electrical current to aid wound healing) and closed pulse irrigation (pressurized wound irrigation). A Physical Therapy (PT) Plan of Treatment dated 9/16/15 indicated Resident 2 was referred to PT due to a very slow to heal Stage 4 pressure ulcer on the top of the resident's right foot causing risk for infection [MEDICAL CONDITION] (a potentially life threatening complication of infection). PT services were required to debride (removal of dead tissue) the wound, stimulate blood flow and wound healing and ensure maximum health. The resident had a Stage 4 pressure ulcer on the top of the right foot measuring 6.3 cm by 5.0 cm by 0.6 cm deep. The wound was 35% necrotic tissue, 10% granulation and 40% slough with tendons exposed, moderate serous (clear or pale yellow body fluid) drainage and foul odor. This was a significant and aggressive change in wound treatment to a wound which was previously described as improved on Resident 2's Non-Pressure Skin Condition Record from 8/12/15 through 9/16/15. A review of Resident 2's clinical record revealed no nursing assessment to indicate the rationale for the treatment change. An Alzheimer's Special Care Center Nurses' Admission assessment dated [DATE] indicated Resident 2 had a ten by seven centimeter wound on the top of the right foot with red and purple colored skin surrounding the wound. Nurses Notes from the Alzheimer's Special Care Center indicated the following: - On 9/20/15 Resident 2 had a ten by seven centimeter Stage 4 wound on the top of the right foot. The wound had purulent discharge and odor with red and purple colored skin surrounding the wound. The wound appeared to need a wound-vac (a method of applying negative pressure to a wound for healing) or IV (intravenous) antibiotics as soon as possible. The resident needed extensive wound care evaluation and treatment as soon as possible to avoid further complications such as osteo[DIAGNOSES REDACTED] (bone infection). - On 9/21/15 Resident 2 was sent to the hospital emergency department for evaluation and treatment of [REDACTED]. The physician ordered Keflex (antibiotic) three times daily for seven days. The physician instructed the resident's family to follow-up with a plastic surgeon. - On 9/22/15 Resident 2 was seen by a plastic surgeon who gave new wound care orders and instructed the resident to be seen by a wound care and vascular surgeon. Hospital ED Notes dated 9/21/15 indicated the resident was seen for right foot redness. The resident stated the foot infection had been going on for quite awhile. X-rays of the right foot indicated the wound extended very close to the underlying bone and osteo[DIAGNOSES REDACTED] was not excluded. The resident had minimal options due to the resident's age. Given the resident's complicated open wound and risk factors for infection antibiotics were ordered for likely [MEDICAL CONDITION] (skin infection). The physician discussed treatment options from further wound care to amputation as the most severe. The resident was given strict return precautions and was advised to follow-up with a plastic surgeon within one day. During interviews on 8/4/16 at 10:30 am, 8/9/16 at 2:23 pm and 8/23/16 at 1:35 pm Staff 1 (DNS) stated Resident 2 was evaluated by PT but did not receive services prior to being discharged from the facility on 9/20/15. Staff 1 stated she did not know why the treatments were changed and acknowledged Resident 2's physician was not notified the resident's right foot wound had deteriorated. Staff 1 acknowledged there was no assessment to indicate why Resident 2's right foot wound deteriorated. She stated the wound looked worse on paper than it looked in person.

Based on interview and record review, it was determined the facility failed to follow the care plan for an assistive device for 1 of 2 sampled residents (#16) reviewed for accidents. Resident 16 fell resulting in pain to the left hip, decreased mobility, decreased appetite and the resident required increased narcotic pain medication for comfort. Findings include: Resident 16 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a Fall CAA dated 1/23/15 revealed the resident was at risk for falls due to impaired balance, weakness, history of falls, delirium and dementia. The CAA indicated the resident needed one person assistance with transfers and would self transfer from bed to a wheelchair to use the bathroom. The CAA indicated the resident received hospice services. Review of a physician's orders [REDACTED]. Review of a comprehensive care plan updated 5/20/15, revealed the resident was at risk for falls related to a history of falls, impaired mobility, weakness, pain, poor safety awareness and impulsiveness. The care plan indicated fall interventions included keeping the resident's wheelchair next to the resident's bed to use for self transfers. The care plan also indicated the resident had chronic back pain but there was no documentation the resident had a history of [REDACTED]. Review of a social service note dated 8/6/15 at 1:10 pm, revealed the resident continued to be alert with confusion related to dementia and could make some needs known to staff. The note indicated the resident spent most of the time in her/his room but would come out at times with the use of a wheelchair. Review of a nurse's note dated 8/11/15 at 11:32 pm, revealed the resident was found on the floor sitting up against the resident's bed. The resident had a bruise and abrasion to the left hip. The resident was unable to straighten the left leg and yelled out in pain if the leg was moved. The facility notified the Hospice nurse to come to the facility and assess the resident. At 12:31 am the Hospice nurse told staff the resident's hip could be dislocated or fractured and would contact the resident's physician. The resident was administered Roxanol (morphine/narcotic pain medication) which was effective for the resident's pain. The resident's bruise/abrasion measured 6 cm by 4 cm. Review of a nurse's note dated 8/12/15 at 1:01 pm, revealed the resident was extremely painful and agitated with hallucinations. Hospice was notified and instructed the facility to administer Roxano. Review of a hospice note dated 8/13/15, revealed the resident was too painful to move and was unable to get out of bed to void. The facility was to increase the resident's methadone to 25 mg every 12 hours for pain and monitor the resident for oversedation. Review of a Incident Follow-up & Recommendation Form dated 8/13/15 revealed the resident was found on the floor by the resident's bed with severe left leg pain. Hospice recommended to administer medication for pain and an x-ray was deferred secondary to pain. The form also indicated the resident had a presumed fracture secondary to the fall and the care plan was not followed to have the resident's wheelchair at bedside. A nurse's note dated 8/14/15 at 12:40 pm, revealed a review of the resident's fall determined the resident fell after an attempted self transfer from bed. The note indicated the care plan was not followed to have a wheelchair next to the resident's bed for safer transfers. The note also indicated the resident was suspected to have a pelvic or hip fracture and the plan was to manage the resident's pain and focus on interventions to promote comfort. The resident's PRN Roxanol and Methadone (a pain medication) dose were increased for breakthrough pain. The note indicated the resident was not able to get out of bed due to the injury. Review of a nurse's note dated 8/14/15 at 6:54 pm, revealed the resident continued to have left hip pain with movement. Review of a nurse's note dated 8/15/15 at 5:26 pm, revealed the resident moaned when turned and repositioned. The note indicated the resident was medicated prior to turning and incontinent changes. Review of a nurse's note dated 8/16/15 at 6:44 pm, revealed the resident was unable to take food or fluids when offered and cried out when turned and repositioned. Review of a Physician Communication form dated 8/18/15, revealed the resident was declining and had not attempted to get out of bed since the fall on 8/11/15. Review of a PRN Administration Record for August 2015 revealed the resident was to receive Morphine (roxanol/narcotic pain medication) every hour as needed for pain. The record indicated 8/1/15 through 8/10/15 the resident had not received morphine for pain and was administered 53 doses of morphine from 8/11/15 through 8/21/15 for pain. Review of a meal monitor for August 2015 revealed the resident's average meal intake from 8/1/15 through 8/11/15 was 53%. The resident's average meal intake from 8/11/15 through 8/23/15 was 9%. On 9/1/15 at 2:53 pm, Staff 14 (LPN) said on 8/11/15 she was at the nurse's station and Staff 16 (CNA) asked for assistance with Resident 16. Staff 14 said she found the resident sitting on the floor in the resident's room next to the resident's bed. Staff 14 said she assessed the resident for injury and found the resident was painful in the left leg and hip. Staff 14 said the resident was not able to extend the left knee or hip. Staff 14 said the resident's wheelchair was care planned to be next to the resident's bed and was located about four feet away from the resident's bed. Staff 14 said the resident had a history of [REDACTED]. On 9/2/15 at 7:26 am, Staff 15 (CNA) said on 8/11/15 at around 11 pm she heard Resident 16 yelling for help and went to the resident's room and found the resident sitting on the floor next to the resident's bed. Staff 15 said she told Staff 16 to get the charge nurse. Staff 15 said the resident tried to get out of bed and go to the bathroom. Staff 15 said the resident would self transfer from bed to the bathroom using a wheelchair but the wheelchair was not placed next to the resident's bed. Staff 15 said the wheelchair was approximately 8 feet away from the resident's bed when she entered the resident's room. Staff 15 said the resident did not appear injured but complained of left hip and leg pain. On 9/2/15 at 2:38 pm, Staff 16 (CNA) said on 8/11/15 around 11 pm she heard Resident 16 yell for help. Staff 16 said Staff 15 (CNA) was in the room with the resident who asked her to get the charge nurse. Staff 16 said the resident was sitting on the floor next to the resident's bed. Staff 16 said she alerted Staff 14 (LPN) the resident had fallen. Staff 16 said the resident did not appear to have any injuries but the resident complained of left hip pain. Staff 16 said the resident was able to self transfer from bed with the assistance of a wheelchair but the wheelchair was located approximately six feet away from the resident's bed. On 9/3/15 at 8:29 am, Staff 1 (Administrator) said the facility completed an investigation of the resident's fall on 8/11/15 and found facility staff failed to follow the care plan to keep the resident's wheelchair next to the resident's bed for transfers. Staff 1 said Resident 16 had a history of [REDACTED]. Staff 1 said the failure of not having the wheelchair next to the resident's bed resulted in the resident's fall.

Based on observation, interview and record review, it was determined the facility failed to provide a safe transfer with a sit-to-stand lift (Sara lift) for 1 of 4 sampled residents (#1) who were reviewed for Sara lift transfers. Resident 1 fell from the lift, and sustained a fractured arm resulting in two hospital visits. Findings include: A Nursing Facility Incident Self-Report indicated on 1/9/11, Resident 1 was being transferred with a sit-to-stand lift without a safety strap in place. Resident 1 let go of the hand grip and slid from the harness falling on the resident's right side. The resident sustained [REDACTED]. Nurse's Notes dated 1/11/11 indicated that a UTI (urinary tract infection) had been discovered when the resident was at the hospital on [DATE], which was treated with an antibiotic, Cipro. There was bruising noted on the right arm and left hand. The resident slept for two days, and on 1/12/11 the resident remained lethargic and weak, and was sent to the hospital. A hospital History and Physical dated 1/12/11 indicated the resident had a decreased level of consciousness. It was found the resident had anemia, secondary to blood loss in the fracture site, and from Coumadin (a blood thinner) at the time of the injury. The resident had hypoxia (low oxygenation) probably exaggerated by sedation and anemia. Resident 1 was given 2 units of blood to increase alertness and treat hypoxia. Coumadin was held for one night, but continued the next day. Resident 1 returned to the nursing facility on 1/14/11. On 1/25/11 at 9:50 am Resident 1 was observed lying in bed; the right arm was in a sling, and observed to have extensive bruising. The resident was able to respond to questions, stating her/his arm and chest hurt. At 11:20 am, Staff 3, CNA attempted to arouse the resident in order to transfer the resident to a wheelchair for lunch. However, the resident stated she/he was too tired to get up, and kept closing her/his eyes, appearing to fall asleep. The resident was left to rest in bed. A family member present at 10:15 am on 1/25/11 stated the resident had physically declined and was weaker since the fracture and subsequent anemia. On 1/25/11 at 12:30 pm, Staff 4, RNCM confirmed the resident had anemia from blood loss. Staff 2, DNS confirmed the resident was transferred without the safety strap in place, resulting in the fall and fracture. On 1/26/11 at 9:15 am, Staff 1, the CNA who transferred Resident 1 without the safety strap in place, stated the safety strap was not used because the resident had asked her not to, as the resident's "tummy hurt."